Oceanside Senior Living

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Allegation investigated: Licensee did not ensure the facility was free from pests Food service did not meet residents needs Staff did not respond to resident call buttons in a timely manner

Licensing Program Analyst (LPA)Tiffany Holmes contacted the facility to deliver findings for a complaint investigation via tele-virtual. LPA identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Wes Habner, Executive Director. LPA previously conducted interviews with residents, staff, and outside sources, made observations, and obtained and reviewed pertinent records. LPA Borruda conducted the initial visits on March 13, 2025, April 15, 2025, April 28, 2025 and May 01, 2025 and conducted tours of the facility. It was alleged that the licensee did not ensure the facility was free from pests. Interviews and prior LPA observations revealed that the LPA visually checked the flooring throughout the kitchen and LPA did not observe any food particles on the kitchen floor. Observations revealed the dry food was stored on shelves that elevated the food items off the floor. Dry food storage areas did not contain any litter or food particles on the floor, and the facility walk in refrigerator door was maintained closed. In the facility loading dock/garage area, LPA observed multiple cardboard boxes stored on shelves that elevated them from the floor. LPA did not observe any evidence of rodent activity or rodent droppings in either the facility kitchen or garage space. LPA also did not observe any rodent or insect traps in either location. LPA did not observe any trash cans that were overflowing, leaking, or contained a noticeable or foul odor. LPA did not detect any foul odors in either the kitchen or the garage. LPA did not observe any insects, flying or otherwise in the kitchen. Unsubstantiated It was alleged that the food service did not meet residents needs. Interviews revealed that they don't have any complaints about the food. Interviews revealed that the food is good and that there is plenty. Interviews revealed that there is enough food for seconds if they wanted. Interviews revealed that the chef makes reasonable accommodations for the residents when needed or asked. It was alleged that the staff did not respond to resident call buttons in a timely manner. Interviews revealed that they have not had any issues with the call times of the staff responding. Interviews revealed that the staff respond and assist them with what they called about. Interviews with staff revealed them denying not responding to the residents call buttons. The investigation did not produce supporting evidence or supporting witness statements to substantiate the licensee did not ensure the facility was free from pests, the food service did not meet residents needs and staff did not respond to resident call buttons in a timely manner. Based on the evidence obtained from interviews, the complaint allegations are unsubstantiated. 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 with Wes Habner, Executive Director and a copy of this report and Licensee Rights (LIC 9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 18, 2026 · control 08-AS-20250305093733

Allegation investigated: Facility staff handled resident in a rough manner, resulting in fracture.

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 Wes Hebner. On 09/26/2025 it was alleged that staff handled Resident 1 (R1) in a rough manner, resulting in a fracture. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Relevant staff members familiar with R1 were interviewed. Staff informed that R1 was placed on hospice due to falls and neurocognitive impairment; R1 was noted to be non-cooperative with care. Staff consistently informed that R1 preferred to sleep on their sofa and became irritable when staff attempted to transfer them to their bed. All staff members interviewed denied observing another staff physically abuse R1. Staff indicated that R1’s hip fracture may have been caused by one of the falls they had from their sofa to the floor. (Continued on LIC9099 p.2) Unsubstantiated (Continued from LIC9099 p.1) Staff informed that R1 was checked on frequently and R1 also pushed their pendent frequently due to their inability to walk independently. Staff noted that R1 tended to slide from their sofa to the floor because they believed they could still walk independently. Staff would place R1 away from the edge of the sofa, place their feet on an ottoman and place a foam mat on the floor in front of the sofa to mitigate them from slipping down and falling to the ground. R1’s doctor and family were aware of R1’s refusals to sleep in their bed. Staff informed that R1 made various accusations about staff, such as swaying them up in the air, placing them on the edges of furniture, and purposely dropping them. The facility added a second caregiver to assist with transfers; this second person also provided a witness due to R1’s claims. The incident in question pertained to an assisted transfer where R1 claimed staff slammed them against the wall. The staff member accused of rough handling, S1, denied handling R1 roughly and affirmed that the proper procedure for transfers was completed for R1 each time. S1 did not observe R1 sustain any injuries during the transfer in question and noted that R1 regularly screamed out in pain during transfers. The second staff member (S2) who was present during the transfer in question denied that S1 physically abused R1. The transfer procedure stated by S2 was consistent with S1’s statements. Outside sources familiar with R1’s care, OS1 and OS2 were interviewed. OS1 and OS2 informed that R1 suffered chronic pain from an injury sustained over five (5) years ago due to a medical procedure, and that sleeping on the sofa exacerbated it. The outside sources informed that cameras had been placed in R1’s room due to R1’s claims of abuse by staff. The camera footage showed that R1’s statements against staff were not true, and that R1 refused to sleep on their sofa instead of their bed. The sources corroborated staff statements that R1 became angry and resistant with care, which resulted in R1’s care plan being updated to require a second caregiver. The sources informed that the camera footage showed two occasions where R1 slid from their sofa to the floor, possibly attempting to walk. OS2 believed that R1 may have exaggerated the act of the caregivers positioning them toward the back of the sofa to mitigate falls. A medical professional familiar with R1’s medical condition was interviewed (OS3). OS3 informed that the nature of the allegation that R1 was pushed into a wall would not have caused their hip injury. OS3 informed that R1’s hip condition history, combined with co-morbidities and impact such as a ground-level fall, could have caused the injury. (Continued on LIC9099 p.3) (Continued from LIC 9099 p.2) R1 was interviewed during the investigation. R1 denied being physically abused by staff, and informed that staff assisted them with ambulation. R1 stated during interview that they had fallen in the past when trying to find water. Relevant records were reviewed regarding the allegation. R1’s Needs and Services plan reflected R1’s history of falls and goals to mitigate them. Facility documentation showed that R1 hired a private companion, effective 07/18/2025 and additionally received Home Health services for physical therapy. Hospital discharge paperwork on 09/26/2025 and 09/28/2025 showed R1 to have a diagnosis of a hip socket condition and hip fracture with inability to ambulate. Charting notes from March 2025 to September 2025 showed that R1 suffered from chronic leg pain and swelling with hospitalization. The charting notes additionally showed R1’s progression of cognitive impairment decline, as R1 was noted to experience episodes of disorientation, anger/agitation toward staff, and non-compliance with care. Additional notes revealed that R1 suffered unwitnessed falls on 05/20/2025, 05/21/2025, 05/31/2025, 06/04/2025, 06/17/2025, and 07/04/2025. The notes further showed that the facility contacted R1’s primary care physician multiple times regarding R1’s condition, and the facility provided R1 with a reclining chair for leg elevation, however R1 refused to use it. R1 was noted to prefer sitting and sleeping on their sofa. On 09/25/2025 staff documented initiating emergency services for R1 due to leg pain with X-rays requested. On 09/26/2025 R1 returned to the facility with discharge paperwork noting the diagnosis of a hip socket condition and hip socket fracture. Additional health records showed that R1 suffered from chronic swelling of the feet, experienced significant leg pain and did not consistently take their medications. Outside source documentation showed that R1 made claims to healthcare and outside protective agency personnel that staff banged them against the wall, held their legs, and dropped them on their bed. Medical records and physician statements indicated that at the time R1 alleged to have been physically abused, their hip socket was chronically abnormal, and it would not have taken significant force for their hip to have become partially dislocated. The age of the dislocation remained unclear, and it may have occurred prior to 09/25/2025. The evidence did not definitively show if R1’s injuries were a result of rough handling or a result of some other cause, unrelated to abuse or neglect. 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 of staff handling R1 in a rough manner resulting in fracture is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Wes Hebner, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 17, 2026 · control 08-AS-20250926143734

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Wes Hebner to discuss the purpose of the visit. During an unrelated investigation it was discovered that a specific staff member, S1, handled residents roughly while providing care. Former and current residents were interviewed regarding staff care, and revealed instances where they felt they were handled roughly by S1. The residents provided examples such as being held too tightly and being rushed in care tasks. One resident was told by S1 that S1 “Did not have time” and was impatient while providing the care. Another resident stated that S1 left bruises on them after providing care. Staff interviews additionally revealed observations and knowledge of S1 rushing and/or being rough with resident care. Based on resident and staff interviews, a preponderance of evidence has been met that residents were handled roughly in care by S1. LPA conducted a wellness check at the facility; no health or safety issues were identified. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Wes Hebner, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 17, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Aug 28, 2026

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature… Based on interviews, the licensee did not ensure that staff provided care free from abuse (rough handling) in 3 of 99 persons in care. This posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Aug 17, 2026

Plan of correction: Licensee agreed to retrain staff on personal rights specific to resident care and handling. Proof of training will be submitted to the Department by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to initiate a Case Management investigation regarding a self-report by the facility for the potential financial abuse of a resident. LPA identified themselves and met with Executive Director Wes Hebner to discuss the purpose of the visit and elements of the self-reported incident. During the visit LPA collected facility records, conducted a tour of the facility, and interviewed residents and staff. A health and safety check was conducted for the resident in question, R1. Further investigation is needed, and future visits may be necessary to determine the outcome of the investigation. An exit interview was conducted with Executive Director Wes Hebner. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Jul 15, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to conduct follow up regarding an incident. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Kristel Johnson. On 4/15/2026, the Department was made aware of a fire that occurred in the facility's memory care building on 4/13/2026. During today’s visit, LPA conducted a health and safety check, toured the memory care building, observed residents in care, and briefly spoke with the Executive Director. LPA did not observe any health or safety concerns in the facility's memory care. Interviews revealed that a laundry machine in the facility's memory care caught fire, resulting in memory care residents being temporarily evacuated from the building. The Fire Department was contacted, put out the fire, and cleared the memory care building for resident repopulation the same day. No residents or staff were injured during the fire and residents were not required to be evacuated to an alternative location off facility property. Interviews revealed that the facility did not report the fire to the Department by the next working day, which was 4/14/2026. The following deficiency was cited for reporting requirements and noted on the attached LIC809-D page. An exit interview was conducted with Executive Director Kristel Johnson, 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, Apr 15, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(3) · Plan of correction due date: Apr 30, 2026

87211(a)(3) Fires or explosions which occur in or on the premises shall be reported... no later than the next working day to the licensing agency. This requirement has not been met as evidenced by: Based on interviews, the Licensee did not comply with the section cited above in that the Licensee did not notify the Department of the fire the following working day. This poses a potential safety risk of 90 of 90 residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Executive Director (ED) will review regulation 87211 and submit a letter to the Department confirming their reporting requirement responsibilities by POC due date of 4/30/2026. Executive Director expressed understanding of their responsibility to report fires to the Department as soon as possible, and no later than the following working day.

Allegation investigated: Staff handled resident roughly, resulting in bruising Staff did not treat residents with dignity

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and 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 Virginia Rodriguez. During today’s visit, LPA observed residents in care, obtained copies of facility records, and interviewed staff. 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 staff handled Resident 1 (R1) roughly, resulting in bruising and staff did not treat resident with dignity. Review of R1’s medical and care assessment records dated 2021 revealed that R1 did not have any cognitive impairment and required assistance with bathing, dressing, grooming, and toileting. Continued on LIC9099-C page... Unsubstantiated However, review of progress notes in 2022 and 2023 revealed that beginning in October 2022, R1 began experiencing visual hallucinations and was noted to be confused and disoriented. Outside source interviews provided supporting evidence that that R1 occasionally had hallucinations and had issues with short-term memory. R1 stated during interviews that they felt some staff were pleasant, however staff personalities determined if R1 felt comfortable with their care. Unfortunately, R1 did not provide clarifying details regarding the care provided by staff. Additionally, R1 did not provide any information or details to support the allegation that R1 sustained injuries from staff care. Outside sources were also unable to provide information regarding R1 sustaining any injuries, including one outside source who stated that they had not observed any bruising on R1. Interviews with other residents did not reveal concerns regarding the care provided by the staff at the facility. Interviews with staff did not reveal any evidence that R1 had any unexplained bruising or other marks and denied knowledge of any complaints regarding staff behaviors. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Executive Director Kristel Johnson, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Mar 9, 2026 · control 08-AS-20230511105627

Allegation investigated: Staff failed to supervise resident resulting in injury Insufficient staffing to meet resident care needs

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and 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 Virginia Rodriguez. During today’s visit, LPA observed residents in care, obtained copies of facility records, and interviewed staff. The Department’s investigation consisted of interviews with staff and outside sources, records review, and a tour of the facility. It was alleged that staff failed to supervise resident resulting in injury and insufficient staffing to meet resident care needs. Continued on LIC9099-C page... Unsubstantiated Review of Resident 1’s (R1’s) medical and care assessment records dated 2021 revealed that R1 had mild cognitive impairment, was confused and disoriented, and required assistance with bathing, grooming, dressing, toileting and multiple safety checks per shift. While assessment records noted that R1 was not a fall risk, review of progress notes for R1 in 2021 revealed that R1 had multiple falls a month, usually with no injuries. Each time R1 fell, staff would assess R1 for any pain or injuries. Review of progress notes for R1 in 2021 revealed that in July 2021, R1 was found on the floor in a common area by staff and was observed to have minor injuries to the head and leg, and R1 complained of pain. Staff called 911 and emergency personnel assessed and transported R1 to the hospital. The Department was unable to obtain copies of R1’s discharge paperwork resulting in the Department’s inability to determine the severity of R1’s injuries. R1’s progress notes showed a pattern of staff conducting regular safety checks on R1, as well as encouraging R1 to attend communal meals and activities. Review of progress notes for residents revealed that an outside source complained that one staff working in the facility’s memory care was not sufficient to supervise residents overnight. Review of regulations regarding overnight supervision requirements for facilities caring for up to 100 residents revealed that at least one awake staff member was required to be on site with another staff on call and available to respond within 10 minutes. The Department was unable to interview any relevant staff that were working in 2021 or obtain staff schedules in 2021 to determine the staffing level in the facility’s memory care in 2021. However, interviews with staff responsible for oversight of the memory care in 2022 through 2024 revealed that the memory care was staffed with a minimum of 3 care staff during the morning and afternoon shifts, and a minimum of 2 care staff during the overnight shift. Those staff also stated that if a caregiver called out for a shift, other caregivers would be contacted to cover the shift, or the Memory Care Director would provide direct resident care. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Executive Director Kristel Johnson, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Mar 9, 2026 · control 08-AS-20210713163713

Allegation investigated: Lack of supervision resulting in elopement and injury

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA Hurt met with Facility Business Office Manager, Virginia Rodriguez, and explained the purpose of today’s visit. Regarding the allegation of lack of supervision resulting in elopement and injury, the investigation determined that on 05/17/2025 at approximately 12:00 AM, resident 1 eloped from the facility and was found outside with injuries including a hematoma and a laceration. Facility staff intervened, and Resident 1 was transported to Tri-City Hospital for evaluation and treatment. Staff and administrative interviews confirmed that Resident 1 had wandered on multiple prior occasions (including an incident on 04/04/2025), and facility records show a care plan meeting was held on 05/14/2025 to discuss moving her to the Memory Care unit due to her exit-seeking behavior. Despite the identified need for a higher level of care, the resident was not relocated immediately, reportedly due to hesitation from her family. Investigators concluded that the resident clearly required more supervision than was being provided in Assisted Living and should have been moved to a secured Memory Care environment sooner to ensure her safety. Based on interviews conducted, and records reviewed the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. The following deficiencies are being cited (see LIC 9099D) from the California Code of Regulations, Title 22, and the California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on H&S Code section 1569.49(f). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted with Facility Business Office Manager, Virginia Rodriguez, and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Feb 22, 2026 · control 08-AS-20250519111234

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 23, 2026

87464 Basic Services (a) The services provided by the facility shall be conducted so as to continue and promote, to the extent possible, independence and self-direction for all persons accepted for care. Such persons shall be encouraged to participate as fully as their conditions permit in daily living activities both in the facility and in the community.(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). The following requirement has not been met as evidenced by: Based on interviews conducted Resident1 eloped from the facility resulting in injury, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2026

Plan of correction: Administrator will provide training to all staff on elopement prevention, including identifying residents at risk of elopement, supervision expectations, monitoring of exits, and appropriate respone when a resident attempts to leave the facility unsupervised. Training will also include reporting and documentation process, and submit to LPA by POC date of 02/23/2026.

Allegation investigated: Unlawful Eviction

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to open an investigation and deliver findings regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Executive Director Kristel Johnson. During today’s visit, LPA toured the facility, observed residents in care, reviewed and obtained copies of facility records, and interviewed residents and staff. LPA was away from the facility for approximately one hour between 12:15pm and 1:15pm. 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 unlawfully evicted Resident 1 (R1). Continued on LIC9099-C page... Unsubstantiated Interviews and reviews of R1’s financial ledgers revealed that in May 2025, R1 stopped submitting payments for basic services and care rates. Interviews and review of assessment records from April and May 2025 revealed that R1 was declining cognitively and was moved into the facility’s memory care in late May 2025. Review of email exchanges between R1’s responsible party and facility management starting in late July 2025 revealed that both parties were in communications regarding managing R1’s finances and bringing R1’s balance in good standing. On August 1, 2025, the facility hand delivered an eviction notice to R1 regarding failure to pay for fees issued between May 2025 and July 2025 and mailed and emailed a written copy to R1’s responsible party. After not receiving any payment prior to the eviction notice’s effective date of September 1, 2025, the facility filed for an unlawful detainer with the San Diego County Superior Court on September 4, 2025. Email communications between R1’s responsible party and facility management documented that R1’s responsible party was in the process of having R1’s long term care insurance cover R1’s future basic rate and care fees starting in May 2025. Emails showed that R1’s responsible party mailed multiple physical checks to the facility, however, issues with dates and not covering the full amount of R1's outstanding balance caused the checks to be unable to be cashed. The facility did not receive any other payments until mid-January 2026, when the facility received and cashed a check which almost covered R1’s existing balance at that time. Interviews and review of a Notice to Vacate revealed that R1 was issued a notice to vacate by the San Diego Sheriff and R1 would be physically evicted on January 22, 2026. Interviews revealed that R1's responsible party submitted payments to the facility in January 2026, which settled R1's outstanding balance. Interviews with facility management revealed that the eviction through the local Sheriff was cancelled during LPA’s visit, and LPA Borunda verified that R1 remained at the facility and had not been evicted as of the end of today’s visit. The Department has investigated the above-mentioned allegation and based on interview 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 Kristel Johnson, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 08-AS-20260116172340

Allegation investigated: Licensee did not maintain the facility at a comfortable temperature

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Kristel Johnson. During today's visit, LPA observed residents in care and interviewed staff. 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 maintain the facility at a comfortable temperature. Interviews with residents and staff revealed that sometime in late August 2025, there was an issue with the facility’s AC system. Interviews and review of work orders submitted between July and September 2025 revealed that multiple residents complained that apartment thermostats were not working, and that resident apartment temperatures were measuring up to 82 degrees Fahrenheit. Continued on LIC9099-C page... Unsubstantiated Interviews with residents and staff revealed that the facility offered portable AC units to residents, however, some residents claimed that they were not offered portable AC units, fans, or any other cooling devices despite residents wanting those devices. Interviews with staff provided conflicting information, stating that some residents complained that the portable AC units were too noisy and residents did not want to use them. Interviews with residents and LPA observations of thermostat readings in resident rooms did not reveal any evidence that the temperature in resident rooms rose above 85 degrees. Review of work orders and interviews with staff revealed that an outside vendor assessed the facility’s AC system in late July 2025 and determined that there was a leak in the AC system, which the vendor fixed. Interviews with staff and residents revealed that the issue with the AC system took approximately two weeks to fix. The Department has investigated the above-mentioned allegation and based on interviews and observations, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Executive Director Kristel Johnson, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Dec 8, 2025 · control 08-AS-20250904100142

Allegation investigated: Licensee did not assist resident with transportation

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Kristel Johnson. During today's visit, LPA observed residents in care and interviewed residents. The Department’s investigation consisted of interviews with residents and staff, records review, and a tour of the facility. It was alleged that the licensee did not assist Resident 1 (R1) with transportation. Interviews with staff and review of transportation documents revealed that the facility provided transportation services for medical appointments on Tuesdays and Thursdays, religious services on Sundays, and recreational outings on Mondays and Wednesdays. Residents were able to register for all types of outings using sign-up sheets located at the front desk. Continued on LIC9099-C page... Unsubstantiated Review of outing sign-up sheets for June and July 2025 showed that the facility offered transportation to multiple different religious services on Sundays. Outing sign-up sheets revealed that R1 signed up for transportation for almost every single recreational outing and religious services in June and July. Interviews with activities staff revealed that the facility owned three vehicles, a bus with a wheelchair lift, a van with a drive-up ramp, and a spare bus given to the facility from a different community. Interviews revealed that the facility’s two buses required repairs, one of which would not be repaired until 7/23/2025. The facility’s van also required smog testing on 7/22/2025 to renew its vehicle registration and facility staff feared that the van would not pass the smog testing. Due to these concerns, the facility had been borrowing a bus from a sister facility when that bus was not already in use by the sister facility. Interviews with staff revealed that R1 attended all outings and religious services that R1 signed up for except for a religious service on one occasion. Staff stated that R1 and another resident used electric wheelchairs and had both signed up for the same religious service, causing staff to question if the borrowed bus, which was the only available vehicle, could accommodate the size of both wheelchairs. Additionally, interviews with staff revealed that the borrowed bus had a physically smaller wheelchair lift with a lower weight capacity than the facility’s normal bus. Interviews revealed that R1 refused to provide facility management with information on the weight of R1’s wheelchair when asked by staff. Additionally, staff stated that due to the smaller size of the lift, R1’s wheelchair wheels would have hung off the edges of the lift, putting R1 in a very unsafe situation. Interviews did not reveal any other instances where R1 was not able to attend outings. 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 Kristel Johnson, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Dec 8, 2025 · control 08-AS-20250711083149

Allegation investigated: Licensee did not issue a refund

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Kristel Johnson. During today's visit, LPA interviewed Executive Director. The Department’s investigation consisted of interviews with staff and outside sources, records review, and a tour of the facility. The Department was unable to interview R1 due to R1’s death sometime in 2025. It was alleged that the Licensee did not issue a refund. Review of R1’s charting notes revealed that R1 moved into the facility on 1/31/2024 and moved out of the facility on 4/7/2024. R1’s financial ledger revealed that R1’s responsible party paid a community fee of $4,000 upon move-in. Continued on LIC9099-C page... Substantiated The facility’s admission agreement stated that individuals who moved out of the facility within 3 months of admission would be entitled to a 40 percent refund of the community fee, minus $500, which amounted to $1,400. Review of R1’s financial ledger and interviews with facility management revealed that a $1,400 refund was processed and refunded in June 2025, which exceeds the time frame set by regulation. The Department has investigated the above-mentioned allegation and based on interview and record review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. An exit interview was conducted with Executive Director Kristel Johnson, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22). Review of R1’s physician’s orders in January 2024 revealed that R1 had a medication order for Escitalopram and Amitriptyline which were both ordered on 1/18/2024 and discontinued on 1/31/2024. Review of R1’s needs and services plan and medical assessment dated January 2024 revealed that R1 was unable to administer prescription medication independently and was receiving medication management from facility staff. Review of the facility’s charting notes and faxes sent to R1’s physicians revealed that on 2/12/2024, the Resident Services Director (RSD) notified R1’s physicians via fax that R1 had not been taking Escitalopram and Amitriptyline since 1/30/2024 and requested physician advice on R1 restarting the medications at the previous dose and requested a written physician order for both medications. RSD received written medication orders for Escitalopram on 2/13/2024. RSD reached out to R1’s physicians daily regarding the Amitriptyline medication until the RSD received a written medication order for Amitriptyline on 2/16/2024. Interviews and review of R1’s medication administration record (MAR) revealed that R1 began receiving Escitalopram on 2/14/2024 and Amitriptyline on 2/16/2024. 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 Kristel Johnson, 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, Oct 30, 2025 · control 08-AS-20250613163403

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(5)(E)(3)(c) · Plan of correction due date: Nov 26, 2025

87507(g)(5)(E) Preadmission fees shall be refunded according to the following conditions:(3)... paid preadmission fees greater than five hundred dollars ($500) shall be refunded... as follows: (c) Refunds... shall be paid within 15 days of issuing the notice... This requirement has not been met as evidenced by: Based on interview and record review, the licensee did not ensure that R1 was issued a refund of their pre-admission fee within 15 days of notice. This poses a potential personal rights risk to R1.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: Licensee already issued $1,400 refund to R1 and their responsible party. Executive Director and Business Office Manager will receive training on refunds and provide proof of training to the Department by POC due date of 11/26/2025.

Allegation investigated: Licensee financially abused a resident Staff did not treat resident with dignity

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Kristel Johnson. The Department’s investigation consisted of interviews with residents, staff, and outside sources, review of facility records, and a tour of the facility. It was alleged that the Licensee financially abused a resident and staff did not treat resident with dignity. Interviews with multiple residents did not reveal issues or concerns with staff interactions and residents denied that staff interactions made residents feel rushed, disrespected, or that staff were rude. Residents stated that staff were polite and nice. However, interviews with Resident 1 (R1) expressed feelings of disrespect when interacting with staff. Interviews with residents and staff revealed that R1 had a tendency to video record interactions that R1 had with other residents and staff, resulting in those residents and staff feeling uncomfortable. Continued on LIC9099-C page... Unsubstantiated LPA observations during multiple on-site visits between January and May 2025 did not reveal any instances of staff interacting with residents, including R1, in an inappropriate, disrespectful, or rude manner. Interviews with R1, residents, staff, and LPA observations revealed that R1 could be difficult to interact with due to R1’s personality. During interviews, staff and residents expressed a desire to avoid interactions with R1 due to R1’s video recording behaviors and personality. Interviews and records review revealed that R1 was evicted from the facility in early October 2025 due to violating house rules regarding treating residents and staff with respect. Review of R1’s financial statements from November 2024 to October 2025 revealed that R1 had monthly reoccurring charges for basic room and board and R1 did not receive any care, resulting in R1 not being charged for any care. Review of R1’s admission agreement revealed that the facility would charge a late fee of $250 for any payments received after the fifth day of the month. Despite R1 submitting payment for basic room and board after the 5th of the month on multiple occasions, R1 was not charged a late fee. Additionally, multiple interviews with R1 did not disclose any concerns that R1 was charged for services that R1 did not receive or were not previously explained. The Department has investigated the above-mentioned allegations and based on interviews, record review, and observation, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Executive Director Kristel Johnson, 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, Oct 30, 2025 · control 08-AS-20250124110344

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to continue the annual started on 10/20/2025. LPA identified herself to and explained the purpose of the visit with Business Office Manager Nishimwe Valentin. Executive Director Kristel Johnson arrived during the visit. During today's visit, LPA observed residents in care, reviewed facility records, and toured the facility. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. No deficiencies were cited on today's date. An exit interview was conducted with Executive Director Kristel Johnson, 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, Oct 30, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Kristel Johnson. During today's visit, LPA observed residents in care and reviewed facility records. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. No deficiencies were cited on today's date. An exit interview was conducted with Executive Director Kristel Johnson, 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, Oct 20, 2025

Allegation investigated: Licensee did not provide resident with a refund

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Kristel Johnson. The Department’s investigation consisted of interviews with residents, staff, and outside sources and review of facility records. It was alleged that the facility did not provide Resident 1 (R1) with a refund. Review of R1’s financial ledger and interviews with staff, outside sources, and R1 revealed that on 5/1/2025, the facility received an electronic payment for R1’s basic services for May from R1’s bank account. Interviews also revealed that sometime in early May 2025, R1’s responsible party provided the facility with a physical check for R1’s basic services rate for May, which was supported by interviews with facility management. The physical check was entered into R1’s financial ledger logs on 5/6/2025. Continued on LIC9099-C page... Unsubstantiated Interviews with R1 and outside sources revealed that R1 and their responsible party had multiple discussions with facility management, including the Executive Director (ED) regarding refunding one of the payments. Review of email communication between facility staff and the facility corporate office revealed that on 5/6/2025, the Business Office Manager sent an email to the corporate billing office explaining the situation including that R1’s responsible party had requested a refund check, not a credit to their billing account, and that the facility was requesting a refund of one of the payments. Between 5/9/2025 and 5/16/2025, the ED sent multiple emails requesting follow-up on the refund request for R1 with no response from the corporate office. On 5/20/2025, the basic service rate for June 2025 posted in the facility’s electronic billing system, which automatically applied the overpayment for May 2025 to the June charges. Emails from the corporate office on 5/21/2025 stated that because the June charges had already been added to the billing system and R1’s financial ledger showed a balance of $0, the facility was unable to refund R1’s overpayment from May 2025. As of 6/2/2025, the facility has not issued R1 or their authorized representative a refund check for the overpayment for May 2025. Facility management did not deny during interviews that the facility received two payments for R1’s basic service rate for the month of May and that R1’s account showed an overpayment between 5/6/2025 and 5/20/2025. Review of R1’s admission agreement signed 3/27/2025 revealed that according to the facility’s refund policy regarding unused portions of the monthly fee, any extra money would be refunded within 30 days of the termination of the agreement upon relocation from the facility or resident death. However, R1’s agreement was still valid as of 6/2/2025, since R1 had not relocated from the facility or had died. Review of regulations did not reveal any regulations that would require the facility to issue a refund check instead of applying the overpayment to future billing charges. 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 Kristel Johnson, 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, Jun 2, 2025 · control 08-AS-20250512112409

Allegation investigated: Staff did not allow resident to choose to participate in activities

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Kristel Johnson. During today's visit, LPA toured the facility, observed residents in care, and interviewed residents and staff. 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 staff did not allow resident to choose to participate in activities, specifically that Resident 1 (R1) was not allowed to choose which activity to attend. Interviews with staff revealed that R1 was forgetful and required reminders to attend activities. Interviews with staff and outside souces revealed that sometime in April 2025, R1 was attending a movie activity in the facility's theater. Continued on LIC9099-C page... Unsubstantiated Another resident, Resident 2 (R2) told R1 that R1 would miss a different activity that occurred at approximately the same time and attempted to make R1 leave the movie activity. This interaction with R2 caused R1 to become confused and agitated. The Activity Director (AD) was able to calm R1 down and asked R2 to allow R1 to make their own decisions regarding which activity to attend. Staff stated during interviews that AD provides R1 with reminders on which activities are happening around the facility and R1 would choose which activity to attend. On that occasion, R1 attended half of the movie activity and attended the other activity afterward. Interviews with R1 did not reveal any relevant information regarding R1's participation in activities due to R1's cognitive state, which was supported by R1's assessment records dated October 2024 and interviews with staff. Interviews with other residents did not reveal any information that supported the allegation. Interviews with the AD revealed that they held monthly meetings for residents to make activity suggestions and was in regular communication with the members of the resident council regarding activities. 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 Resident Services Director Loida Baskins, 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, Jun 2, 2025 · control 08-AS-20250404152940

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to conduct follow up regarding an incident report. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Kristel Johnson. On 5/21/2025, the Department received an incident report from the facility that described that on 5/6/2025, Resident 1 (R1) was found unresponsive in their room by facility staff. Staff called 911 and performed CPR until emergency personnel arrived. Emergency personnel contacted a physician via telephone. R1 was pronounced dead by the physician over the phone. Law enforcement also responded to the facility in regards to the death. During today’s visit, LPA observed residents in care, and reviewed and obtained copies of facility records. LPA Borunda requested a copy of R1's death certificate when it became available from Executive Director. Additional investigation may be needed following review of R1's death certificate. No deficiencies were cited on today’s date. An exit interview was conducted with Executive Director Kristel Johnson, 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, May 22, 2025

Allegation investigated: Staff did not ensure that residents rooms were kept clean Staff did not ensure that residents rooms were kept free from odors

Licensing Program Analyst (LPA) Rebecca Borunda 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 Executive Director Kristel Johnson. 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 staff did not ensure that residents rooms were kept clean and that staff did not ensure that residents rooms were kept free from odors. Interviews with residents and staff and review of the admission agreement revealed that the facility provided weekly housekeeping services which included vacuuming, dusting, cleaning the bathroom, changing linens, and disposing of trash. Continued on LIC9099-C page... Substantiated Interviews with residents, including Resident 1 (R1) and facility management revealed that in April and May of 2024, the facility experienced a shortage of housekeeping staff resulting in housekeeping services being missed, with at least one resident experiencing two weeks between services. [Executive Director was provided with an LIC811 Confidential Names List to identify R1] According to residents, the facility did not provide any written or verbal communication regarding the housekeeping staff shortage. Interviews with the facility management confirmed that there was difficulty with hiring and maintaining housekeeping staff and during the months of April and May of 2024, the facility only had one full time housekeeper and the housekeeping supervisor was on restricted work duty. Those interviews with facility management also stated that maintenance staff were assisting housekeepers to clean resident rooms, which residents confirmed during interviews. Interviews with housekeeping staff revealed that when fully staffed, two housekeepers were assigned to split the facility’s four two-story buildings in assisted living, and one housekeeper was assigned to the memory care building. Staff estimated that a common daily workload was to clean approximately 5 to 10 resident rooms a day, which included: sweeping, mopping, vacuuming, dusting, taking out the trash, and general cleaning of the apartment’s living area, bathroom, and kitchenette. While housekeepers denied any difficulties with meeting the workload, all housekeepers interviewed by the Department were hired after April 2024 and the alleged timeline of the allegations. Residents stated in interviews that during April and May 2024, the housekeeping services that were provided often did not include all promised tasks, or the service was rushed. Interviews with R1 and housekeeping staff revealed that R1’s room would frequently contain items on the floor such as food wrappers, crumbs, and other clutter. Interviews with R1 and staff revealed that R1 used incontinence briefs and disposed of them in the trash in R1’s bathroom. Additionally, R1, housekeeping staff, and outside sources confirmed that during April and May 2024, soiled incontinence briefs caused R1’s room to smell strongly of urine. Review of the admissions agreement revealed that the facility also offered additional housekeeping services for a fee, and review of R1’s admission agreement addendum signed in 2019 revealed that R1 agreed to pay for an additional day of housekeeping services, totaling two housekeeping services a week. The Department has investigated the above-mentioned allegations and based on interviews, the preponderance of the evidence has been met, therefore, these allegations are deemed substantiated and noted on the attached LIC9099-D page. An exit interview was conducted with Executive Director Kristel Johnson, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 08-AS-20240424134234

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 28, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers... as necessary to perform... house cleaning... This requirement has not been met as evidenced by: Based on interviews, the licensee did not comply with the section cited above in that there were not enough housekeeping staff employed to provide weekly housekeeping services per the admission agreement. This poses a potential personal rights risk to 110 of 110 residents in care.the state’s words, verbatim · CDSS document, Feb 27, 2025

Plan of correction: Executive Director stated that the facility is currently fully staffed for housekeeping staff. Executive Director stated that she will provide an inservice training for housekeeping staff on proper cleaning procedures and speak to the housekeeping supervisor. Executive Director will provide a copy of the staff sign in sheets for the inservice training to the Department by POC due date of 3/28/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Mar 28, 2025

87625 Managed Incontinence (b) ... the licensee shall be responsible for the following: (3) Ensuring that... the facility remains free from odors from incontinence. This requirement has not been met as evidenced by: Based on interviews, the licensee did not comply with the section cited above in that resident apartments smelled of urine due to soiled incontience briefs. This poses a potential personal rights risk to 110 of 110 residents in care.the state’s words, verbatim · CDSS document, Feb 27, 2025

Plan of correction: Executive Director will speak with R1 to adjust standby assistance days to increase R1's trash disposal to 4 times a week. Executive Director will be providing inservice training for caregivers to check and dispose of trash during any care services. Executive Director will provide sign in sheet for inservice training to Department by POC due date of 3/28/2025.

Type of visit: Case Management - Licensee Initiated

Licensing Program Analyst (LPA) Rebecca Borunda conducted an announced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Kristel Johnson. During today's visit, LPA provided Executive Director Kristel Johnson with guidance and consultation regarding facility documentation, reporting requirements, staffing, and eviction procedures. No deficiencies were cited on today’s date. An exit interview was conducted with Executive Director Kristel Johnson, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Feb 25, 2025

Allegation investigated: Staff did not provided food of good quality

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced complaint investigation visit. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Kristel Johnson. Throughout the investigation, the Department secured records and conducted interviews with several sources including staff and residents. It was alleged staff did not provide food of good quality. On 02/28/2024, it was reported to the Department the food served at the facility was cold, over cooked, or under cooked. Interviews with several sources, including staff and residents, confirmed there were occasions when the food was cold, over seasoned, under cooked. or overcooked, making the food inedible. Sources consistently described the food as not fresh, including vegetables, tough to cut with a fork and knife, and not of good quality. One source recalled an instance when food was delivered to the memory care unit and the food was overcooked, therefore, it could not be served to the residents. Substantiated An additional source revealed the food not being of quality was an ongoing issue. This was mentioned to management on several occasions, but the concern persisted. Although there were interviews with several sources that did not disclose any concerns with the quality of food, there was enough evidence to substantiate the allegation. This deficiency was cited in an LIC 9099D form and a plan of correction was jointly formulated with Executive Director Johnson. An exit interview was conducted with Kristel Johnson, to whom a copy of this report, LIC 9099D, and Licensee/Appeals Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 08-AS-20240220215636

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Feb 20, 2025

87555 General Food Service Requirements (b) (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure the food provided to residents was of good quality, which posed a potential health, safety, and personal rights risk to all residents in care.the state’s words, verbatim · CDSS document, Feb 20, 2025

Plan of correction: Executive Director agreed to train dining staff on quality of food and submit proof to the LPA by 3/20/2025. ED agreed to discuss food concern with residents during town hall meeting on 2/26/2025.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to conduct follow up regarding an incident report. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Jackie Banks. On 11/5/2024, the Department received an incident report from the facility which described that on 11/1/2024 at approximately 4:45am, Resident 1 (R1) was discovered by facility staff outside in the internal courtyard and had sustained multiple injuries. [Executive Director was provided with an LIC811 Confidential Names List to identify R1] Staff assessed R1 and brought R1 back inside and staff called 911 after R1 was observed to be confused and disoriented. R1 was transported to the hospital where R1 received treatment for the injuries and returned to the facility the same day. During today’s visit, LPA conducted a health and safety check, observed residents in care, including R1, and reviewed and obtained copies of facility records. No deficiencies were cited on today’s date. An exit interview was conducted with Executive Director Jackie Banks, whose signature below confirms receipt of a copy of this report, the LIC811 and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Nov 14, 2024

Allegation investigated: Questionable death Staff did not administer medications as prescribed

Licensing Program Analysts (LPAs) Rebecca Ruiz and Hannah Rodgers conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above mentioned allegations. LPAs were greeted by, identified themselves to, and explained the purpose of the visit and the basic elements of the complaint with Business Office Manager Virgina Rodriguez. During today’s visit, LPAs reviewed and obtained copies of facility records. The Department’s investigation consisted of interviews with staff and outside sources, records review, and a tour of the facility. It was alleged that Resident 1’s (R1’s) death was questionable and that staff did not administer medications as prescribed. Continued on LIC9099-C page... Unsubstantiated Review of R1’s physician report dated January 2024 and pre-appraisal assessment records dated 1/27/2024 revealed that R1 did not have any memory impairment, had a diagnosis of heart disease, was confused, but able to follow directions and communicate needs, was not able to administer or store own medications and was not receiving hospice services. Review of facility progress notes for R1 revealed that in early February 2024, R1 was observed by facility staff to have a change in condition and was experiencing increasing confusion. R1 was transported to the hospital where R1 received medication and treatment for a urinary tract infection. On 2/21/2024, R1 expressed feeling drowsy to facility staff and staff notified R1’s spouse. R1’s spouse spoke to R1’s primary physician who requested that R1 be sent to the hospital. Facility staff called 911 and R1 was assessed to be lethargic and non-responsive by paramedics. Paramedics administered a Narcan injection and transported R1 to the hospital, where R1 was admitted and treated for a urinary tract infection. At the hospital, R1 tested positive for narcotics during urine analysis testing. R1 was discharged back to the facility on 2/23/2024 and was readmitted to the hospital on 2/24/2024 after displaying stroke-like symptoms. R1 was moved out of the facility on 2/27/2024 and review of R1’s death certificate revealed that R1 passed away on 3/5/2024 with the cause of death listed as cerebral atherosclerosis and unspecified heart failure. Additionally, R1’s death certificate did not list the presence of narcotics in R1’s urine, the Narcan administration on 2/21/2024, or any other conditions as having contributed to R1’s death. Review of R1’s medication record dated 2/29/2024 and interviews with facility staff revealed that R1 was not prescribed any narcotic medications and staff denied administering narcotic medications to R1. Interviews with facility staff revealed that all narcotic medications are stored in a locked cabinet in the medication room and are counted at the beginning of each shift by medication technicians. Interviews with staff and R1’s progress notes stated that R1’s spouse notified facility staff on 2/21/2024 that R1 had tested positive for narcotics and the Resident Care Director and medication technicians on shift conducted an additional narcotic medication count that day and did not discover any inconsistencies. Review of narcotic count records for February 2024 did not reveal any inconsistencies with narcotic medication counts for residents at the facility. Continued on LIC9099-C page... Interviews with an outside medical professional revealed that the administration of Narcan could cause a false positive on a drug screening. Additionally, the outside medical professional stated that the administration of Narcan and the potentially false positive narcotic result were not a direct cause of death for R1. Interviews with staff and outside sources and review of records did not reveal how R1 could have taken the narcotics. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Business Office Manager Virginia Rodriguez, 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, Sep 16, 2024 · control 08-AS-20240314090813

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Case Management - Annual Continuation visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Resident Care Director Kristel Johnson. Executive Director Jackie Banks arrived during the visit. LPA was away from the facility for approximately one hour between 12:15pm and 1:15pm. The facility is licensed for a maximum capacity of 165 non-ambulatory residents, 6 of which may be bedridden in identified rooms. The facility has a waiver for 15 hospice residents. During today’s visit, the facility had a census of 103 residents. The Administrator for the facility is Jackie Banks and their certificate was valid and current. During visits on 8/15/2024 and 8/26/2024, LPA toured the facility and inspected a random sampling of resident rooms, private and common bathrooms for resident and staff use, kitchen, common areas, and outside space. No bodies of water were observed on the premises. LPA observed delay egress in the facility's memory care which is approved by the facility's fire clearance. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 105.7, 108.0, 109.9, 114.6 and 115.3 degrees Fahrenheit in a random sampling of resident bathrooms. The facility’s internal temperature was measured at 73 and 74 degrees Fahrenheit in different parts of the facility. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Jackie Banks, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. Continued on LIC809-C page… LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 37 degrees Fahrenheit, and the facility freezer was kept at -7 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property, and personal rights. LPA spoke with staff and residents present at the facility during the time of the inspection. The Executive Director will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days. No deficiencies were cited on today’s date. An exit interview was conducted with Executive Director Jackie Banks, 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, Aug 26, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Jackie Banks. During today's visit, LPA reviewed facility records and observed residents in care. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. LPA was away from the facility for approximately one hour between 12:15pm and 1:15pm. No deficiencies were cited during today's visit. An exit interview was conducted with Executive Director Jackie Banks, 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, Aug 15, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Sales Director Jiovanni Anderson-Diaz and Business Office Manager Fina Tuisee. LPA also spoke via phone with Executive Director Jackie Banks during the visit. Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 11/15/2023), involving Resident #1 (R1) and Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying they were safe. LPA reviewed and collected copies of pertinent care and administrative/personnel records. LPA also interviewed R1 and relevant staff. According to R1’s latest LIC602 Physician’s Report (dated 01/18/2022): R1 was diagnosed with Dementia and relied on staff for help with personal care tasks, to include dressing and incontinence care. R1’s physician wrote that while R1 was confused/disoriented, they were still able to communicate their needs. During interview of R1, LPA observed: R1 could not recall the incident due to their baseline memory loss. However, R1 demonstrated the ability to converse. R1 made good eye contact, used appropriate social graces, quickly understood what was said to them, and quickly constructed full, coherent sentences in their replies to LPA. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] According to records and staff interviews: Sometime around September 2023, S1 used their cell phone to film a video of themselves, S2 and S3, while the three staff were with R1 inside R1’s bedroom. The video, which was around four to five minutes long, depicted S2 providing incontinence care to R1. R1 was seen in the video to lay in bed bottomless (i.e., without pants or depends on). While S2 performed care on R1, S3 said multiple profanities, including a racial slur, towards S2. While these comments were not directed at R1 per se, R1 was in immediate ear shot and the racial slur S2 used coincided with R1’s actual race/ethnicity. On 11/11/2023, facility management received constructive knowledge regarding the existence of an inappropriate video, and obtained the footage the same day. S1, S2, and S3 were immediately suspended pending internal investigation. The incident was timely reported to CCLD, the San Diego Long-Term Care Ombudsman, and local police. While S3 denied knowledge of the video, S1 did acknowledge the video’s existence. S2 also acknowledged its existence, and further confirmed that the video accurately depicted what the three staff did in the room on the date in question. Personnel records showed: Licensee terminated the employment of S1, S2, and S3 based on the investigation findings, and on 11/12/2023 retrained its remaining staff on topics related to Resident’s Personal Rights. A preponderance of evidence exists to show that during the above incident, the actions and/or inaction of licensee’s staff undermined R1’s personal rights to both dignity and privacy. Also, per records review, and corroborated by manager interview: Licensee did not possess an updated LIC602 Physician’s Report (or equivalent medical assessment) completed within the last twelve (12) months for R1, which is a requirement for any resident diagnosed with Dementia. Three (3) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plans of Correction were jointly developed with the licensee. An exit interview was conducted with Tuisee, to whom a copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Dec 8, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Dec 9, 2023

87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff...” This requirement was not met, as evidenced by: Based on records and interviews, during the incident, licensee’s staff (S1, S2, and S3) did not accord 1 of 112 residents (R1) dignity, which posed an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 8, 2023

Plan of correction: Manger interviews, corroborated by personnel records, showed: Licensee suspended S1, S2, and S3 on 11/11/2023, then administratively terminated their respective employments on 11/20/2023. On 11/12/2023, Licensee retrained its remaining staff on topics related to Resident’s Personal Rights. These actions resolve the deficiency.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.2(a)(1) · Plan of correction due date: Dec 9, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in…personal care and assistance…” This requirement was not met, as evidenced by: Based on records and interviews, during the incident, licensee’s staff (S1, S2, and S3) did not uphold the personal privacy of 1 of 112 residents (R1), which posed an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 8, 2023

Plan of correction: Manger interviews, corroborated by personnel records, showed: Licensee suspended S1, S2, and S3 on 11/11/2023, then administratively terminated their respective employments on 11/20/2023. On 11/12/2023, Licensee retrained its remaining staff on topics related to Resident’s Personal Rights. These actions resolve the deficiency.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Jan 7, 2024

87705 Care of Persons with Dementia: “(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.” This requirement was not met, as evidenced by: Based on records and interviews, licensee did not ensure that 1 of 112 residents (R1), who was diagnosed with dementia, had a medical assessment performed within the last year, which posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 8, 2023

Plan of correction: Licensee agreed to coordinate with R1’s responsible person and physician, as needed, to obtain an updated LIC602 Physician’s Report for R1. Licensee agreed to E-mail a copy of R1’s updated LIC602 to LPA, by the POC due date.