Park Place Assisted Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 10:45am to conducted a 1 year annual visit to the facility above. LPA met with Back up to 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, 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). Physical Plant & Environment Safety: The facility has 10 bedroom/10 bathroom for residents, 3 common area restrooms with coded locked doors, kitchen, dining room, laundry room, activity room, code locked office with locked medication closet, currently occupying 10 residents with 14 staff of which 2 are administrators. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has dual smoke and carbon monoxide detectors with a sprinkler system. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe and sanitary. 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 basement, cleaning closet and laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has an enclosed courtyard for client use with plenty of shade gates are locked by a key fob which automatically open with fire alarms. The facility has telephone and internet service for resident use. Continued 809-C The facility has video surveillance in the common areas without voice or sound capability for privacy purposes. The flooring is going to be replaced due to peeling and lifting, LPA found no tripping hazards in the flooring on the tour, the staff peel away anything lifting and put gorilla tape over the flooring so it does not cause a hazard. Administrator will send incident report with details of when the repairs will start and end and the plan for residents when each room is being done. 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 did not have proof of insurance at visit and will send copy to LPA. The facility is approved for a capacity of 13, with 13 Non-Ambulatory of which 12 may be bedridden. Hospice waiver is approved for 8. The facility is currently working on securing a fire clearance for delayed egress and secured coded locked gates for entry and exit, a this time it is not being utilized until the fire chef and company that is doing the install can met and go over it together then it will be granted by Fire for use. Staffing: The facility employes 13 staff of which 2 are certified Administrators. Staff records are kept confidential. Five 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. Administrator Certificates expire 03/11/2028 and 08/27/2027. 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. Staff handling medications had annual training of 8 hours of medication training. 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. Continued 809-C 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. 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 in office. Medication were checked for expiration, llabels were not altered 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/Family 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 along with CCL reports and PIN's were posted. Visitation policy is posted at entry. Internet and a device for residents use is provided to residents 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 July 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 5 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 services records are kept on file. The facility does not currently have delayed egress, forms have been submitted to the department and fire for clearance. The facility has exiting door alarms. 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, Mar 26, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) De Leon conducted a case management -Incident visit to the facility above. LPA met with Diana Barnhill Licensee/Administrator of the facility and explained the purpose of the visit. LPA toured the facility and checked on the 10 residents in care. LPA requested the following records from the facility: Residents roster, Staff Roster, Staff Schedule for date of incident, copy of the video surveillance for 10/26/2025, 10 Residents care plans, Call pendants records for October 25th, 26th and 27th, and Copy of Staff 1 (S1)’s file for application, job description, mandated reporting, photo ID, CCL Clearance form, and training, as well as any remaining records not received from 10/27/2025 request. Licensee called LPA on Monday October 27, 2025, at 12:30pm to report an incident that happened on Sunday Oct. 26, 2025, around 1:30am-5:30am, Staff 1 (S1) on duty NOC caregiver text Licensee and Staff 2 (S2) that S1 was not feeling good and was leaving to go home. This text message was not read until after 5:15 am by S2, who immediately called the facility and got no answer called the Licensee, changed and headed over to the residence. The front door was found unlocked and all 10 Residents were found sleeping around 5:35am, Licensee arrived at 6:03pm and Staff 3 (S3) arrived before the start of S3’s 6am shift at 5:51am. The Licensee said company policy is for Staff to call and not to text when in an emergency. Continued 809-C LPA requested records from Licensee on 10/27/2025 after learning of the incident: Video Surveillance for 10/26/2025, Incident Report, SOC 341 sent to local law enforcement, Long Term Care Ombudsman (LTCO) and CCL. S1’s full name, address and phone number, call pendant calls for 10/26/2025 for all residents in care, list of residents that get up during the night and a list of residents that need toileting or briefs changes during the night, if S1 worked in the Licensee’s other facility, in which S1 did, Job description for Caregiver on NOC shift and a copy of S1’s texts to Licensee and S2. The Licensee sent the Incident Report on Monday October 27, 2025, at 1:34pm to Community Care Licensing (CCL) which provided additional details. S1 text message Licensee and S2 at 1:21am and after reviewing the video surveillance S1 left the facility at 1:23am. The residents were alone in the facility from 1:23am to around 5:39am when S2 arrived. Staff checked on residents, a few of them needed to be changed and had been left soiled and wet. The Licensee tried to call and Text S1 with no response and S1 was terminated on 10/27/2025 for the neglect of 10 residents in care by leaving them alone in the facility. S2 verified the text came into S2's phone at 1:23am and S2 did not hear the text message then upon waking read the message and immediately called the facility with no answer, then proceeded to get dressed and drove straight over to the facility and arrived at 5:39am, door was unlocked, checked residents in care and all 10 were accounted for and sleeping. S2 watched the video surveillance which showed Resident 1 (R1) had gotten up out of bed and set off the floor alarm and proceeded to the dining room around 1:23am, S1 had just walked out the door at this time video shows S1 turned around and came back into the facility and redirected R1 to R1's room, S1 proceeded to leave out the door again, front door unlocked and left the facility with 10 residents in care alone until 5:39am. S2 watched the full video and said no other residents got up from 1:30am- 5:39am when S2 arrived at the facility. Licensee watched the videos and confirmed the times of the incident. Continued 809-C LPA attempted to call S1 on 10/31/2025 at 8:49am the phone had restrictions set and would not accept LPA's call, LPA text on 10/31/2025 at 8:58am with a picture of business card and asking S1 to call LPA due to having restrictions set on phone was not able to call or leave a message. LPA attempted to call again on 10/31/2025 at 9:05am the phone number on file and was not able to get through due to restrictions being set on the phone number. LPA attempted 1 more call to S1's phone at 10:02am and the call would not go thorough. Exit interview conducted, deficiency cited, civil penalty assessed, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, Oct 31, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 3, 2025

(a)Facility personnel shall at all times be sufficient in numbers, ...competent to provide the services necessary to meet resident needs. ...This requirement was not met as evidenced by: Based on interviews, video surveillance, incident reports, the Licensee failed to comply with the regulation above S1 left shift at 1:23am leaving 10 residents alone for over 4 hours which possess an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 31, 2025

Plan of correction: The Licensee agreed to schedule adequate staff coverage and send schedules to CCL for the next 90days. Train facility personnel in Facility Policy and Procedures for calling out, leaving the facility, and Cont. below contact names and numbers to call when an emergency need arises, send proof of training and LIC 500 with all current staff listed.

Allegation investigated: Licensee did not ensure that the facility obtained fire clearance and approval of a delayed egress device on facility door.

Licensing Program Analyst (LPA) De Leon conducted a 10 day complaint visit to the facility above. LPA met with Administrator/Licensee Diana Barnhill and explained the purpose of the visit. LPA requested the following records: Staff Roster, Staff Schedule for August 2025, Resident roster and copy of video surveillance of the kitchen area on 08/26/2025. LPA interviewed staff around 10:30am, toured the kitchen, dining, took photographs of the front exiting doors, and observed the secured perimeter patio to have fencing all around courtyard with a magentic locking mechanicsm on the gates around patio with a magnetic key phobe for opening gates. On the allegation: Licensee did not ensure that the facility obtained fire clearance and approval of a delayed egress device on facility door. The facility was originally licensed on 03/16/2021 and at that time the front door had key coded exit, and the facility courtyard was a fenced secured perimeter with a magnetic key phobe on gates. The fire clearance was reviewed and this was not indicated as approved. Cont. 9099-C Substantiated LPA De Leon spoke with Administrator and provided the fire department with a updated clearance for approval or denial. The facility had a new company come out to the facility and install delayed egress on the front entry/exiting door and it is not currently working as the Licensee is waiting for the approval from Fire to be able to use the device. On 08/26/2025 Witness 1 (W1) visited the facility and was not able to leave until the staff put the code in the front door to exit. W1 said the front door has a sliding lock located towards the top of the door that is used by sliding it over to lock. The door knob still has a key coded lock on it and it locks from the inside to go outside, the staff would need to come to the door with the code to let someone exit. The fire department has not granted or denied the delayed egress inspection request at this time. LPA has spoken to administrator and let them know the door knobs will need to be removed and a normal locking door knob placed until the fire department can come out to inspect and approve the delayed egress. The front entering door can remain locked at night and overnight for safety but can not have day time locks or delayed egress until it is approved by the fire department and sent to CCL for final approval on the license. Based on the evidence this allegation is deemed Substantiated at this time. Exit interview conducted, deficiency cited, civil penalty assessed, copy of report and appeal rights printed for Administrator. LPA watched the video surveillance on the date of 08/26/2025 around 10:00am and 1 staff was on break sitting at the bar counter between the kitchen and dining room. At no time did a resident enter the kitchen area. According to the staff there was 3 staff on duty, 2 caregivers helping residents and one housekeeper, the housekeeper was on break and if needed would have re-directed any residents that would have tried to go in the kitchen area at this time. Witness 1 (W1) stated the sharps and knives drawer was unlocked and accessible to residents in care. After watching the video surveillance the housekeeper was siting between the kitchen and the dining area and no residents had attempted to go into the kitchen area, the knife drawer was unlocked with a staff in the immediate area making it inaccessible to residents in care. Staff were directed to lock the drawer and did so at that time. Based on the staff being in the immediate area and no residents entering the kitchen area this allegation is Unsubstantiated at this time. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 29-AS-20250827130039

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Sep 4, 2025

(f) Licensees that lock exterior doors or perimeter fence gates...(2)The licensee shall ensure that the fire clearance includes approval of locked exterior doors or perimeter fence gates... This requirement was not met as evidenced by: Based on records review and observation the licesee did not comply with the regulation above the front entry/exit door has an automatic lock when exiting the front door and a sliding lock at the top of the door for locking at night which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Administrator agreed to remove all locks off of the entry/exit door and put a manual knob and lock for overnight until the delayed egress can be approved by the fire department, read and review regulation 87705 and train staff provide proof of training to CCL.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 12:35pm 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. Physical Plant & Environment Safety: The facility is a 10 bedroom with 10 bathrooms, 3 common restrooms, kitchen, dining room, laundry room, activity room, locked office with medication locked closet currently occupying 12 residents and employs 11 staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has dual 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. 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 basement, cleaning closet and laundry rooms. The facility has sufficient space inside and outside for activities and visiting. The facility has an enclosed courtyard for client 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. Staffing: LPA will return at a later date to review staffing records. Personnel Records & Training: LPA will return at a later date to review personnel records and training. Resident Records & Incident Reports: LPA will return at a later date to review resident records. 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 is approved for a capacity of 13 with 13 Non-Ambulatory of which 12 may be bedridden. Hospice approved for 8. 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. Incidental Medical and Dental Services: LPA will return at a later date to review Incidental Medical and Dental services. 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 along with CCL reports and PIN's were 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 08/04/2024. 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 4 hospice residents in care. Hospice care plans are kept on file and up to date. The facility currently has 2 residents receiving Home Health services. Home Health services records are kept on file. The facility does not have delayed egress. The facility has a key code on the front exterior door which is not being used at this time. Administrator has ordered and awaiting new delayed egress doors, a pending fire clearance is awaiting the completed work. The facility has exiting door alarms. LPA will conduct interviews at a later date. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Mar 26, 2025

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility did not give a resident sufficient notice of rate increases. Facility is not following a resident's care plan.

At 9:30am on10/07/2024, Licensing Program Analyst (LPA) Jeffries conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with BOM, Letica Ruiz-Guerrero and explained the purpose of the visit. During the investigation, LPA De Leon conducted an initial visit on 12/28/2023 from 12:30pm to 2:10pm, where LPA interviewed staff and residents and requested documents. LPA conducted additional resident and staff interviews on 7/22/2024 from 10:15am to 3:15pm on another complaint with a similar allegation. Additional interviews with witness, Administrator and staff were conducted on 10/3/2024. On the allegation: Facility did not give a resident sufficient notice of rate increases. It was alleged R1 was not given proper 60 days written notice for the increase, as the notice was provided 11/20/2023, less than 60 days before 1/1/2024. In August 2023, R1’s rent was originally $7000 per month. LPA reviewed a text message dated 11/21/2023 from the Administrator to R1’s responsible party stating they would be sending a 2-day notice “by Monday” that includes a rate increase to add a second overnight staff to provide supervision at a cost of $4880 per month. CONTINUED on 9099-C Substantiated The texts states it will be a second fulltime staff to supervise R1 between 10pm to 6am. The text states the increase would start 2 days after receiving the notice. The text states November would be prorated, December’s rent would be $11,880 (the original $7000 rent plus the one on one fee), and starting 1/1/2024 it would be $13,068 per month. The written rate increase notice reviewed, dated 11/20/2023, states the rate as of 12/1/2023 would be $11,800 per month and as of 1/1/2024 would be $12,980 due to a 10% increase. Based on the information, the facility did not give sufficient notice of rate increases for January 2024. Another concern brought forth was that the facility wanted to increase R1’s rent starting in January by more than 10%. However, Title 22 regulations and health and safety code currently do not have increase caps for RCFEs. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility is not following a resident's care plan. It was alleged that R1 required a one-on-one staff overnight for wandering behavior, so the facility increased R1’s monthly fee in order to provide additional staff in the facility. However, it was alleged the facility did not provide additional staff following the rate increase. A witness stated they did a “stakeout” at the facility from 10pm to 6am and did not see any additional staff go into the facility. LPA reviewed a text message dated 11/21/2023 from the Administrator to R1’s responsible party stating they would be sending a 2-day notice that includes a rate increase to add a second overnight staff to provide supervision at a cost of $4880 per month. The texts states it will be a second fulltime staff to supervise R1 between 10pm to 6am. The written increase states an additional $4800 would be added for “one on one supervision.” Administrator stated R1 was very aggressive and was up most of the night and would go through the kitchen refrigerator and pantry, and had other aggressive behaviors. Administrator stated the one NOC staff could not attend to round on the other residents and properly supervise R1, so they added an extra staff overnight. Administrator stated typically the PM shift stayed an extra 1-2 hours to help the NOC staff, and then Administrator came in around 11pm-12am and stayed until 4-5am after R1 went to bed. Administrator stated R1 did not need a one on one to watch them every second, but rather they just needed a second staff overnight to provide adequate supervision to R1. CONTINUED on LIC9099-C Facility charting notes for December 2023 were reviewed. There were notes from the AM and NOC shifts. NOC shift notes stated on 12/19/2023, R1 was up when the staff got to work, but went to bed at 12:30am and stayed asleep. On 12/20/2023, the notes state R1 came out of their room at 10:45pm to eat dinner, went back to their room at 2am and stayed there. On 12/21/2023, the notes state R1 came out of their room around 10pm and 10:20pm looking for a particular staff. R1 went to their room but kept coming out all night. On 12/22/2023, the notes state R1 was awake when they got to work but went to bed at 11:30pm and stayed asleep. On 12/24/2023, the notes state R1 stayed awake, came out of their room to eat again, and went to sleep at 2am and stayed asleep. Based on the investigation, the written two-day increase for R1 states specifically “one on one supervision,” which was not provided based on Administrator’s interview. Therefore this allegation is deemed Substantiated at this time. Exit interview, deficiencies cited on 9099-D, report given, appeal rights given. On 8/25/2023 they were invoiced for a medication that was $33.97, and wrote a check on 9/2/2023. On 10/1/2023 they wrote a check to cover medication gummies at $27.93 and briefs at $44.50. Administrator confirmed R1’s responsible party did state the VA would pay for the medications and briefs, however the Administrator stated they were unable to access the VA. Administrator stated they told R1’s responsible party that as their responsible party/POA they could access the VA on R1’s behalf and provide the items. However the items were never provided, so Administrator purchased the items for reimbursement to ensure R1 had the medication and care items they needed. Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. On the allegation: Facility staff yell at residents. It was alleged a staff yelled at a resident they were not getting any lunch. Multiple residents interviewed stated they were treated “fine,” “well,” “very well,” and said there was no yelling or disrespect. One resident stated a staff was disrespectful. Staff stated they never yell at residents, and treat residents with respect. Administrator stated staff have never yelled or been disrespectful, and they would not tolerate that behavior from staff. A credible witness was interviewed who stated they had never witnessed or heard of staff yelling at the residents, but had consistently heard and/or witnessed staff are rude or mean to residents. Witness indicated one resident stated some staff are kinder than others. Administrator stated one resident does not want to be at the facility so they complain about a lot of things. Based on the information obtained, this allegation is deemed Unsubstantiated at this time, and staff’s disrespectful behavior will be addressed on complaint 29-AS-20240715084408. On the allegation: Facility staff did not ensure that a resident's clothing was free of stains. It was alleged R1 spilled food on a new jacket, and it had not been washed but R1 continued to wear the jacket. Administrator confirmed that R1 had very aggressive behaviors, and often refused care verbally and by hitting and kicking staff. Administrator stated R1 had one jacket and wore it often. Administrator stated they tried to wash the jacket but R1 would refuse to allow staff to take it off or launder it, in similar way that R1 refused showers. One time, R1 went outside in the heat and removed their jacket and left it on the patio, so the housekeeper took it and washed it. A credible witness interviewed stated they have not heard of any issues regarding laundry, and have not observed any stained clothes. Administrator stated R1’s behaviors were conveyed to R1’s responsible party. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. Exit interview, report given.the state’s words, verbatim · CDSS document, Oct 7, 2024 · control 29-AS-20231227101251

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569,655(a) · Plan of correction due date: Oct 21, 2024

1569.655(a)…the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs…This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when they issued a general rate increase with less than 60 days notice, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2024

Plan of correction: POC: Administrator agrees to submit a written statement of acknowledgement and understanding of 1569.655 by 10/21/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(e) · Plan of correction due date: Oct 21, 2024

87507(f) Admission Agreements. The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by:Based on interviews, the licensee did not comply with the section cited when they stated in writing R1 would have one on one care and did not provide it, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2024

Plan of correction: POC: Administrator agrees to refund R1’s one on one care charges, since one on one care was not provided. Administrator will send proof by 10/21/2024.

Allegation investigated: Staff did not treat residents with respect

At 9:30am on 10/07/2024, Licensing Program Analyst (LPA) Jeffrues conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with BOM, Letica Ruiz-Guerrero and explained the purpose of the visit. During the investigation, LPA De Leon conducted an initial visit on 7/22/2024 from 10:15am to 3:15pm, where LPA toured the facility, interviewed staff and residents and requested documents. Additional interviews with witness, Administrator and staff were conducted on 10/3/2024. On the allegation: Staff did not treat residents with respect. It was alleged residents cry due to being yelled at by staff. Multiple residents interviewed stated they were treated “fine,” “well,” “very well,” and said there was no yelling or disrespect. One resident stated a staff was disrespectful. Staff stated they never yell at residents, and treat residents with respect. Administrator stated staff have never yelled or been disrespectful, and they would not tolerate that behavior from staff. A credible witness was interviewed who stated they had never witnessed or heard of staff yelling at the residents, but had consistently heard and/or witnessed staff are rude or mean to residents. CONTINUED on LIC9099-C Substantiated Witness indicated one resident stated some staff are kinder than others. Administrator stated one resident does not want to be at the facility so they complain about a lot of things. Based on the information obtained, the allegation is deemed Substantiated at this time. Exit interview, deficiencies cited on 9099-D, report given, appeal rights given. If they were positive asymptomatic, they were allowed to work with positive residents in alignment with local health department guidelines. Administrator stated they contact public health for every COVID-19 case or exposure for guidance, and take infection control seriously. No infection control issues were observed during the visits. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. Exit interview, report given.the state’s words, verbatim · CDSS document, Oct 7, 2024 · control 29-AS-20240715084408

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 21, 2024

87468.1(a)(1) Personal Rights. 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 requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when residents were not treated with respect, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2024

Plan of correction: POC: Administrator agrees to hold personal rights from a third-party vendor for all staff and submit proof of completion by 10/21/2024.

Allegation investigated: Staff did not provide adequate food service Staff did not provide a comfortable temperature for residents

Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above. LPA met with Diana Barnhill Administrator/Licensee and explained the purpose of the visit. LPA requested the following documentation: Staff Roster with telephone numbers, Staff Schedule for 07/2024, Resident Roster, a new and an old copy of Resident 1 (R1) LIC 602A Physicians report, 5 weeks of resident food menus, and any residents special diets. Administrator provided all records except no residents are currently on any physican precribed special diet. LPA toured the facility kitchen, food supply in refrigerator/freezer, food pantry, additonal food stored in basement refirgerators, 3 resident rooms and the secured courtyard. LPA conducted interviews with staff at 11:15am, 11:35am, 12:20pm and 12:27pm. LPA conducted interviews with residents at 12:45pm, 1:00pm, and 1:10pm. Continued 9099-C Unsubstantiated On the allegation: Staff did not provide adequate food service. LPA toured the kitchen, pantry and additional food it the basement refrigerators. LPA observed staff serve lunch to residents in the dining room, the residents were eating and ate what was provided on the plates. The meal served today was a sandwich, chips, pickles, and Jell-O with fruit punch and water, which meets requirements and the supply of food meets the regulation requirements of two day perishables and seven day non-perishable. LPA interviewed staff and residents which revealed the facility provides 3 meals per day, 2 snacks, and dessert. Interviews reveal food, beverages and snacks are available when the residents want them. Resident interviews revealed the food is not great but it is not bad either, would say it is ok. Resident interviews revealed resident would like to have a residents choice on the menu and the menu should be changed up so it is not repeated as often. LPA reviewed the residents menus and the food being served differs from day to day. Resident interviews stated they would prefer more options of bread being offered. Administrator stated the facility will provide food the residents like, and if residents tell the staff/Administrator what they want or need the facility will look into it so they can supply it. Residents interviews revealed the portion size of meals and meals themselves are adequate. Based on the evidence this allegation is Unsubstantiated at this time. On the allegation: Staff did not provide a comfortable temperature for residents. LPA toured the facility, each resident room has its own air-conditioning unit. Resident interviews revealed the facility is not cold or hot, the temperature is fine and can be adjusted if needed. The staff interviews revealed the facility air-conditioning units are working properly and can be changed as needed if and when the resident wants it. LPA observed on visit the facility outside temperature was at 86 degrees, a warm day and the facility temperature was very comfortable not hot or cold inside. Based on the evidence this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report printed for Administrator/Licensee.the state’s words, verbatim · CDSS document, Jul 22, 2024 · control 29-AS-20240715084408

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.

Allegation investigated: Licensee does not ensure an adequate supply of food is maintained and accessible at the facility. Staff are not adhering to food service requirements.

On 06/28/2024, at 10:00am Licensing Program Analyst (LPA) Jeffries arrived unannouced to the facility to deliver final findings to both allegations to this complaint. LPA met with Administrator Diana Barnhill, announced who he is and the reason for the visit. As to the allegation of, “Licensee does not ensure an adequate supply of food is maintained and accessible at the facility.” It was alleged that on 09/20/23, and 10/11 and 12/2023 the facility did not have sufficient food for residents and fresh fruit is not available to residents. It was discovered through documentation, grocery receipts, observations and interviews that on 10/23/23, LPA Jeffries conducted interviews of 6 or 12 Residents (R1, 2, 3, etc…) residing at the facility, R1-R6 all stated that they can request food or snacks at any time and have never been denied food or snacks at this facility. Interviews of Staff 1-4 (S1, S2, and S3) on 10/23/23, all stated that they provide residents with snacks twice a day and whenever requested and provide 3 meals per day. All stated that they have never denied any resident food at any time. CONTINUED on LIC9099-C Unsubstantiated All stated that one resident would take one bite of fruit then take another fruit and bite it without finishing fruit, which required fruit to be available upon request. All stated that there is always enough food supply, all 4 staff stated they have been trained in preparing meals for residents. Interview of Administrator on October 23, 2023 stated that the facility always has food, 3 meals a day, two specific snack times and pantry for “on request” snacks, Administrator added that due to confusion, wandering, and sundowning behavior of one Resident, the fresh fruits and all snacks are available for residents on request. Administrator stated at least two staff are on duty at all times to provided resident request. On 10/23/23, LPA Jeffries observed more than 2 days of perishable foods and more than 7 days of non-perishable foods on hand at the facility, LPA took photographs to document food supply. On 10/23/23 LPA Jeffries collected and reviewed facility grocery receipts from September to October 2023. Receipts for grocery items that were delivered to the facility show; on 09/05/23 Costco $197.31, 09/07/23 Costco $156.52, 09/11/23 Food4Less $143.81, 09/12/23 Costco $198.17, 09/14/23 Food4Less $112.26, 09/17/23 Costco $129.80, 09/18/23 Grocery Outlet $118.88, 09/22/23 Costco $163.48, 09/26/23 Vons $215.74, 09/27/23 Food4Less $155.78, 10/03/23 Costco $138.16, 10/04/23 Food4Less $106.09, 10/04/23 Food4Less $101.19, 10/06/23 Costco $164.23, 10/08/23 Food4Less $234.30, 10/10/23 Vons $191.81, 10/10/23 Food4Less $84.90, 10/10/23 Costco $75.03, 10/11/23 Food4Less $85.26, 10/12/23 Costco $343.13, and 10/16/23 Food4Less $209.26. ($3114.03 + $1930.25 = Total of $5044.28 spent in 45-day period) Of the receipts that were not delivery to the facility receipts during this time frame were as follows; 10/17/23 Smart and Final $120.59, 10/17/23 Grocery Outlet $143.43, 10/17/23 Vons $304.28, 10/20/23 Wall Mart $422.50, 10/20/23 Grocery Outlet $292.07, and unverifiable date Costco $647.38. Collectively, all receipts reviewed between the dates of 09/05/23 and 10/20/23 show an average of grocery shopping every 1.7 days at $112.10 per every day for 45 days on average in the time frame from 09/05/23 through 10/20/23. LPA noted that observations on 10/23/23 show crackers, cookies, mini doughnuts, potato chips, and assorted snack foods were stocked in pantry, fresh fruits were on the counter in the kitchen area visible to residents, and ice cream bars, and ice cream were stocked in freezers available to residents upon request. At this time, there is not enough evidence to support the allegation of, “Licensee does not ensure an adequate supply of food is maintained and accessible at the facility.” and is unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegation of, “Staff are not adhering to food service requirements.” It was alleged that the facility was using unsafe food handling methods regarding cross contamination of meats. It was discovered through observations, documentation, training records, and interviews that on 10/23/23 LPA Jeffries conducted interviews of S1-S3. All 3 staff stated they have been trained in preparing meals for residents. All three staff stated that they had their initial 40 hours of training that included meal preparation. S1-S3 all denied any cross contamination of foods while preparing meals at this facility. On 10/23/2023, LPA Jeffries interviewed R1-R7, who all stated, they like the food at this facility. All stated that they get snacks and 3 cooked meals per day. All stated they have never had an issue with the food service at this facility. On 10/23/2023, LPA Jeffries observed more than 2 days of perishable foods and more than 7 days of non-perishable foods on hand for at least 13 residents and staff. At this time there is not enough evidence to support the allegation of, “Staff are not adhering to food service requirements.” and is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Jun 28, 2024 · control 29-AS-20231016094648

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 10:30am 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 tight fitting covers. Physical Plant & Environment Safety: The facility is a 10 bedroom with 10 bathrooms, 3 common restrooms, kitchen, dining room, laundry room, activity room, locked office with medication locked closet currently occupying 13 residents and employs 12 staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has dual 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. 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 basement, cleaning closet and laundry rooms. The facility has sufficient space inside and outside for activities and visiting. The facility has an enclosed courtyard for client 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 13 with 13 Non-Ambulatory of which 12 may be bedridden. Hospice approved for 8. Staffing: The facility employes 11 staff and 1 Administrators. 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 expired 08/2023 waiting on renewal process. 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. Staff handling medications had annual training of 8 hours of medication training. 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. 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 closet in office. Medication were checked for expiration. Medication labels were not altered 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 along with CCL reports and PIN's were 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 08/04/2023. 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 2 residents receiving Home Health services. Home Health services records are kept on file. The facility does not have delayed egress. The facility has a key coded exit on the front exterior door. 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, Mar 20, 2024

The state marks this report as 15 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide medications as prescribed. Staff did not assist with medications refills in a timely manner.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings. LPA met with Care Staff and explained the purpose of the visit. LPA spoke with Administrator/Licensee by phone and LPA will have staff sign report. LPA De Leon conducted the initial 10-day complaint visit to the facility on 05/22/2023, conducted interviews at 10:00am, reviewed records and requested copies of records. LPA De Leon interviewed witness at 4:54pm on 05/22/2023. On 05/23/2023 LPA De Leon received additional medication records. LPA De Leon reviewed all medication records on 11/18/2023 and requested additional records. LPA De Leon reviewed additional records on 11/20/23, 11/22/2023 and 11/27/2023. On the allegation: Staff did not provide medications as prescribed. LPA De Leon reviewed Medications records for R1 which revealed 2 medications Timolol and Latanoprost were not being ordered monthly. Continued 9099-C Substantiated Medication Timolol Mal Sol 0.5% OP 15ml bottle expired approximately 1 year after order date according to the Pharmacy Model Drug. The facility Centrally Stored Medication and Destruct Record (CSMDR) showed Timolol medication logged in for the months of April, July, November of 2022 and February, March of 2023. The facility Medication Administrator Record (MAR) shows medication Timolol listed from April 2022-March 2023 being given daily in 1 eye 2x’s per day as prescribed by the doctor. The Timolol medication ordered in July 2022 and then ordered in November of 2022 would not have provided enough medication to fill the requirements of the prescription order of 1 eye 2x’s per day. The Medication Latanoprost Sol 0.005% 2.5ml bottle needed to be discarded 6 weeks after the bottle was opened according to the Pharmacy Model Drug. The facility CSMDR record showed Latanoprost logged in for the months of May, June- 2x’s, July of 2022 and February, March 2023. The facility MAR showed the medication Latanoprost given in 1 eye 1 time per day from April 2022-March 2023 as prescribed by the doctor. The Latanoprost 2.5 ml bottle will last approximately 30 days according to the Pharmacy Model Drug and the medication needs to be discarded 6 weeks after opening the bottle. Medication Latanoprost would have needed to be ordered and logged on to the CSMDR every 6 weeks to be able to fill the doctor’s order and not be expired while using. The pharmacy Model Drug payment invoices showed there were no re-orders for Latanoprost in August, September, October, November, or December of 2022 and January of 2023. LPA reviewed the medication orders/invoices from Pharmacy Model Drung which showed Timolol was ordered on 04/07/22, 07/25/22, 11/15/22, 02/24/2023, 03/18/2023, and the medication showed Latanoprost was ordered on 04/06/22, 05/17/22, 06/20/22, 07/25/22, 02/24/23, and on 03/18/23. Based on the evidence this allegation is deemed Substantiated at this time. On the allegation: Staff did not assist with medications refills in a timely manner. LPA reviewed the medication order/invoices from the Pharmacy Model Drug which showed medications were not ordered monthly. The medication Timolol was not ordered in the months of May, June, August, September, October, December of 2022, and January of 2023. The medication Latanoprost was not ordered in August, September, October, November, December of 2022, and January of 2023. The medications were not being ordered to fill the doctor’s prescriptions orders or enough of the medication Latanoprost for it to not to be expired while using. Based on the evidence this allegation is deemed Substantiated at this time. Exit interview conducted, deficiency issued, copy of report and appeal rights printed for Licensee/Administrator.the state’s words, verbatim · CDSS document, Dec 1, 2023 · control 29-AS-20230517162207

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 8, 2023

(a)...The plan...provide assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review the licensee did not comply with the regulation above R1’s medications was not being reordered as often as needed and one medication was being used after it expired which poses a immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 1, 2023

Plan of correction: Licensee/Administrator agreed to hold staff training for all staff handling medications on regulation 87465, CCL Medication Guide, and facility policy and procedures for handling and reordering medications, audit medications for expiration dates, provide an up-to-date LIC 500 with training documents and staff signatures to CCL.