Sunview Gardens 2

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Required Annual Inspection. LPA identified himself and discussed the purpose of the visit with Administrator Felicity Arcangeli. The facility is licensed for a capacity of fifteen (15), of which twelve (12) could be bedridden. The facility was also approved for a hospice waiver for five (5) residents. LPA, accompanied by Administrator toured the interior and exterior of the facility, and inspected every resident's room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. Hot water temperature was measured in the facility at 113 degrees F. The ambient temperature inside the facility was measured at 73 degrees F. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. Their are no bodies of water on the premises. Per Administrator, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C] LPA reviewed multiple staff and resident records/files. LPA file review did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Administrator Felicity Arcangeli whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, May 26, 2026

Allegation investigated: Licensee’s staff injured resident.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Lead Caregiver Michelle Rodriguez. LPA also met briefly with Licensee/Administrator Felicity Arcangeli, who arrived later during the visit. The Complainant alleged that Licensee’s staff injured Resident #1 (R1). [See LIC811 Confidential Names List for a description of person identifiers used in this report.] CCLD’s investigation involved an unannounced facility tour/welfare check and interviews of relevant facility staff and outside sources. The Department also reviewed pertinent photographic evidence and hospice agency care records on R1. [CONTINUED ON LIC 9099-C, 1 of 2] Unsubstantiated [CONTINUED FROM LIC 9099] The Complainant claimed that around 02/17/2021, R1 sustained a large skin tear on their right leg and two smaller skin tears on their left leg, and that around 03/04/2021, R1 sustained a small skin tear on their face/cheek and abrasions on their lips. The Complainant said that R1 appeared distrustful of facility staff, who the Complainant suspected caused R1’s injuries. Hospice care records showed: Around the time R1 moved into Sunview Gardens 2 in December 2021, R1 was diagnosed with “cerebral infarction [aka ‘stroke’]” and “dementia with behavioral disturbance,” was “forgetful, disoriented, and agitated,” experienced pain during movement/repositioning, was restless, and had sundowning confusion. R1’s skin, which had baseline “poor turgor,” was susceptible to “bruising” and damage from bedsheet “friction and shear.” R1’s hospital bed also had bedrails on it. R1’s intermittent agitation, restlessness, and combativeness persisted throughout the next few months. Medication was not always effective at calming R1. Sometimes R1 would spit out their medication. During late January 2021, R1 received Abreva for treatment of a cold sore on their lip. On 02/17/2021, a hospice Registered Nurse (RN) conducted a follow-up visit to address a skin tear on R1’s right leg and bruising to both legs, which occurred “during a period of increased anxiety and agitation.” Facility staff cleaned and dressed R1’s skin tear prior to the RN’s arrival. During said visit, the RN was unable to assess R1 further due to “[patient] agitation.” The RN wrote that R1 had a mild fever with “foul smelling urine,” which were indicative of a Urinary Tract Infection (UTI). That same day, R1’s hospice physician ordered a 7-day course of antibiotics for R1 and increased the allowed dosage of their as-needed antipsychotic medication, used to treat “uncontrolled anxiety.” Subsequent hospice notes tracked the healing of R1’s legs and mentioned R1 “has [had] multiple infections of the eye, lip, and UTI,” and that R1 remained “prone to severe bruising and closed skin tears to lower legs due to self injury during agitation.” During a 03/02/2021 visit, a hospice Licensed Vocational Nurse (LVN) tried unsuccessfully to perform a dressing change on R1’s right calf. R1 “began to kick and sink nails into any skin [they] could reach.” A hospice RN visited R1 on 03/03/2021, upon arrival finding R1 in bed with both of their legs “over side of bed.” They wrote R1 was alert but “confused” and “paranoid,” speaking in a “non-sensical” manner and intermittently crying. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] R1’s hospice doctor made multiple adjustments to R1’s medication regimen and subsequent visits from hospice nurses were increased from once per week to five (5) times per week. During 03/04/2021 visit, a hospice RN wrote that R1 had a “new open mark” on their right facial cheek; it was an “approximately 2 cm X 1 cm oblong circle.” R1 also had redness/abrasion on their upper and lower lips. The nurse documented that during this visit, R1 was “lying in bed smiling” upon their arrival, was “talkative, alert, and oriented to self,” speaking about their family, denying pain, and agreeable to consuming yogurt and medications. The RN wrote that facility staff could not specify how R1 sustained their cheek injury, but also that R1 was awake and yelling during the preceding night, per staff. LPA was unable to interview R1 for this case, due to R1 having moved out by the date the complaint was received, and due to R1 having passed away shortly thereafter. Yet nothing in the hospice records ever showed R1 claiming someone at the facility had physically abused them or caused the injuries in question. LPA interviewed multiple outside sources and 2 of 2 managers and 10 of 11 caregivers who worked at the facility during the complaint timeframe. (One caregiver had since left employment and could not be reached for interview). The interviews did not corroborate facility staff physically abusing R1 or being too rough in their handling of R1. On the contrary, multiple staff interviews showed that R1 had on occasion scratched themselves and/or hit their own arms/legs into their hospital bed’s railing (requiring staff to add padding). Based on records and interviews, a preponderance of evidence does not exist to show that Licensee’s staff injured resident. The allegation is therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Lead Caregiver Michelle Rodriguez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. An electronic set of these same documents was E-mailed to Licensee/Administrator Felicity Arcangeli.the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 08-AS-20210310131222

Allegation investigated: -Licensee did not assist resident(s) with eating. -Licensee did not give medications as prescribed. -Licensee did not meet resident’s hygiene needs.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Lead Caregiver Michelle Rodriguez. LPA also met briefly with Licensee/Administrator Felicity Arcangeli, who arrived later during the visit. The Complainant alleged that Licensee did not assist Resident #1 (R1) and Resident #2 (R2) with eating, that Licensee did not give R1 and R2 medications as prescribed, and that Licensee did not meet R2’s hygiene needs. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] CCLD’s investigation involved an unannounced facility tour/welfare check and interviews of relevant facility staff and outside sources. The Department also reviewed pertinent hospice agency care records on both R1 and R2. [CONTINUED ON LIC 9099-C, 1 of 2] Unsubstantiated [CONTINUED FROM LIC 9099] The Complainant claimed that R1 and R2 each lost significant body weight during the approximate three (3) months that these residents lived at the facility, and that facility staff either claimed the residents refused to eat or did not wake the residents up to eat. However, according to regulations, assistance with eating does involve forcing a resident to eat/drink when they are not in the mood. When R1 moved into the facility in mid-December 2020, their admitting diagnosis was “senile degeneration of the brain.” R1’s hospice nursing assessment said they displayed “clinical evidence of advancing illness” and an “inability to maintain sufficient fluid and caloric intake,” with R1 typically eating only “50-75% of meals.” Over the successive months, visiting hospice nurses noted R1 was generally unhappy about living at a facility (instead of their own home), was sometimes agitated, was increasingly lethargic, and declined many meals offered to them by facility staff. By 03/08/2021, a hospice nurse wrote R1’s nutrition was “very poor” and that R1 “rarely [ate] more than 1/3 of any food offered.” R1 moved out to another care facility on 03/15/2021; yet even in this new setting, R1’s appetite did not improve. When R2 moved into the facility in mid-December 2020, R2’s terminal diagnosis was “cerebral infarction [aka “stroke”] due to embolism of unspecified cerebral artery.” Their hospice nursing assessment at that time showed R2 was oriented only to themselves, showed fluctuating level of consciousness with periods of “significant lethargy,” was “forgetful and confused,” and their baseline oral intake was “sips and bites.” It also showed R2 “rarely [ate] a complete meal,” that they “generally [ate] only about 1/2 of any food offered,” that they had “inability to maintain hydration and caloric intake,” and that “dysphagia prevents [R2] from receiving enough food/fluid.” Successive hospice visit notes showed R2’s eating skill showed some improvement starting 12/29/2020, but R2’s appetite was still inconsistent; some days R2 refused to eat and spat out their medicines. R2 moved out to another care facility on 03/15/2021; yet even in this new setting, R2’s appetite did not significantly improve. The Complainant said there was a dramatic decline in R1 and R2’s respective level of alertness and physical functioning during their time living at the facility. However, the Complainant later conceded that they believed facility staff gave R1 and R2 their medications according to how they were prescribed. Hospice care records for R1 or R2 did not suggest a pattern of facility staff deviating from the physician’s medication orders. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] Per hospice records, R2 did have a rash in their peri area that was observed during their first week at the facility, but R2 had also recently arrived to the facility following a long inpatient stay at a hospital. Nystatin powder was applied to the rash, which successfully resolved the issue. The rash did not return for the remainder of R2’s residency at the facility. The Complainant told LPA they first observed R2’s teeth being “dirty” on 03/21/2021, but this date was also nearly a week after R2 had moved out of Sunview Gardens 2 (to their next care facility). Per hospice records, that agency’s Home Health Aide consistently visited the facility twice per week to bathe R1 and R2; there was no pattern of missed bed baths detectable to CCLD. LPA was unable to interview R1 and R2 for this case, due to both residents having passed away by the date CCLD received the complaint. However, LPA interviewed multiple outside sources and 2 of 2 manager and 10 of 11 caregivers who worked at the facility during the complaint timeframe. (One caregiver had since left employment and could not be reached for interview). The interviews did not support violations relating to the allegations; on the contrary, they tended to show staff provided necessary assistance to R1 and R2 with regard to eating/feeding, correct medications, and personal hygiene. Based on records and interviews, a preponderance of evidence does not exist to show that Licensee did not assist resident(s) with eating, that Licensee did not give medications as prescribed, or that Licensee did not meet resident’s hygiene needs. These three (3) allegations are therefore Unsubstantiated, and no deficiencies were cited for them. An exit interview was conducted with Lead Caregiver Michelle Rodriguez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. An electronic set of these same documents was E-mailed to Licensee/Administrator Felicity Arcangeli.the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 08-AS-20210419154608

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Michelle Rodriguez. Administrator Felicity Arcangeli arrived during the visit and assisted the LPA. The facility was licensed for a capacity of fifteen (15), of which twelve (12) could be bedridden. The facility was also approved for a hospice waiver for five (5) residents. The LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled and stored in locked areas. No pools or bodies of water on the premises. Per staff, no firearms or ammunition are kept at the facility. Smoke detectors detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and reviewed multiple staff and client records/files. No deficiencies were cited during today's annual inspection. An exit interview was conducted with Administrator Arcangeli,, to whom a copy of this report and, the Licensee/Appeal Rights (LIC9058) were provided.the state’s words, verbatim · CDSS document, May 17, 2024