Rose Garden

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon conducted a 1 year annual visit to the facility above. LPA met with Administrators Leticia Ruiz and Diana Barnhill, LPA explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrators. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out clipboard for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, and hand soap. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE) upon hire and annually thereafter. Physical Plant & Environmental Safety: The facility is a 4 bedroom with 2 bathrooms, 1 staff/visitor restroom, kitchen, dining room, locked laundry room, locked storage room off the master bathroom, locked medication closet currently occupying 5 residents, employs 17 staff and 2 Administrators. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The kitchen oven knobs are taken off stove to make it inaccessible to dementia residents in care when not in use. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in the laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard with in enclosed patio and an open patio for resident use with plenty of shade. The facility has telephone and internet service for resident use. The facility has video surveillance in the common areas without voice or sound capability for privacy purposes. Continued 809-C Operational Requirements: The facility has a current plan of operation on file. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance. The facility is approved for a capacity of 6 with 6 Non-Ambulatory of which 1 may be bedridden. Hospice approved for 6. Staffing: The facility employes 17 staff and 2 Administrators. Staff records are kept confidential. Five staff files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificates. The facility keeps confidential files for each staff member. Personnel Records & Training: LPA reviewed 5 staff training records for Initial 40 hours and/or Annual Training Requirements of 20 plus hours for 2026. All files reviewed had training records covering ADL's, resident characteristics, Medications, emergency preparedness policy and procedures, infection control requirements Hospice care, Postural Supports and Restricted health conditions and Quarterly Disaster Drills as well dementia training. Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. The kitchen has a gate that opens and closes to keep range and ovens inaccessible to dementia residents in care when not in use. Incidental Medical and Dental Services: Facility provides or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). Medications are kept in a locked medication closet. Medication were checked for expiration dates, no altered labels, and medication were stored in original containers. Administrator and Medication Technicians destroy medications by logging and taking to the pharmacy for destruction. Resident Records and Incident Reports: LPA reviewed 5 resident files, files reviewed for signed Admission Agreement, Physicians Report LIC 602A with TB results, pre-appraisal, Appraisal Needs and Services Plan , Safeguard for property and valuables, and Personal Rights. All files were up to date. Continued 809-C Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license was posted. Visitation policy is posted at entry. Internet and a device for residents use is provided to resident with confidentiality and privacy. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers was charged and inspected. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility currently has 1 resident with oxygen, signs are posted. The facility has 4 hospice residents in care. Hospice care plans are kept on file and up to date. The facility does not currently have any resident receiving Home Health services. The facility does not have delayed egress. The facility has exiting door alarms. LPA conducted interviews with 2 residents and 2 staff. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Aug 12, 2026

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) De Leon arrived at 1:50pm to conducted a 1 year annual visit to the facility above. LPA met with Back up Administrator Leticia Ruiz and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out clipboard for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, and hand soap. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environmental Safety: The facility is a 4 bedroom with 3 bathrooms, kitchen, dining room, locked laundry room, locked storage room off the master bathroom, locked medication closet currently occupying 5 residents and employs 8 staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe and sanitary. The knobs are taken off stove to make it inaccessible to dementia residents in care, the hall has a sliding gate that closes off to the kitchen at night and it does not lock. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in the laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard with in enclosed patio and an open patio for resident use with plenty of shade. The facility has telephone and internet service for resident use. The facility has video surveillance in the common areas without voice or sound capability for privacy purposes. Cont. 809-C Operational Requirements: The facility has a current plan of operation on file. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance. The facility is approved for a capacity of 6 with 6 Non-Ambulatory of which 1 may be bedridden. Hospice approved for 6. Staffing: The facility employes 7 staff and 1 Administrator. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. Administrator Certificate expires 08/27/2027. The facility keeps confidential files for each staff member. Personnel Records & Training: LPA reviewed 5 staff training records for Initial 40 hours and/or Annual Training Requirements of 20 plus hours for 2025. All files reviewed had ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements and Quarterly Disaster Drills. Resident Records & Incident Reports: Completed on last visit to facility. Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. The kitchen has a gate that opens and closes to keep range and ovens inaccessible to dementia residents in care. Incidental Medical and Dental Services: Facility provides or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). Medications are kept in a locked medication closet. Medication were checked for expiration dates, no altered labels, and medication were stored in original containers. Administrator and Medication Technicians destroy medications by logging and taking to the pharmacy for destruction. Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license was posted. Visitation policy is posted at entry. Internet and a device for residents use is provided to resident with confidentiality and privacy. Continued 809-C Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers was charged and last inspected 08/28/2025. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not currently have residents with oxygen. The facility has 3 hospice residents in care. Hospice care plans are kept on file and up to date. The facility currently has 1 resident receiving Home Health services. Home Health records are kept on file. The facility does not have delayed egress. The facility has exiting door alarms. LPA conducted interviews with 2 residents and 2 staff. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Nov 12, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon conducted qa 1 year annual visit to the facility above. LPA met with Administrator Diana Barnhill and explained the purpose of the visit. Resident Records and Incident Reports: LPA reviewed 4 resident files, files reviewed for signed Admission Agreement, Physicians Report LIC 602A with TB results, pre-appraisal, Appraisal Needs and Services Plan , Safeguard for property and valuables, and Personal Rights. All files were up to date meeting all regualtion requirements. LPA will return at a later date to completed the annual visit. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Aug 25, 2025

Allegation investigated: Facility staff used inappropriate restraint on residents for an extended period of time Licensee does not ensure enough staffing to meet the needs of residents

Licensing Program Analyst (LPA) De Leon conducted a 10 day Complaint Visit to the facility above. LPA met with Diana Barnhill and explained the purpose of the visit. LPA De Leon requested the following records: Staff Roster with Telephone numbers, Staff schedule for June 2025, Resident Roster, Resident 1 (R1) LIC. 602A Physicians Report, R1's Physicians order for gait belt, and Appraisal Needs and Services Plan. LPA interviewed staff at 11:45am, 12:00pm and observed 5 residents in the facility. On the allegation: Facility staff used inappropriate restraint on residents for an extended period of time. LPA interviewed staff which revealed Resident 1 (R1) was tied to the reclining chair with a gate belt for safety due to a recent change in condition, the belt was tied loosely and R1 was able to lift it over R1's head if needed. Continued 9099-C Substantiated The facility did not have a doctor's order for a gait belt for R1. LPA interviewed witnesses 1 & 2 (W1)(W2) which revealed while at the facility visiting R1, R1 raised up R1's arms and witnesses noticed a gait belt wrapped around R1's waist and tied to the back of the reclining chair R1 was sitting in. W2 stated they had never been told about a change in condition or the use of a gait belt for R1. Several texts messages were sent back and fourth between Administrator and R1's family regarding the incident. Based on the evidence this allegation is Substantiated at this time. On the allegation: Licensee does not ensure enough staffing to meet the needs of residents. LPA interviewed Licensee/Administrator regarding the staffing needed for R1. R1 had a recent change in condition and sun downing was becoming an issue for R1. The change in condition was reported to R1's physician and Administrator is getting an up to date LIC 602A physicians report for the change, and will update the appraisal needs and services plan accordingly. Administrator stated R1 does need additional staffing during sun downing from 3pm-7pm or 4pm-8pm. Administrator plans to do a two day rate increase for the change in condition and to provide a staffing 1 on 1 to R1 during sun dowing to keep R1 safe. Administrator said the facility has hired 3 new staff in February 2025 but all 3 staff are no longer working, the administrator is currently hiring for caregivers and hired 2 new caregivers yesterday, once trained the staff will be added to the schedules. Based on the evidence this allegation is Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator/Licensee.the state’s words, verbatim · CDSS document, Jun 11, 2025 · control 29-AS-20250604141924

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(1) · Plan of correction due date: Jun 12, 2025

(a)...(1)Postural supports shall be limited to appliances...soft ties, used to achieve proper body position and balance,..or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirment was not met as evidenced by: Based on interviews the Licensee did not comply with the regualtion above Administrator used a gait belt to tie a resident to reclining chair which poses an immediate Health, Safety and Personal rights risk to reisdnets in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Administrator will not use any ties or gait belt with R1, get updated LIC 602A & Apprisal Needs and Services plan for R1 and train staff in Regulation 87608, provide proof of trianing and requested records to CCL by 06/12/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jun 18, 2025

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement was not met as evidenced by: Based on interviews the Licensee did not comply with the regulation above, the facility will need additional staffing to take care of R1 due to change in condition and meeting R1's needs which posses a potential Health, Safety and Personnel rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Administrator agreed to higher more staff and provide a up to date LIC 500 for current staffing working at the facility, Administrator also will do a care increase to account for a 1 on 1 for R1 while sun downing, and review regulation 87411 and provide written letter of understanding to CCL by 06/18/2025.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) De Leon conducted a Case Management deficiencies visit to the facility above. LPA met with Administrator Diana Barnhill and explained the purpose of the visit. During a recent complaint investigation LPA learned the facility Licensee Barnhill and Barnhill Inc. was not in good standing with the Secretary of the State. LPA cited facility back on 08/2024 for the same deficiency. LPA explained the Administrator this needs attention immediately. Exit interview conducted, deficiency cited, civil penalty assessed, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, Jun 11, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87205(b) · Plan of correction due date: Jun 18, 2025

(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement was not met as evidenced by: Based on record review the Licensee did not comply with the regulation above, the Incorporation is not in good standing with the Secretary of the State and needs immediate attention which posses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Administrator agreed to make contact with SoS to bring corporation into good standing and if not able will do application to change the Licensee to an individual or LLC. provide proof to CCL by 06/18/2025.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 11:00am to conducted a 1 year annual visit to the facility above. LPA met with Administrator Diana Barnhill and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out clipboard for visitors at entry with hand sanitizer.The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and waste baskets have lids or tight fitting covers. Physical Plant & Environment Safety: The facility is a 4 bedroom with 3 bathrooms, kitchen, dining room, laundry room, locked storage room of the master bathroom, locked medication closets currently occupying 5 residents and employs 8 staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe and sanitary. The knobs are taken off stove to make it inaccessible to dementia residents in care, the hall has a sliding gate that closes off to the kitchen at night and it does not lock. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in the laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard with in enclosed patio and an open patio for resident use with plenty of shade. The facility has telephone and internet service for resident use. The facility has video surveillance in the common areas without voice or sound capability for privacy purposes. Continued 809-C Operational Requirements: The facility has a current plan of operation on file. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 09/28/2024. The facility is approved for a capacity of 6 with 6 Non-Ambulatory of which 1 may be bedridden. Hospice approved for 6. Staffing: The facility employes 7 staff and 1 Administrator. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. Administrator Certificate expires 08/27/2025. Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training with all subjects covered over a 3 year period, 4 hours of hospice care, postural supports and restricted health condition, and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements and Quarterly Disaster Drills. Initial and Annual training has not been completed on all staff and they are currently working on completing it. Hospice and Home Health provide training to staff for residents under those services and facility keeps records on file. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The Facility does not handle cash resources on residents in care. Facility does submit incident reports to the department when required. Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. The kitchen has a gate that opens and closes to keep range and ovens inaccessible to dementia residents in care. Continued 809-C Incidental Medical and Dental Services: Facility provides or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). Medications are kept in a locked medication closets. Medication were checked for expiration dates, no altered labels, and medication were stored in original containers. Administrator and Medication Technicians destroy medications by logging and taking to the pharmacy for destruction. Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license was posted. Visitation policy is posted at entry. Internet and a device for residents use is provided to resident with confidentiality and privacy. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers was charged and last inspected 08/02/2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not currently have residents with oxygen. The facility has 2 hospice residents in care. Hospice care plans are kept on file and up to date. The facility currently has 1 resident receiving Home Health services. Home Health records are kept on file. The facility does not have delayed egress. The facility has exiting door alarms. The facility gate on the side of house needs to be fixed so it continues to be self closing and latching. LPA conducted interviews with 2 residents and 2 staff. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, Aug 16, 2024

The state marks this report as 20 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.