The Commons at Union Ranch

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

Type of visit: Case Management - Incident

On 09/28/2026, Licensing Program Analyst (LPA) Melina Oropeza arrived at facility unannounced to conducted a Case Management visit regarding incidents involving R1. LPA Oropeza met with administrator, Sheryl Bravo and explained the purpose of today's visit. LPA conducted interview with administrator, Sheryl Bravo.LPA requested and reviewed R1's : Special Incident Reports (SIRs), Physician’s Report (LIC 602), Needs and Service Plan and Preplacement Appraisal Information. Record review indicated that on 08/18/2026, R1 exited the facility through a bedroom window and left the facility unsupervised. R1 was subsequently located and returned to the facility. On 09/07/2026, R1 again exited the facility through a bedroom window at approximately 3:30 a.m. and left the facility unsupervised. Law enforcement was contacted, located R1 off facility grounds and R1 returned to the facility at approximately 4:55 a.m. Based on information obtained during today’s Case Management visit and records reviewed, a deficiency is being cited on the attached LIC 809-D pursuant to California Code of Regulations, Title 22. An immediate civil penalty in the amount of $500 is assessed for lack of care and supervision. An exit interview was conducted with the Administrator, Sheryl Bravo. A copy of the reports, LIC 421, and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 28, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 29, 2026

87464(f)(1) Basic Services 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). Based on record review, the facility failed to provide adequate care and supervision to R1 when R1 eloped from the facility without staff supervision on 08/18/2026 and 09/07/2026. During the 09/07/2026 incident, R1 left facility grounds and was located by law enforcement. This posed an immediate immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Sep 28, 2026

Plan of correction: The facility shall conduct an in-service training with staff to review procedures on how staff shall ensure that residents do not elope. Executive Director , Sheryl Bravo shall send the in-service training materials, plan on how staff will ensure residents do not elope and a signature sheet of all staff who attended via email to LPA Oropeza at Melina.Oropeza@dss.ca.gov by POC date 09/29/26 by 5:00pm.

Allegation investigated: Staff are not ensuring residents medical needs are met Unqualified staff providing care

On 08/11/2026, Licensing Program Analyst (LPA) Melina Oropeza arrived unannounced to continue the complaint investigation regarding the allegations above. LPA met with Administrator Sheryl Bravo and explained the purpose of the visit. During the investigation, LPA conducted interviews with the Administrator and 2 staff members. LPA also reviewed facility documentation including resident and staff rosters, incident reports, Medication Technician (MT) training records, annual MT training verification, Activities of Daily Living (ADL) task sheets, hospice notes and residents’ care documentation. Based on interviews conducted and records reviewed, information obtained did not determine that residents' medical needs were not being met or that staff providing care lacked the required qualifications and training. Records reviewed reflected residents' care needs and services provided and staff records reviewed reflected applicable training. continue 9099-c... Unsubstantiated As a result, the preponderance of evidence standard is not met, and the allegations are UNSUBSTANTIATED.A finding of unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with the Administrator, Sheryl Bravo and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 11, 2026 · control 27-AS-20260624153604

Allegation investigated: Staff did not provide adequate supervision resulting in resident falling while being assisted with showering Staff are not following reporting requirements regarding resident(s) in care Licensee does not ensure that staff are adequately trained

On 08/11/2026, Licensing Program Analyst (LPA) Melina Oropeza arrived unannounced to conduct a complaint investigation. LPA met with Administrator Sheryl Bravo and explained the purpose of the visit. During the investigation, LPA conducted interviews with the Administrator, 2 staff, resident (R1) and reviewed facility documentation, including staff training records. Information obtained from interviews and records reviewed did not determine that staff failed to provide adequate supervision to residents in care, failed to follow reporting requirements, or that staff were not adequately trained. As a result, the preponderance of evidence standard is not met, and the allegations are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with the Administrator, Sheryl Bravo and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 11, 2026 · control 27-AS-20260629114650

Allegation investigated: Staff member consumed drugs during work hours, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care

On 08/11/2026, Licensing Program Analyst (LPA) Melina Oropeza arrived unannounced to conduct a complaint investigation. LPA met with Administrator Sheryl Bravo and explained the purpose of the visit. During the investigation, LPA conducted interviews with the Administrator, 6 staff members and 3 residents. LPA also conducted facility observations and reviewed facility documentation. Based on interviews, records reviewed and observations, information obtained did not determine that staff consumed drugs during work hours resulting in impairment of their ability to provide adequate care and supervision to residents. During the visit, LPA observed staff providing care and supervision and did not observe staff displaying observable signs of impairment. As a result, the preponderance of evidence standard is not met, and the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with the Administrator, Sheryl Bravo and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 11, 2026 · control 27-AS-20260702102215

Allegation investigated: Staff did not reorder residents mediations timely resulting in missed medication

Licensing Program Analysts (LPA) Melina Oropeza and Licensing Program Manager (LPM) arrived to the facility unannounced regarding a complaint investigation into the allegations above. LPA Oropeza met with Administrator, Sheryl Bravo and explained the purpose of the visit. During the visit that was conducted on June 16, 2026, LPA reviewed ten residents Medication Administration Records (MARs) for a period of three months and interviewed staff which report when the residents' run out of medication it is documented as medication not available and is missed until refilled. At that visit, evidence of standard was met, therefore the above allegation is found to be Substantiated. However, no citation will be given today as Incidental Medical was cited for this reason on the above date. Exit interview was conducted. A copy of the report and appeal rights were provided to the administrator. Substantiatedthe state’s words, verbatim · CDSS document, Jul 1, 2026 · control 27-AS-20260624153604

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On June 17,2026, Licensing Program Analysts (LPA) Melina Oropeza and Licensing Program Manager (LPM) Liza King arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by Business Office Director, Admin is on vacation. LPA explained the purpose of the visit, LPM observed breakfast service in the main dining room consisting of corn beef hash, fruit and cereal. The menus were accessible on the dining tables of AL. The environment was clean and inviting. LPM and LPA conducted a tour of the Memory Care (MC) area. The general area was clean with no odor, breakfast service was finished and residents were seated in different areas of the community. Residents appeared well kept. LPM conversed with several residents throughout the MC, all appeared pleasant and engaged. LPM entered 5 resident rooms 5/5 (R6, R7, R8, R9, R10) had personal care supplies and 1/5 had cleaning supplies accessible (this room was locked and resident manages key to room) and reviewed the LIC602 for these residents. 2 of 5 are at risk if allowed access to personal care and/or cleaning supplies. TA was provided that although 1 of 5 is allowed access per the LIC602, it may benefit the community to have the resident reassessed, the LPM observed a coffee cup full of shaving cream which could be ingested. Additionally, TA was provided to develop a plan to assist staff in identifying those residents there are and are/not allowed access to dangerous substances. LPM pulled a cord in R9s room which was answered in one minute. R10 has their own refrigerator in their room which contained expired foods. Late morning activities in MC were observed, residents were engaged in singing and Fit and Fun. continue.... LPA reviewed 5 MC resident files (R1, R2, R3, R4, R5) with no concerns. LPM followed up incident reports while at the facility for R3, R6. R3 has experienced 5 falls from March to current. Prior assessment documented resident as independent updates have been made to provide stand by assist to full assist. R6 had 12 falls over a 1 month period, updates to the Care plan have been made and family is informed. A review of these 2 resident MARs was conducted, R6 was provided a prn on two occasions, discussion occurred related to pain management or possible discomfort associated with pain which may have attributed to the number of falls. A standing order for pain management following several falls may have been implemented had the resident had a medical assessment or contact made with the PCP. Additional conversation occurred related to the facility policy regarding unwitnessed falls in the MC area, families refusal for medical evaluation and the facilities liability if an injury or change in condition occurs and medical assessment was not sought. Additionally, according to the facility representative if emergency response is contacted, they do not leave documentation of refusal of medical treatment if family refuses over the phone. MARS did reveal that the facility is documenting medications not available and residents are going without prescribed medications for a period of time. Discussion occurred with the MCD and a MT re facility practice and obligation to provide meds as ordered and bill back the resident. Fire Extinguishers are monitored monthly by staff and last serviced on 04/15/2026. Water temp within regulation at 110 degrees. Assisted Living (AL) was observed in the afternoon. Residents were engaged in arts activities prior to lunch and some residents went on a restaurant outing. Five resident files were reviewed from AL, 4/5 (R14, R15, R13, R12) functional assessment portion of the preplacement appraisal was incomplete or not signed. Three resident MARS for AL were reviewed, same concerns. A tour of AL was conducted incl. kitchen, dinning room, resident areas and 2 resident bedrooms - no concerns. Stairwells were clear and within regulation. Ancillary system and fire extinguishers in the area were serviced in 2026. Adequate food available including snacks and water stations throughout. LPM reviewed two resident council meeting notes, Emergency preparedeness, fire drills care staff in-service notes with no concerns. LPA and LPM reviewed 11 staff files with no concerns. Exit interview held with staff and copies of reports left at conclusion of visit. Citations are issued during todays visit and referenced on the 809D page. An exit interview was conducted with the Director of Health Services, the report, citations and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 17, 2026

Type of visit: Case Management - Incident

LPA Oropeza and Lewis arrived unannounced at the facility and met administrator to conduct a case management visit regarding an incident that took place on 03/22/2026. LPA'S conducted a case management inspection to ensure Title 22 compliance and health and safety concerns. An interview was conducted with the administrator. LPA'S also reviewed resident records to check for completeness, all necessary documents were in place. R1 hit R2 in the hallway of the facility causing an injury. LPA will interview R1 and R2 . The facility provided the SOC 341. Based on inspection, and documentation reviewed during this case management, deficiencies are being cited during todays visit per California code of regulations, Title 22, see 809-D page... Exit interview conduct. Copy of the report an appeal rights given to the administrator.the state’s words, verbatim · CDSS document, May 7, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a) · Plan of correction due date: May 7, 2026

87468 Personal Rights (a) Residents in residential care facilities for the elderly shall have personal rights which include, but are not limited to, those listed in Sections 87468.1, Personal Rights of Residents in All Facilities, and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. Based on incident report received from the facility and interview with administrator there is no dispute that R1 was struck by R2 which caused an injury to R1. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2026

Plan of correction: Facility has already completed staff training during an all staff meeting and covered behaviors, re-direction and how to maintain safety. No POC is due at this time.

Type of visit: Case Management - Incident

LPA Lewis and Oropeza arrived unannounced at the facility and met administrator to conduct a case management visit regarding an incident that took place on 03/02/2026 . LPA'S conducted a case management inspection to ensure Title 22 compliance and health and safety concerns. An interview was conducted with the administrator. LPA'S also reviewed resident records to check for completeness, all necessary documents were in place.R1 AWOL'd from from the facility. R1 is not able to leave the facility unassisted per the physician's report. Based on inspection, and documentation reviewed during this case management, deficiencies are being cited during todays visit per California code of regulations, Title 22, see 809-D page... Exit interview conduct. Copy of the report an appeal rights given to the administrator.the state’s words, verbatim · CDSS document, Apr 1, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Apr 2, 2026

87411(a)- Personnel Requirements - General-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement is not met by records review. R-1 AWOL'd from the facility. The LIC 602 states the resident was not allowed to leave the facility unassisted. This presents an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: The facility shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. Executive Director shall send the in-service training materials, plan on how staff will ensure residents do not AWOL and a signature sheet of all staff who attended. Executive Director shall email the date of the in-service training to LPA by COB on POC date 04/03/26.

Allegation investigated: Facility staff are not meeting residents toileting needs Facility staff leave residents soiled for an extended period of time Facility staff are not meeting residents nutritional needs Facility staff did not provide adequate supervision to a resident who is a fall risk Facility staff are not meeting residents bathing needs

Unannounced complaint visit made out to this facility on 11/25/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility representative, Marcy Borland, who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator, Sheryl Bravo, to inform her that CCL was present at this time. This LPA was informed that the facility designated Administrator was not able to come to this facility at this time due to health concerns. This visit was conducted with the Business Officer Manager, Marcy Borland, at this time. Current census was 103 residents. The purpose of this visit was to inform this facility, and its representatives, about the findings of this investigation in relation to the above allegations. Based on interviews conducted during this investigation, it was learned that this facility used to employ the services of a third party agency who provided temporary staff to serve as caregivers to this facility. This practice was utilized until the end of September 2025 when this facility finally decided to end the contract and no longer accepted any temporary caregivers from this agency. Unsubstantiated It was learned that this facility employed staff to cover 24 hours of care and supervision and broke the hours into three 8 hour shifts. These shifts were the AM, PM, and NOC shift. It was learned that in the Memory Care Unit there were 3 caregivers present at each shift with one dedicated Medication Technician as well. It was learned that the staff coverage was related to the overall resident census and would fluctuate if the census went down or go up if additional residents were admitted for care. Based on a review of the forms and documents provided, specifically the LIC 500, it was observed that the number of staff present for each shift did reflect the outlined numbers of 3 caregivers with one Medication Technician at this time. A tour of the memory care unit was conducted and it was observed that furniture, furnishings, and most items intended for resident use were observed to be maintained and able to meet the needs of the residents at this time. Based on a review of the forms and documents obtained during this investigation, it was learned that resident assessments were performed quarterly in order to address any changes to the needs and services that had to be updated with the residents. It was also learned that additional assessments and appraisals were performed when a resident was sent out to the hospital with new orders from their attending physician in order to address any new changes to their conditions. It was learned that these incidents of hospitalization or residents being sent out were duly reported to CCL within the allotted time frames. It was learned that any changes were then also reported to the resident, and their responsible parties, so that the change in level of care could be discussed at that time. Based on a review of the forms and documents obtained during this investigation, it was learned that there were designated residents who required assistance with showers, toileting, and other Activities of Daily Living (ADLs) from assigned facility staff. It was observed that these tasks and duties were assigned and fulfilled by facility staff for each shift throughout the day. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Nov 25, 2025 · control 27-AS-20250731150030

Allegation investigated: Staff do not provide adequate care and supervision Staff do not have planned activities for the residents Staff did not ensure the facility is properly maintained Staff are not properly reporting incidents involving the residents Staff are not abiding to the admission agreement Staff are retaliating against the residents

Unannounced complaint visit made out to this facility on 11/25/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility representative, Marcy Borland, who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator, Sheryl Bravo, to inform her that CCL was present at this time. This LPA was informed that the facility designated Administrator was not able to come to this facility at this time due to health concerns. This visit was conducted with the Business Officer Manager, Marcy Borland, at this time. Current census was 103 residents. The purpose of this visit was to inform this facility, and its representatives, about the findings of this investigation in relation to the above allegations. Based on a review of the facility activities calendar, it was observed that it was completed and filled with events throughout the days, and entire month, with specific times detailing the various events and locations if any interested residents wanted to participate in them. Unsubstantiated Based on interviews conducted during this investigation, it was learned that this facility used to employ the services of a third party agency who provided temporary staff to serve as caregivers to this facility. This practice was utilized until the end of September 2025 when this facility finally decided to end the contract and no longer accepted any temporary caregivers from this agency. It was learned that this facility employed staff to cover 24 hours of care and supervision and broke the hours into three 8 hour shifts. These shifts were the AM, PM, and NOC shift. It was learned that in the Memory Care Unit there were 3 caregivers present at each shift with one dedicated Medication Technician as well. It was learned that the staff coverage was related to the overall resident census and would fluctuate if the census went down or go up if additional residents were admitted for care. Based on a review of the forms and documents provided, specifically the LIC 500, it was observed that the number of staff present for each shift did reflect the outlined numbers of 3 caregivers with one Medication Technician at this time. A tour of the memory care unit was conducted and it was observed that furniture, furnishings, and most items intended for resident use were observed to be maintained and able to meet the needs of the residents at this time. Based on a review of the forms and documents obtained during this investigation, it was learned that resident assessments were performed quarterly in order to address any changes to the needs and services that had to be updated with the residents. It was also learned that additional assessments and appraisals were performed when a resident was sent out to the hospital with new orders from their attending physician in order to address any new changes to their conditions. It was learned that these incidents of hospitalization or residents being sent out were duly reported to CCL within the allotted time frames. It was learned that any changes were then also reported to the resident, and their responsible parties, so that the change in level of care could be discussed at that time. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Nov 25, 2025 · control 27-AS-20250813151544

Type of visit: POC

Unannounced Plan of Correction visit made out to this facility on 07/28/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Sheryl Bravo. A brief interview was conducted with the facility designated Administrator at this time. Current census was 103 residents. The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 07/07/2025. This visit was to follow up on the Plans of Correction that were due. The following deficiencies were observed and cited on 07/07/2025: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This facility did complete the Plans of Correction and provided all of the required forms and documents at this time. Plan of Correction clearance letters were printed and copies were provided to the facility staff person at this time. There were no further deficiencies observed or cited during today's Plan of Correction visit. Exit Interviewthe state’s words, verbatim · CDSS document, Jul 28, 2025

Type of visit: Required - 1 Year

Unannounced Annual visit made out to this facility on 07/07/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Sheryl Bravo, who was briefly interviewed at this time. Current census was 103 residents. It was learned that there were (10) residents under the care of hospice at this time while other residents were receiving services through home health as well. This facility does have a hospice waiver approved for (25) residents and does have a program on file to address dementia care for residents at any given time. It was learned that there were (4) residents deemed to be bedridden at this time. This facility does have a fire clearance to be able to accept/or retain up to (10) residents deemed to be bedridden at this time. A tour of this facility was conducted. Administrator certificate was observed to be present for facility designated Administrator Sheryl Bravo. The expiration date was set for 03/03/2024. All documents have already been submitted to renew at this time. Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication rooms, located on each floor, were reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications were discussed with the facility designated medication technicians at this time. The medication carts were observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. It was learned that there were several different floor plans for residents on the Assisted Living portion of this facility. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Linen closet, located in the facility laundry area, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time. A tour of the Memory Care unit, referred to as Connections for Living (CFL), was conducted. Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 04/01/2025 by the local fire extinguisher company, Edison Fire Protection Co., and in compliance at this time. First aid kits were observed to be present and contained all of the required components at this time. Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted. A review of (7) facility resident files was conducted and noted on the following LIC 858. A review of (7) facility personnel files was conducted and noted on the following LIC 859. The following forms and documents were requested to be updated and submitted into CCL for review by this LPA: LIC 308 LIC 400 LIC 500 LIC 610 The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal Rights were printed and a copy was given to the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jul 7, 2025

Type of visit: POC

Unannounced Plan of Correction visit made out to this facility on 04/10/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Sheryl Bravo, who was briefly interviewed at this time. Current census was 103 residents. The purpose of this visit was to follow up on the deficiencies that were cited from a prior complaint visit conducted on 03/24/2025. This visit was to follow up on the Plans of Correction that were due. The following deficiencies were observed and cited on 03/24/2025: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This facility did complete the Plans of Correction and provided all of the required forms and documents at this time. Plan of Correction clearance letters were printed and copies were provided to the facility designated Administrator at this time. There were no further deficiencies observed or cited during today's Plan of Correction visit. Exit Interviewthe state’s words, verbatim · CDSS document, Apr 10, 2025

Allegation investigated: Staff did not transfer resident properly.

Unannounced complaint visit made out to this facility on 03/24/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met the facility designated Administrator Sheryl Bravo. A brief interview was conducted with the facility designated Administrator at this time. Current census was 107 residents. The purpose of this visit was to inform this facility, and its representative, about the completion of this investigation and present the findings from this investigation at this time. Based on interviews and a review of the forms and documents gathered during the course of this investigation, it was learned that there were (2) caregivers present when attempting to assist R1 in R1's bedroom. It was learned that the caregivers were present to assist R1 in transferring from R1's wheelchair to the bed. It was learned that R1 was prompted to stand up even though R1 was unable to bear weight and prompted to grab a hold of the top of the headboard in order stand up and to avoid falling down. It was learned that after R1 grabbed the headboard and stood up, R1 was no longer able to stand on R1's own Substantiated thereafter could not maintain this standing position and had started to fall down. It was learned that one of the facility staff reacted and pushed R1 onto R1's bed in order to avoid the resident falling onto the floor possibly sustaining additional injuries. It was learned that facility staff then proceeded to reposition R1 in order to turn and pivot R1 to lay correctly in R1's bed. It was learned that the facility resident was solely dependent on the (2) caregivers to assist her in this process so that R1 could be repositioned correctly in R1's bed. It was learned that the facility caregivers attempted to maneuver R1 in R1's bed without grabbing or pushing the resident excessively to prevent further injuries and bruising. It was learned that, at no point in this whole incident, did the facility caregivers climb onto R1 while trying to turn her. In addition, it was learned that the facility caregivers did not ever use their knees to push or pivot R1 while R1 was laying in the bed. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. Exit Interview power and started to fall down. It was learned that the caregivers who were present did not properly assist in this transfer which led to the eventual fall of R1. As R1 was falling down, it was learned that one of the facility caregivers pushed R1 to one side onto the bed in order to avoid R1 from falling onto the floor and possibly sustaining additional injuries. Based on interviews, it was learned that this was not the correct steps that facility caregivers should have taken in order to properly assist in the transfer of a resident. It was learned that the policies and procedures for an appropriate transfer of the residents were not correctly followed in order to avoid any further injuries and falls related to individuals unable to independently transfer. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Mar 24, 2025 · control 27-AS-20250115093855

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 25, 2025

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This facility was found to be deficient as evidenced by the improper transfer of a facility resident by facility staff from their wheelchair onto their bed. This posed an immediate threat the Health, Safety, and Personal Rights of all residents in care.the state’s words, verbatim · CDSS document, Mar 24, 2025

Plan of correction: The facility designated Administrator stated that all facility staff providing care and supervision to all residents in care will be trained, for no less than (1) hour in duration, on the topic of proper assistance in transfer techniques. A statement of correction, along with proof of updated staff training, will be completed and submitted into CCL by the due date. Proof of correction will include name of trainer, topic of training, and list of attendees.

Type of visit: Case Management - Incident

Unannounced case management visit made out to this facility on 03/24/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Sheryl Bravo, and was briefly interviewed at this time. Current census was 107 residents. The purpose of today's case management visit was to follow up on several incidents, including death reports, that were recently submitted into CCL. The following LIC 624s were reviewed and discussed for the following residents that were in care: R1 R2 It was learned that the above referenced residents(R1 and R2) were under the care of a hospice agency prior to passing away at this facility. It was learned that the hospice agencies were present and responsible family and friends were made aware of the situation and passing of the resident. There were no deficiencies observed or cited during today's case management visit. Exit Interviewthe state’s words, verbatim · CDSS document, Mar 24, 2025

Type of visit: Case Management - Other

Unannounced case management visit made out to this facility on 03/10/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Sheryl Bravo, and was briefly interviewed at this time. Current census was 107 residents. The purpose of today's case management visit was to follow up on several incidents, including death reports, that were recently submitted into CCL. The following LIC 624s were reviewed and discussed for the following residents that were in care: R1 R2 R3 It was learned that all three residents(R1, R2, and R3) were under the care of a hospice agency prior to passing away at this facility. It was learned that the hospice agencies were present and responsible family and friends were made aware of the situation and passing of the resident. There were no deficiencies observed or cited during today's case management visit. Exit Interviewthe state’s words, verbatim · CDSS document, Mar 10, 2025

Type of visit: Case Management - Other

Unannounced case management visit conducted on 09/25/2024 out to this facility by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated representative, Business Office Manager Marcy Borland, who was briefly interviewed at this time. Current census was 98 residents. The purpose of this case management visit was to follow up and inquire about recent incident reports in regards to facility residents and their related care. An interview was conducted with the facility designated representative Marcy Borland in regards to these incident reports. A phone call was also made to the facility designated Administrator Sheryl Bravo to inquire and discuss these incident reports as well. It was learned that this facility self reported a medication error that took place in regards to a resident's care and supervision. This facility did take steps to address the concerns of the responsible parties involved, train and evaluate all facility personnel responsible for handling and dispensing medications, and put into place updated policies and procedures to prevent future infractions. There were no deficiencies observed or cited during today's case management visit. Exit Interviewthe state’s words, verbatim · CDSS document, Sep 25, 2024

Allegation investigated: Staff mishandled a resident's medication while in care.

Unannounced complaint visit made out to this facility on 08/19/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Sheryl Bravo. A brief interview was conducted with the facility designated Administrator at this time. Current census was 98 residents. The purpose of this visit was to deliver the findings of this complaint investigation to this facility and it's designated representative at this time. Based on interviews and a review of the forms and documents conducted during the course of this investigation, it was learned that R1 did not have a history of missing or not having the prescribed medications. There weren't any documented incidents where it was observed that R1 did not receive R1's medications as prescribed by his/her responsible licensed medical professional or ran out of them while under the care of this facility since being admitted on 02/24/2022. It was learned that since the filing of this complaint, there have not been any further incidents reported in regards to R1's medications not being administered or mishandled by facility medication technicians. Unsubstantiated Based on interviews conducted during the course of this investigation, it was learned that a pill for R1 was found in R1's room which may have appeared that R1 did not properly take the medication as prescribed for that day. It was learned that on the date of the reported incident of the pill being discovered, R1 was in the dining area of this facility where R1 took all of R1's prescribed medications without any issues. It was learned that it would have been difficult for the lone pill to appear in the room of R1 when R1 would have taken all of his/her prescribed medications in a different area on that day without any incident. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited during today's complaint visit. Exit Interviewthe state’s words, verbatim · CDSS document, Aug 19, 2024 · control 27-AS-20240513143948

Type of visit: POC

Unannounced Plan of Correction visit made out to this facility on 08/19/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Sheryl Bravo. A brief interview was conducted with the facility designated Administrator at this time. Current census was 98 residents. The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 07/17/2024. This visit was to follow up on the Plans of Correction that were due. The following deficiencies were observed and cited on 07/17/2024: All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. Each resident's record shall contain at least the following information: 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 facility did complete the Plans of Correction and provided all of the required forms and documents at this time. Plan of Correction clearance letters were printed and copies were provided to the facility staff person at this time. There were no further deficiencies observed or cited during today's Plan of Correction visit. Exit Interviewthe state’s words, verbatim · CDSS document, Aug 19, 2024

Type of visit: Required - 1 Year

Unannounced Annual visit made out to this facility on 07/17/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Sheryl Bravo. A brief interview was conducted with the facility designated Administrator at this time. This facility was not vendorized at this time to accept and retain any regional center clients at this time. Current census was 96 residents. It was learned that there were (10) residents under the care of hospice at this time. This facility has an approved hospice waiver to be able to accept/retain up to (25) residents at any given time. It was learned that there were (21) residents diagnosed with dementia at this time. It was learned that there were (12) residents receiving services through home health agencies at this time. A tour of this facility was conducted. Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. Additional food storage units were observed to be present and in use at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication cabinet and supplies, located in the facility dedicated medication room, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated staff person at this time. This medication carts were observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Linen storage closets were observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time. Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time. Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 04/02/2024 by the local fire extinguisher company, Edison Fire Extinguisher Inc, and in compliance at this time. Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted. A review of (8) facility resident records was conducted and noted on the following LIC 858 form. A review of (8) facility staff records was conducted and noted on the following LIC 859 form. The following forms and documents were requested to be updated and submitted into CCL: LIC 308 LIC 400 LIC 500 LIC 610 The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal rights were printed and a copy was given to the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jul 17, 2024

Type of visit: POC

Unannounced Plan of Correction visit made out to this facility 04/19/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Morgan Ware who was briefly interviewed at this time. Current census was 96 residents. The purpose of this visit was to follow up on the most recent deficiencies that were observed and cited on the last complaint visit conducted on 03/21/2024: 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, residents, and other persons. Proof of corrections were mailed into CCL for review by this LPA. Plan of correction letters were printed and copies were given to the facility designated Administrator at this time. There were no further deficiencies observed or cited during today's Plan of Correction visit. Exit Interviewthe state’s words, verbatim · CDSS document, Apr 19, 2024

Type of visit: Case Management - Incident

Unannounced Case Management visit made out to this facility 04/19/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Morgan Ware who was briefly interviewed at this time. Current census was 96 residents. The purpose of this visit was to follow up on the most recent Special Incident Reports (SIRs) submitted from this facility in regards to resident care and supervision. A review of the SIRs submitted was conducted in regards to multiple falls and frequency of falls with the facility designated Administrator and Resident Services Director at this time. There were no deficiencies observed or cited during today's case management visit. Exit Interviewthe state’s words, verbatim · CDSS document, Apr 19, 2024

Allegation investigated: Facility does not have a qualified Administrator Staff do not follow procedures to prevent the spread of illness

Unannounced complaint visit made out to this facility on 03/21/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Morgan Ware, and was briefly interviewed at this time. Current census was 97 residents. The purpose of this visit was to deliver the findings from this complaint investigation to the facility and its representative at this time. Based on a review of the forms and documents gathered during the course of this investigation, it was learned that the current facility designated Administrator, Sheri Kimbro, was certified with an Administrator Certificate #7014585740 that was set to expire on 01/25/2024. A review of the Administrator Certification Bureau information system revealed that this certificate number #7014585740 was renewed with all required hours completed and applicable fees paid. A new expiration date was then set for 01/25/2026. Based on a review of this facility's infection control plan and requirements set forth from the Department of Public Health, this facility was required to do response testing since it was under quarantine for COVID Unsubstantiated positive staff and residents that were reported to CDSS and the Department of Public Health. It was learned that facility personnel were required to come to this facility for response testing until clearance from the Department of Public Health. It was learned that facility staff who tested negative were allowed to enter the lobby area and get tested on a weekly basis. On the other hand, positive staff and those who were exhibiting symptoms, were not allowed to enter the facility premises and were tested out in their vehicles as designated staff persons met them out there. Based on interviews, it was learned that there were not any incidents where facility staff persons broke protocol and entered the premises with a COVID positive test to endanger the facility staff and other facility residents. It was learned that the policies and procedures were followed until the quarantine was eventually lifted by the Department of Public Health. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Mar 21, 2024 · control 27-AS-20240129143242

Allegation investigated: Staff made an inappropriate comment about a resident

Unannounced complaint visit made out to this facility on 03/21/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Morgan Ware, and was briefly interviewed at this time. Current census was 97 residents. The purpose of this visit was to deliver the findings from this complaint investigation to the facility and its representative at this time. Based on a review of the forms and documents gathered during the course of this investigation, it was learned that there was a facility staff person, S1, who was found to have made an inappropriate comment in regards to a resident in care. This facility did suspend this particular staff person, S1, pending an internal investigation to the above allegation. Based on the internal investigation conducted by facility personnel and department managers, the facility staff person, S1, did make an inappropriate comment in regards to a resident in care. This staff person, Substantiated S1, was going to be allowed to return to work with a written warning of possible termination if this type of behavior occurred again in the future. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Mar 21, 2024 · control 27-AS-20240122114208

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Mar 22, 2024

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, residents, and other persons. This facility was found to be deficient as evidenced by findings that facility staff did make an inappropriate comment in regards to a facility resident in care. This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: The facility designated Administrator stated that all facility care staff will be in-serviced, for no less than (1) hour in duration, on the topics of Resident Personal Rights and upholding their dignity at all times. A statement of correction, along with proof of training, will be completed and submitted into CCL by the due date. Proof of training will include the name of the trainer, topics of training, and a list of all attendees.

Type of visit: Case Management - Other

Unannounced case management visit made out to this facility on 01/10/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Sheri Kimbro, who was briefly interviewed at this time. Current census was 90 residents. The purpose of this visit was to follow up on several Special Incident Reports (SIRs) that were received recently in relation to resident falls. Interview was conducted with the facility designated Administrator in regards to these most recent falls. There were no deficiencies observed or cited during today's case management visit. Exit Interviewthe state’s words, verbatim · CDSS document, Jan 10, 2024

Type of visit: POC

Unannounced Plan of Correction visit made out to this facility on 11/27/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the Resident Services Director, Karen Silva, who was briefly interviewed at this time. Current census was 89 residents. The purpose of this visit was to verify the plan of corrections that were required to be completed and submitted into CCL for deficiencies that were cited and due by 11/23/2023. The Plan of Correction letters were generated and a copy was left with the facility designated representative at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Nov 27, 2023

Allegation investigated: Staff handles resident(s) in a rough manner. Staff does not respond to resident's call button. Staff speaks to resident(s) in an inappropriate manner.

Unannounced complaint visit made out to this facility on 11/16/2023 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Sheri Kimbro. A brief interview was conducted with the facility designated Administrator at this time. Current census was 89 residents. The purpose of this complaint visit was to deliver the findings for this investigation unto the facility and its representative at this time. Based on interviews and the evidence that was gathered throughout the course of this investigation, it was learned that facility staff would often times become frustrated with facility residents when attempting to assist them. These incidents primarily took place when facility staff were tasked to assist residents with Activities of Daily Living (ADLs), incontinence care, and showers. It was learned that, often times, the facility residents would be unable to assist with their care needs and were unable to follow instructions when offered by the attending staff person. This would frustrate the attending staff person which would lead them to handle the residents in a rough manner to get through Substantiated the process quicker. This would eventually lead the staff person to raise their voice in further attempts to gain assistance from the resident. It was learned that this type of treatment, verbal and physical, from the attending staff person left the residents feeling intimidated, stressed, and mistreated. Based on interviews and the evidence that was gathered throughout the course of this investigation, it was learned that facility staff were required to acknowledge and respond to the call buttons once activated by the residents. It was learned that these types of call button activations ranged from requiring assistance in toileting, transferring in/out of bed, or flat out emergencies from falls or injuries. It was learned that facility staff were required to respond as quick as possible since it was unknown as to the reasons for the call button activations and facility staff persons were to never exceed a response time of more than 10 minutes. It was learned that all call button activations were monitored and recorded upon initial activation up until the responding staff person was able to properly reset it in the residents room or personal pendant. Based on a review of the facility call logs obtained for the months of August 2023, September 2023, and October 2023 it was learned that there were a total of 1,156 call button activations in the Memory Care unit of this facility. Of those 1,156 call button activations roughly 176 were responded to by facility staff but those responses were all in excess of 10 minutes or more. This equated to a 15 percent response time by facility staff that were in excess of 10 minutes or more. It was learned that in that time span there also were documented response times that even exceeded the one hour mark as well. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Nov 16, 2023 · control 27-AS-20231030093338

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 23, 2023

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This facility was found to be deficient as evidenced by staff persons handling residents roughly when attempting to assist them with their Activities of Daily Living (ADLs). This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2023

Plan of correction: The facility designated Administrator stated that a review of all facility caregivers training will be conducted. A statement of correction, along with updated facility staff training for no less than (1) hour in duration on the topic of Resident Dignity and Respect will be completed and submitted into CCL by the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Nov 23, 2023

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This facility was found to be deficient as evidenced by staff persons speaking inappropriately when attempting to assist residents with their Activities of Daily Living (ADLs). This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2023

Plan of correction: The facility designated Administrator stated that a review of all facility caregivers training will be conducted. A statement of correction, along with updated facility staff training for no less than (1) hour in duration on the topic of Residents Personal Rights will be completed and submitted into CCL by the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(3) · Plan of correction due date: Nov 23, 2023

All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This facility was found to be deficient as evidenced by staff persons not responding in a timely manner when residents activated their call buttons, often times, exceeding more than 10 minutes which posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2023

Plan of correction: The facility designated Administrator stated that a review of all facility caregivers training will be conducted. A statement of correction, along with updated facility staff training for no less than (1) hour in duration on the topic of Emergency Call Buttons and staff response will be completed and submitted into CCL by the due date.

Allegation investigated: Staff did not adequately assist a resident with showering, resulting in a fall.

Unannounced complaint visit made out to this facility on 11/16/2023 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Sheri Kimbro. A brief interview was conducted with the facility designated Administrator at this time. Current census was 89 residents. The purpose of this complaint visit was to deliver the findings for this investigation unto the facility and its representative at this time. Based on interviews and the evidence that was gathered throughout the course of this investigation, it was learned that a resident, R1, was deemed to be a full assist whenever R1 was in the restroom for a shower. It was learned that this meant the facility had a caregiver solely responsible for all of R1's care needs while R1 was taking a shower. This caregiver would be responsible to wash, soap, and assist the resident in/out of the shower so as to avoid any slips or falls while in the shower. Based on a review of the facility forms and documents for R1, this particular resident experienced (2) falls while taking a shower even though it was determined that R1 required a dedicated staff person to be present Substantiated to assist at all times. This resident was deemed to be a full assist upon initial assessment and admission to this facility. It was learned that there were no other documented reports of any other facility residents sustaining any slips/falls who were also deemed to be a full assist for showers. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was given to the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Nov 16, 2023 · control 27-AS-20230913092220

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Nov 17, 2023

Basic services shall at a minimum include: Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608. This facility was found to be deficient as evidenced by a facility resident sustaining (2) separate falls even though their initial assessment required a caregiver to be present at all times while showering posing an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2023

Plan of correction: The facility designated Administrator stated that a review of all full assist resident care plans for showers will be conducted. A statement of correction, along with updated facility staff training for no less than (1) hour in duration on the topic of full assist with resident showers, will be completed and submitted into CCL by the due date.

Allegation investigated: Staff leave medications unattended making them accessible to residents

Unannounced complaint visit made out to this facility on 11/16/2023 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Sheri Kimbro. A brief interview was conducted with the facility designated Administrator at this time. Current census was 89 residents. The purpose of this complaint visit was to deliver the findings for this investigation unto the facility and its representative at this time. Based on interviews and a review of the facility policies and procedures involving handling, dispensing, and documentation of the resident medications, it was learned that resident medications were primarily stored in medication carts that were supposed to be locked and made inaccessible to the residents at all times. Facility personnel, (Medication Technicians), responsible for handling, dispensing, and documentation of the resident medications would maneuver the medication carts upon the designated times to dispense the medications to the residents. These medication technicians would then verify the medications prescribed to the resident and pour them accordingly and document once taken by the Unsubstantiated residents via electronic medication administration record (e-MAR) system. Based on interviews, it was learned that the medication cart was always maintained to be locked especially if facility personnel stepped away from it. Based on interviews conducted there were no reports or accounts of any medications having been left out on the medication cart making them accessible to residents and visitors. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Nov 16, 2023 · control 27-AS-20230816100215