Delta at the Sherwoods

Allegation investigated: Staff do not ensure facility is free of insects

On 9-17-2026 at 12:25pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate the allegation noted above. LPA met with staff1 (S1) and explained the purpose of the visit. Administrator Tammy Islam arrived at 1:00pm and met with LPA. LPA requested copies of pest control service for previous three months, housekeeping schedule for September 2026, staffing roster, resident roster, and conducted a facility observation. LPA also conducted interviews with three residents in care, and six staff members. Allegation: Staff do not ensure facility is free of insects. LPA conducted interviews, record reviews, and observation as noted above. Based on record reviews, it was revealed that facility has consistently maintained pest control services designed to ensure facility is free of infestation of insects. Housekeeping sechedule reviewed revealed indication of regular cleaning peformed by staff. Additionally, facility observation on 9-17-2026 did not reveal a presence of or evidence of insect infestation including bed bugs within facility. LPA did observe spider webs outside of facility containing trapped insects, which were later removed during LPA's visit by a staff member. {Cont. on 9099C} Unsubstantiated Interviews conducted did not reveal any corroborated statements or evidence to conclude insect infestation. As a result, there is not a preponderance of evidence to conclude facility experienced an insect infestation or fail to perform actions necessary to help ensure facility is free of insects, therefore, this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator and a copy of this report was provided, and reviewed by vice president and chief operations officer Madison Fetyko. Appeal Rights and LIC 811 provided.the state’s words, verbatim · CDSS document, Sep 17, 2026 · control 27-AS-20260914120552

Type of visit: Case Management - Legal/Non-compliance

On 8-6-2026 at 10:15am, Licensing Program Analyst (LPA) Michael Bilger and Licensing Program Manager (LPM) Liza King arrived unannounced to conduct a quarterly inspection visit. LPA and LPM met with Interim Administrator Farina Khan and explained the purpose of the visit. During todays unannounced quarterly inspection the following were reviewed: A. Respondents shall operate the facilities in substantial compliance with the regulations and statutes governing the operations of adult residential facilities and residential care facilities for the elderly. B. During the period of probation, the Department, in its sole discretion, may conduct unannounced site visits for the purpose of determining whether there is compliance with the regulations and statutes governing the operation of adult residential facilities and residential care facilities for the elderly. C. Respondents, and each of them, shall ensure that all individuals working, residing or volunteering in the facility shall, to the extent required by law, obtain criminal record clearances or exemptions prior to their initial presence in the facility and shall maintain proof of such criminal record clearances or exemptions at the facility. VERIFIED by review of staff present today and guardian roster. Staffing schedules reviewed were dated 7/26/2026 to 8/1/2026 and 8/6/2026. D. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period VERIFIED by observation E. Respondents are required to maintain accurate, complete and current client rosters which must be made available to the Department upon request. VERIFIED by record review F. Within thirty (30) days of the effective date of this Stipulation, Respondents shall submit to their respective licensing offices written summaries of their hiring and training practices, including job descriptions for each position at the facility. COMPLETED {Cont. on 809C} G. Respondents shall report to their respective Licensing offices the following: any unusual incident including, but not limited to, client death or injury which requires medical treatment, any allegations of or suspected physical or psychological abuse of any client, any physical plant changes and all unexplained absences, pursuant to applicable statutes and regulations. VERIFIED by record review. Additional documentation for resident1 (R1) and R2 via email to be provided by end of day. H. Respondents shall maintain current personnel records of each employee pursuant to California Code of Regulations, Title 22 Regulation sections 80066, 85066, and 87412 VERIFIED through review of ten staff files and interview with vice president and chief operations officer Madison Fetyko. Personnel training records were provided by Madison Fetyko. I. Respondents shall ensure that medications and any other toxic products are properly stored and kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication pursuant to California Code of Regulations, Title 22 Regulation section 80075, 85075, and 87465, as applicable. Respondents will ensure that medications are properly and timely disposed of according to the applicable regulations VERIFIED by means of facility tour J. Respondents shall ensure that each facility is clean, safe, sanitary and in good repair at all times. VERIFIED by means of facility tour K. Respondents shall provide quarterly training to all facility staff on applicable Title 22 regulations including mental health assessments, client behaviors, observation of the clients/residents, medication protocols, the Department's inspection authority, personal rights, notice requirements, reporting requirements, transfer trauma and care and supervision, generally. Respondents shall keep a record of staff who attend such training and make such records available to Licensing staff upon request. VERIFIED by review of staff training from May 2026 to July 2026 which including training topics of care and supervision. During the past quarter, staff were provided training on care and supervision. L. Vice President and Chief Operations Officer is in process of securing additional information requested to confirm eligibility of prospective new administrator with documents to be sent to Regional Office by 8-7-2026. As a result of today's visit, no citation is issued. An exit interview was conducted with interim administrator and a copy of this report was provided. A copy of this report was further read and verified by vice president and chief operations officer.the state’s words, verbatim · CDSS document, Aug 6, 2026

Allegation investigated: Staff do not provide residents with clean and safe enviroments

On 7-29-2026, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate the allegations noted above. LPA met with Administrator Farina Khan and explained the purpose of the visit. During this investigation, LPA conducted observation of the facility including common areas, various residents rooms, kitchen and storage areas, laundry area and outside of the facility. Additionally, LPA conducted interviews with five staff members and three residents in care. Allegation: Staff do not provide residents with clean and safe environment. LPA conducted observation and interviews as noted above. Based on observation, it was revealed that facility is currently maintaining a clean and safe environment. LPA did not observe prominent stains on floors and walls. An observation of kitchen area did not reveal dirty food storage areas or expired, or soiled food. Additoinally, LPA observed laundry area to contain clean linens with laundry items separated appropriately. {Cont. on 9099C} Unsubstantiated Additionally, interviews conducted did not reveal any corroborated statements of facility not maintaining a clean and safe environment. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted an a copy of this report was provided. A finding of unfouded means the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 29, 2026 · control 27-AS-20260720091048

Allegation investigated: Staff has inappropriate interactions with resident

On 7-17-2026 at 2:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss findings for the allegation noted above. LPA met with acting administrator Farina Khan and explained the purpose of the visit. During this investigation, LPA conducted interviews with five staff members and four residents. Additionally, LPA reviewed facility file documentation including needs and services plan and physician’s report pertaining to resident1 (R1), as well as staff file record for staff1 (S1). Allegation: Staff has inappropriate interactions with resident. LPA conducted interviews and record reviews as noted above. Based on the evidence reviewed, it was revealed that R1 previously resided at facility while S1 was employed as the Administrator, and S1 had regular contact with R1 as part of S1's regular job related duties. It was further revealed that after R1 transferred to another facility, R1 continued to receive visits by S1 who was aware of and consented to the visit. {Cont. on 9099C} Unsubstantiated Interviews also revealed that no corroborated evidence existed to suggest that actions describing inappropriate interaction between S1 and R1 occurred while residing at Delta at the Sherwoods. A review of staffing file did not indicate previous disciplinary action or history of inappropriate interactions with residents. As part of this investigation, a review of R1’s needs and service plan and physician’s report revealed a history of paranoia and hallucinations. As a result of the above evidence reviewed, it is determined that there is not a preponderance of evidence to conclude that staff engaged in inappropriate interactions with a resident, therefore, this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with acting administrator and a copy of this report was provided. Appeal rights provided.the state’s words, verbatim · CDSS document, Jul 17, 2026 · control 27-AS-20260424151028

Type of visit: Required - 1 Year

On 7-8-2026 at 9:55am, Licensing Program Analysts (LPAs) Michael Bilger and Albert Johnson arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the assistant administrator Farina Khan and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a residential care facility for the elderly (RCFE) with a current census of 27. Facility has a formal dining room. LPA also conducted the inspection using the CARE tool. The facility has an approved infection control plan in place. Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 68*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 8-28-25. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and accessible to staff. {Cont. on 809C} During this inspection 3 resident files and 5 staffing files were reviewed for regulatory compliance. All files contained required contents including staff training requirements. All staff reviewed contained criminal background clearances. LPA completed 3 resident interviews and 3 staff interviews. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility does not contain any bodies of water. LPA observed personal rights and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts monthly fire drills. LPA requested an updated copy of LIC 308 and LIC 500. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to assistant Administrator.the state’s words, verbatim · CDSS document, Jul 8, 2026

Type of visit: Case Management - Legal/Non-compliance

On 4-30-2026 at 10:15am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct a quarterly inspection visit. LPA met with the interim administrator Farina Khan9df8dak and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen area, common areas, resident bedrooms; resident bathrooms, laundry area and outside of the facility to ensure compliance with Title 22 regulations. Facility is a residential care facility for the elderly (RCFE) with a current census of 30 The facility has an approved infection control plan in place. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Fire extinguisher was checked 8-28-25. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. {Cont. on 809C} During this inspection 15 staffing files were reviewed for training verification. LPA verified all staff training is current at this time per stipulation order. LPA reviewed current client rosters, and observed current stipulation posted within facility for viewing. All staff files reviewed contained criminal background clearances. LPA observed personal rights and complaint information posted. Facility has appropriate internet access available for resident use. LPA reviewed facility’s disaster plan to ensure regulatory compliance. LPA requested an updated copy of LIC 308 and LIC 500. At this time facility is in transition of hiring a new administrator. LPA spoke with regional manager during today's visit who stated she will be sending necessary information for processing of a new administrator. Previous administrator left employment as of 4-20-2026. During today's visit, LPA reviewed various incident reports involving medication refusals and absence without leaves (AWOLs). LPA reviewed facility's protocol on AWOL procedures and medication procedures. LPA also conducted various staff and resident interviews during today's visit. In regards to a recent reported AWOL attempt, resident3 (R3) was reported to have followed his aunt to a local restaurant after departing facility and from this location departed further. Staff followed resident and called 911 to have resident transported to hospital due to complaints of chest pain. R3 has since returned without further incident. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to interim Administrator. LIC 811 provided for reference.the state’s words, verbatim · CDSS document, Apr 30, 2026

Allegation investigated: Staff did not assist resident with obtaining medical care in a timely manner

On 10/20/25, the Department received a complaint alleging that staff did not respond to Resident 1’s calls for help, that staff were not present on the floor during night or early morning hours, and that R1 experienced delayed medical attention following a reported fall. The complaint also alleged that R1 had experienced similar incidents in the past where staff did not hear or respond to his calls for assistance. LPA conducted an unannounced visit to the facility, interviewed the Administrator, staff, and residents, including R1 and Resident 2 . LPA also reviewed staff schedules, nightshift supervision procedures, incident reports, and hospital discharge documentation. Continued Unsubstantiated Although R1 and R2 reported concerns regarding staff response time, there were no witnesses, no time‑stamped documentation, and no corroborating evidence to confirm that R1 called for help for an extended period without staff response. Staff interviews and facility records indicate staff were present and responded once notified. The allegation that staff failed to supervise residents at night or delayed medical care could not be verified. Based on interviews, record review, and observations, the allegation is determined to be UNSUBSTANTIATED, Although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 27-AS-20251104150620

Type of visit: Office

An in-person office meeting was held on 02/06/2026 at 11:00 AM at the Sacramento Regional Office for the purpose of reviewing the Stipulation and Waiver, and Order. The Stipulation and Waiver; and Order was adopted on 01/09/2026. Licensing Staff Present: · Regional Managers: Brenda White, Stephenie Doub, Acting Regional Manager Troy Ordonez · Licensing Program Manager: Liza King · Licensing Program Analysts: Albert Johnson, Melinda Melina, Michael Bilger and Kevin Mcknelly Facility/Licensee Representatives Present: · Chief Executive Officer, Managing Member, LLC, Dr. Christopher Zubiate and David Fetyko · H & K LLP, Attorney for LLC, Bruce Zabarauskas · COO, Madison Fetyko, Personal Assistant, Heidi Badasci The Regional Manager discussed the purpose of the meeting and explained the conditions and terms of the Stipulation and Waiver with Order, including probationary licensing, compliance expectations, monitoring authority, and enforcement provisions. The Stipulation was reviewed in detail with the Administrator and Licensee, who acknowledged understanding of the terms and conditions. EVER WELL HEALTH SYSTEMS, LLC, EVER WELL CARE SYSTEMS, LLC, Ever Well Health Systems, LLC dba Enclave at the Foothills 10650 Road 256 Terra Bella, California 93270 Ever Well Health Systems, LLC; Ever Well Care Systems, LLC dba Delta at Holly Oaks 1880 Live Oak.Blvd. Yuba City, California 95991 Ever Well Health Systems, LLC dba Delta at the Portside 1950 E. Sonora Street Stockton, California 95250 Ever Well Health Systems, LLC dba Enclave at the Delta 4951 Eight Mile Road Stockton, California 95212 Ever Well Health Systems, LLC dba Delta Manor 1201 W. Swain Rd. Stockton, California 95207 Ever Well Health Systems, LLC dba Delta at the Sherwoods 1215 W. Swain Road Stockton California 95207 Ever Well Health Systems, LLC dba Foothills at the Alta 550 N. Lillie Ave. Dinuba, California 93618 Items Discussed During the Meeting: · The Stipulation and Waiver; and Order was served on 01/09/2026 and is effective immediately. Ever Well Health Systems, LLC dba Foothills at the Alta license was forfeited as a matter of law and revoked upon the Departments adoption of this Stipulation and Waiver. · Revocations: Stayed with Probation from January 9, 2026, through January 9, 2028. · Upon adoption of the Stipulation as an Order, EVER WELL HEALTH SYSTEMS, LLC, EVER WELL CARE SYSTEMS, LLC LLC’s licenses at Licensee facilities are revoked; however, the revocation is stayed for a period of two (2) years, during which probationary licenses are granted. · During the probationary period, Respondents shall operate the facility in substantial compliance with all applicable statutes and regulations governing Adult Residential Facilities and Residential Care Facilities for the Elderly. · The Department may conduct unannounced site visits at its sole discretion throughout the probationary period to assess compliance. · Respondents shall ensure that all individuals working, residing, or volunteering at the facility obtain required criminal record clearances or exemptions prior to presence in the facility and that proof is maintained on-site. · The Stipulation shall be posted in a conspicuous location at the facility for the full duration of probation. · Respondents shall maintain accurate, complete, and current client rosters, which must be made available to the Department upon request. · Within thirty (30) days of the effective date of the Stipulation, Respondents shall submit written summaries of hiring and training practices, including job descriptions for each position, to the appropriate licensing offices. Completion of Probation: · If Respondents LLC successfully comply with all terms of the Stipulation, at the conclusion of the two (2) year probationary period, all imposed conditions shall expire and the licenses shall be granted or restored in full. The Licensees/Respondents/Representatives stated they would abide by the following: Abide by the contents/terms of the Stipulation Provide Licensing an updated Plan of Operation for the type of client serve Submit written summaries of hiring and training practices, including job descriptions for each Position to the Department on or before February 8, 2026 CHRISTOPHER ZUBIATE and DAVID FETYKO shall complete required training's on or before March 10, 2026 and provide proof of completed training to the Department by on or before April 9, 2026. Ensure quarterly training of Staff according to the terms of the stipulation (The first is to be completed by end of February of 2026 and quarterly thereafter for a total of two hours for each session.) CCLD will do the following: Increase monitoring Referral to TSP was offered Per the California Code of Regulations, Title 22, no violations cited during this visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 6, 2026

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Albert Johnson and Jason Lund arrived unannounced to conduct a case management visit. LPAs met with Joshua Riviera and explained the purpose of the visit. The RO referred this case to the Investigations Branch (IB), to investigate the allegation that staff failed to seek timely medical care for R1 which resulted in R1's death. Finding: Unsubstantiated R1 was experiencing vomiting multiple times on 6/1/2025. Medication Services Assistant (MSA) reported R1 was vomiting at approximately 1600 hours. MSA monitored R1 and when her symptoms did not improve, R1 was sent to the hospital at approximately 1900 hours. R1 had a history of constipation and had a small bowel obstruction procedure in 2018. While in the hospital, a scan of the abdomen and pelvis revealed a large amount of stool in the colon, suggesting constipation and a probable mid small bowel obstruction. R1 reported her pain resolved after receiving an enema and passing a large solid bowel movement on 6/2/2025. Administrator Joshua Rivera stated he received confirmation from the hospital on 6/2/2025 that R1 was scheduled to return to the facility on 6/3/2025. However, R1 passed away at St. Joseph’s Medical Center on 6/2/2025 at 2335 hours. R1’s death certificate lists cause of death as small bowel obstruction with onset to “hours” and fecal impaction with onset to “hours.” Medication records obtained from the facility documented R1 was prescribed multiple medications to treat constipation. According to the records, R1 took her medications as prescribed in the days leading up to her hospitalization and death.the state’s words, verbatim · CDSS document, Sep 8, 2025

Type of visit: Required - 1 Year

On 7/7/2025, Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with and explained the purpose of the visit. The facility physical plant was inspected the including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Advisories given for three bags of spoiled Kale (leave were yellow and liquid was forming in the bags), ECO lab reports missing and cloth towels in all residents bathrooms and the paper towel dispensers were not working in 8 of 8 rooms inspected. Hot water temperature was measured at 107.0 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications locked in each section of the facility. LPA reviewed and compared resident medication vs. resident medication logs. LPA attempted to reviewed 10 resident and 5 staff files, including criminal record clearances. Advisories given for incomplete information on staff applications (I-9 form blank and criminal record statements missing explanation for marking yes on the question). Fire drill was completed on 5/28/2025. First aid kit was checked and is complete. No deficiencies were cited. Advisories given. Exit interview conductedthe state’s words, verbatim · CDSS document, Jul 7, 2025

Allegation investigated: Staff will not accept resident back after hospital discharge

Licensing Program Analysts (LPAs) Albert Johnson and Ellen Lindstrom conducted an unannounced facility visit to delivery findings. LPA met with Staff and explained the purpose of today's visit. Later joined by Dr. Zubiate. Based on the information received by the department. R1 was discharged from the facility and referred to another facility for ongoing psychiatric evaluation, medication adherence and stabilization. The hospital discharged R1 to a skilled nursing facility. The Delta Sherwood was unable to excepted R1 back due to the discharge plan written for R1 to be sent to a skilled nursing facility. Although the allegation may have occurred as reported there was insufficient evidence to prove the allegation. The preponderance of evidence standard was not met therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted and a copy of this report with appeal rights was given to Licensee. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 16, 2025 · control 27-AS-20250311135925

Type of visit: Case Management - Other

LPA's Albert Johnson and Ellen Lindstrom arrived unannounced and met with the Licensee who assisted LPA with the visit. LPA's toured the facility, During the tour LPA's witnessed R2's eyes with heavy discharge. The facility has been attempting to send R2 out for treatment and was able to contact the home health agency for antibiotics. R2 had home health services for follow-up for unsteady gait and was discharged by home health on 6/13/2025. The home health agency was not treating R2's eyes. R2's eyes require additional treatment after the discharge from the home health agency. The facility sent R2's out this morning for additional observation and treatment. Exit interview and appeal rights given.the state’s words, verbatim · CDSS document, Jun 16, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Johnson and Program Manager Lisa Rios arrived at facility unannounced to conduct a visit to ensure compliance with Health and Safety Code (HSC) 1569.38 - Posting of Licensing Reports. LPA Johnson and LPM Rios met with Administrator and explained the purpose of today's visit. The facility received accusation notifying the department has commenced proceedings to suspend or revoke the license of the facility pursuant to Section HSC 1569.50. and the facility will be required to post these in a location easily viewable by residents and visitors. A written notice was handed to Administrator of these accusations. The facility will comply with HSC 1569.38(a-h). A licensee who fails to comply with the requirements of subdivision (b) or (c) of the HSC 1569.38 shall be liable for civil penalties in the amount of one hundred dollars ($100) for each day of the failure to provide notification as required in this section. The total civil penalty for each day shall not exceed one hundred dollars ($100) regardless of the number of notices that the licensee fails to send that day. The total civil penalty for a continuous violation of subdivision (b) or (c) shall not exceed five thousand dollars ($5,000). An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst Albert Johnson conducted an unannounced Case Management visit today. LPA explained purpose of visit to staff. LPA conducted a tour through facility with staff to check fire clearance. LPA observed the Ansul system had not be serviced since May 14 2024. There is a semi-annual inspection that is required. The system has not been serviced. Photo taken. Also observed in the conference room was a plug burned out and not operational. Deficiencies were observed and cited from the California Code of Regulations, Title 22. Civil penalties assessed.the state’s words, verbatim · CDSS document, Mar 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Mar 14, 2025

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met based on: Observation.The facility failed to maintained in conformity with the regulations adopted by the State Fire Marshal. The "Fixed System" or "Ansul System", this system is scheduled for a semi- annual maintenance and was last serviced on 05/14/2024.This poses an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 13, 2025

Plan of correction: Administrator will ensure that the fire equipment listed is inspected or a plan is made and sent to CCL by the POC date indicated. Licensee/Administrator shall send picture of the new tags as proof and submit Statement of Compliance by POC date.

Type of visit: Required - 1 Year

On 7/8/2024, Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Essence and explained the purpose of the visit. Later joined by Chris Zubiate. The facility physical plant was inspected the including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 118.0 degrees Fahrenheit in resident bathroom sink, which is not within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications locked in each section of the facility. LPA reviewed and compared resident medication vs. resident medication logs. LPA attempted to reviewed 7 resident and 5 staff files, including criminal record clearances. Fire drill was completed on 6/2024 . First aid kit was checked and is complete. No deficiencies were cited. Exit interview conductedthe state’s words, verbatim · CDSS document, Jul 8, 2024

Allegation investigated: Staff will not allow resident to have a bike

On 3/19/2024, LPA Johnson arrived unannounced to deliver finding for the above listed allegations. Allegation: Staff will not allow resident to have a bike. Based on review of the admissions agreement and program design the facility is following the plan to ensure that the residents in care are safe, free from harm, danger and potential accusations. R1's physician's report does not restrict him from having a bike, however, the bike in question was given to R1 by someone in the community. The origin of how the bike was given to R1 is the question that the facility is attempting to figure out. Continued Substantiated The program states that R1 has a history of taking items that is not his and attempting to sell these items. The facility has not had a police visit or inquiry as it relates to the bike and how R1 may have obtained the bike. Although the facility in good faith is attempting to prevent R1 from the ill effects of what may be. There is no doctor's objection to R1 having a bike, no rule established by the facility or regulation to support R1 not having a bike. The allegation is substantiated. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, a deficiency is being cited on the attached 9099D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. A copy of their rights was provided (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 19, 2024 · control 27-AS-20240112115446

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(3) · Plan of correction due date: Mar 29, 2024

87468.2 (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: . (3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights. This requirement is not met as evidenced by records reviewed and interviews conducted. The bike is not at the facility and is not list on R1 personal property inventory sheet. This is a personal right violationthe state’s words, verbatim · CDSS document, Mar 19, 2024

Plan of correction: The facility will review the policy for personal property and include what may or may not be stored at the facility including modes of transportation etc. The addendum to the program plan will be provided to the department by close of business on POC date 3/29/24.

Allegation investigated: Facility staff are not assisting residents with hygiene needs after digging through the trash

On 03/07/2024 at 09:00 AM, Licensing Program Analyst (LPA) Renee Campbell and Licensing Program Manager (LPM) Lisa Rios conducted an unannounced facility visit to open a complaint investigation. Upon entry, LPA Campbell and LPM Rios met with S1 and S2 and explained the purpose of today's visit. LPA and LPM toured the facility with S2 and met with S3 while on tour of the kitchen. Administrator Tanya Monge arrived at 10 am and arranged interviews with R1, R2, R6 and R7. Over the course of the investigation based on interviews with 4 residents, it was disclosed that 2 to 3 residents dig through the trash at meal time and start eating the food. Staff discourage residents from eating from the trash but 4 out of 4 residents state that they are not reminded to wash their hands after digging in the trash. Based on interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Substantiated Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, a deficiency is being cited on the attached 9099D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. A copy of their rights was provided (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 7, 2024 · control 27-AS-20240228151709

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87101(c)(3)A) · Plan of correction due date: Mar 15, 2024

87101(c)(3)(A) Definition "Care and Supervision" means those activities which if provided shall require the facility to be licensed.(A) Assistance in dressing, grooming, bathing and other personal hygiene; This requirement is not met: Based on 4 out of 4 interviews, staff are not reminding nor assisting residents with hand washing after residents are digging through the trash at meal time. This poses a potential Health, Safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 7, 2024

Plan of correction: Administrator will meet with staff to remind them to ensure client’s to ask for more food if they are still hungry and to urge client's to wash their hands when digging in the class. A sign in sheet will be emailed to LPA Campbell at renee.campbell@dss.ca.gov to verify the meeting..

Type of visit: Case Management - Other

On 03/07/24, Licensing Program Analyst Renee Campbell and Licensing Program Manager Lisa Rios arrived unannounced to the facility to open a new complaint. As we toured the facility LPM Rios observed that there was a tray of prepared sandwiches on top of the counter. Per S3, the cook had just finished making sandwiches before leaving the facility and left them on the counter. At the request by LPM Rios, staff immediately put the sandwiches in the refrigerator. An advisory was then given to remind the cook to immediately place food in the fridge after prepping. No deficiencies were given. Exit interview.the state’s words, verbatim · CDSS document, Mar 7, 2024

Allegation investigated: Staff threatened to restrict resident from leaving the facility premises

Licensing Program Analyst (LPA) Albert Johnson arrived at facility on 1/30/2024 unannounced to deliver findings for the complaint allegation listed above. LPA Johnson met with Tanya Monge and explained the purpose of today's visit. Based on records reviewed it was confirmed that the facilities' admissions agreement has specific information for resident's disciplinary actions for various infractions. The facility provides the residents with alternatives to outings while the residents are serving their consequence from a Targeted Behavior Agreement Contract (TBAC) meeting. Continued Unsubstantiated The TBAC meetings are staffed by behavioral support teams, Administrator and the county if they choose to participate. R1 agreed and signed the TBAC and was placed on the restriction based on violation of the facilities policy as it relates to bullying (staff and residents), fighting and threatening harm. The allegation is unsubstantiated. A finding of UNSUBSTANTIATED means that although the violations may have occurred as reported the preponderance of evidence standard was not met. An exit interview was conducted and a copy of this report with appeal rights given.the state’s words, verbatim · CDSS document, Jan 30, 2024 · control 27-AS-20231017140117

Allegation investigated: Staff is not providing resident access to their money. Staff withhold food from residents. The facility has mold.

Licensing Program Analyst (LPA) Albert Johnson arrived at facility on 1/26/2024 unannounced to deliver findings for the complaint allegations in to the above list. LPA Johnson met with Tanya Monge and explained the purpose of today's visit. Allegation: Staff is not providing resident access to their money. Based on records reviewed it was confirmed that the facility uses a payee service for the Residents in care. The information is outlined in the admissions agreement with specific instructions for disbursements of funds, deposit of funds and how the residents will receive personal and incidentals funds. The facility uses form LIC 405(Record Of Client's/Resident's Safeguarded Cash Resources) for tracking of funds that have been sent over by the facilities corporate head quarters. The allegation is unsubstantiated. Unsubstantiated Allegation: Staff withhold food from residents. Based on interviews with the residents and observation on 10/12/2023, 10/25/2023, and 11/27/2023 the facility provides three meals and snack at specific times through out the day. The residents interviewed denied having food taken away by staff, however they did mention that there is a resident that will take food from them and the staff will have to intervene and redirect the resident and return or replace the food that was taken. The allegation is unsubstantiated. Allegation: Facility has mold. Based on observation, records reviewed and interviews with outside agencies the facility appears not to have/had a problem with mold in or around the facility. The facility provided the department with work orders and receipts for the repair work completed at the facility in the residents shower. LPA observed the work in progress and being completed on 10/12/2023, 10/25/2023, 11/27/2023 and again on 1/26/2024. The facility denies that the presence of mold was present at the time of the first repair and continues to deny that there was mold at anytime. The allegation is unsubstantiated. A finding of UNSUBSTANTIATED means that although the violations may have occurred as reported the preponderance of evidence standard was not met. An exit interview was conducted and a copy of this report with appeal rights given.the state’s words, verbatim · CDSS document, Jan 26, 2024 · control 27-AS-20231011123255

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.