Cadence Millbrae

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

Allegation investigated: - Residents sustained bruises due to staff neglect or physical abuse - Staff sleep at the facility while on shift - Staff left residents on the floor for an extended period of time - Staff mismanaged residents’ medications

On 07/23/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint visit to deliver findings regarding the allegations received. LPA met with the administrator Holly Suiter and explained the purpose of today's visit. During the investigation, LPA conducted interviews with staff, reviewed medications in both memory care and assisted living, toured the facilty to make observations, and reviewed pertinent documents related to the allegations. There were no reported incidents of residents sustaining bruises due to neglect or physical abuse. There is a system in place to report such findings on residents and none have been generated or reported by staff. Per staff schedule reviewed, there are at least 2 to 3 staff scheduled during night hours. There is no evidence of staff sleeping during these hours. Continued on page 2... Unsubstantiated Page 2 The facility does not have live cameras in the common areas of memory care to support such allegations and no other staff reported witnessing staff sleeping during night shift hours. In regards to residents being left on the floor due to falls, the facility has Safely You cameras in resident rooms with no blind spots. There were no alerts of any falls where a resident was left on the floor for an extended period of time. Alerts were reviewed and no evidence of such was identified by staff. A review was conducted of both memory care and assisted living medications was made by LPA with the assistance of facility staff, their logging routine, and their process was reviewed with no findings of missed medications. Per staff schedule reviewed, there are at least 2 to 3 staff scheduled during night hours. There is no evidence of staff sleeping during these hours. The facility does not have live cameras in the common areas of memory care to support such allegations and no other staff reported witnessing staff sleeping during night shift hours. In regards to residents being left on the floor due to falls, the facility has Safely You cameras in resident rooms with no blind spots. There were no alerts of any falls where a resident was left on the floor for an extended period of time. Alerts were reviewed and no evidence of such was identified by staff. A review was conducted of both memory care and assisted living medications was made by LPA with the assistance of facility staff, their logging routine, and their process was reviewed with no findings of missed medications at the time of this investigation. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jul 23, 2026 · control 14-AS-20260702084858

Type of visit: Case Management - Incident

On 07/23/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident report visit. LPA met with the executive director Holly Suiter and explained the purpose of today's visit. On 07/22/2026, the Department received an incident report regarding the kitchen of the facility kitchen being inspected by county Environmental Health Services on 07/20/2026, due to the allegation that the facility freezer did not hold accurate temperature. Environmental Health Services made findings that this was an unfounded allegation. During the same inspection old rodent droppings were found in certain areas, but not contaminating facility food supply. According to the administrator, these droppings were old and not from any current rodent issue. Due to this, Environmental Health closed the kitchen on 07/20/2026 after lunch was served. A food plan was set in place by the facility and food services for dinner took place as scheduled via catering and food preparation by their sister community. The kitchen was reopened by the next morning on 07/21/2026 around 10am by Environmental Health when corrections were observed. Breakfast services were provided to residents on 07/21/2026 as scheduled. The facility has operated with two pest control companies since 2025 with no issues regarding pest infestation. As part of today's visit, LPA toured the kitchen to ensure the freezer is fully operational and observed areas identified in Environmental Health's report where old droppings were found. LPA reviewed plans that were executed and were in place to meet the resident needs. Pest control records were reviewed verifying services as continually in place with no active findings of pests. No citations issued. Report reviewed with administrator and a copy is provided.the state’s words, verbatim · CDSS document, Jul 23, 2026

Type of visit: Required - 1 Year

On 07/08/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with the executive director Holly Suiter and explained the purpose of today's visit. There are currently 110 residents in assisted living and 24 in memory care. This is a multi-level facility approved for all residents allowed to be non-ambulatory, five bedridden, and a hospice clearance for 14 residents. This facility does have a secured memory care area. There are currently 8 residents on hospice at this time. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked and secured in the kitchen. Perishable and non-perishable food supplies are observed as in place. Kitchen grade fire extinguisher is observed as in place and with an inspection date of 07/02/2026. First aid kit is observed as complete with required items as observed in medication room and through out the facility. Medications are observed to be locked in cabinets and medication cart in the medication room in assisted living and in a medication cart in memory care. LPA reviewed resident medications at random and observed them as current. LPA observed that there are multiple fire extinguishers in place on each floor with an inspection date of 06/29/2026 smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating and air conditioning. Last emergency/disaster drill was conducted on 06/25/2026 regarding power outages and procedures with such cases. Continued on next page... Page 2 Laundry areas are also observed as fully operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 107F in resident rooms at random. Cleaning supplies are observed to be inaccessible to residents in care. Resident rooms are observed at random and observed that the rooms appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place through out the facility. Main large laundry room was observed to be in full operation and in good condition. LPA observed that the rear of the large dryers are free of dust and debris. LPA reviewed five staff files and five resident files during today's inspection and all files are observed as current. Staff are actively conducting training via Relias and it is observed as current. Administrator certificate is current expiring 01/14/2027. No citations issued. Report is reviewed with Holly and a copy is provided on this day.the state’s words, verbatim · CDSS document, Jul 8, 2026

Type of visit: Case Management - Incident

On 11/25/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident report visit. LPA met with the executive director Holly Suiter and explained the purpose of today's visit. On 11/14/2025 the Department received an incident report regarding a resident that was observed to be abused by a med-tech on duty. The resident slid from their wheelchair and the med-tech pulled the resident's hair as the resident was on the floor. This abuse was caught on camera and was brought to the attention of the business office director on 11/03/2025 by another caregiver that witnessed the abuse. The hair pulling took place on 10/29/2025 and was caught on camera. Facility leadership reviewed the camera footage and confirmed the staff person's action via the footage. Facility leadership, the administrator and business office director, met with the staff person and addressed the incident observed via camera footage. The staff person denied the allegation despite the camera footage evidence and left their position as med-tech voluntarily on 11/04/2025. The facility terminated the med-tech and has not returned to the facility for work duties since 11/04/2025. Due to the age of the incident, there is no signs of injury to the resident. The resident resides in the memory care portion of the facility. An assessment of the resident was conducted and there were no visible signs of injury. The resident was not sent to the hospital. The facility is being cited for personal rights due to the med-tech's abuse as it is an immediate health and safety concern for the resident in care. Citation issued on the following LIC809D. Report is discussed and a copy is provided to the executive director.the state’s words, verbatim · CDSS document, Nov 25, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 26, 2025

87468.1(a)(2) Personal Rights of Residents in All Facilities - To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This regulation has not been met as evidenced by: Based on interviewes conducted, and incident report recieved, it was confirmed that the med-tech on duty was observed to pull the hair of a resident. This was witnessed by another staff on duty. This was reported to facility leadership and camera footage was reviewed confirming the abuse. This poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: The facility, licensee/administrator, shall conduct an in-service training with staff regarding Resident Rights, including types of abuse, handling residents with behaviors, etc. Evidence of such training to be recieved by due date.

Allegation investigated: - Staff did not keep the facility free of pest

On 08/27/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver finding regarding the recieved allegations. LPA met with facility administrator Holly Suiter and explained the purpose of today's visit. During the investigation LPA conducted interviews, made observations, and reviewed petinent documents regarding the allegations. It was discovered that there was an inspection done by the county Environmental Health Services confirmed the finding of one deceased pest in a trap set by their active contract with a pest control company. The facility is actively monitoring and taking preventative measures in pest control in the facility. Based on the report reveiwed from the county, the kitchen did pass inspections for food safety and storage. This allegation is unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with Holly and a copy is provided on this day. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 27, 2025 · control 14-AS-20250730083335

Type of visit: Required - 1 Year

On 08/27/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with the executive director Holly Suiter and explained the purpose of today's visit. There are currently 136 residents in assisted living and 21 in memory care. This is a multi-level facility approved for all residents allowed to be non-ambulatory, five bedridden, and a hospice clearance for 14 residents. This facility does have a secured memory care area. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked and secured in the kitchen. Perishable and non-perishable food supplies are observed as in place. Kitchen grade fire extinguisher is observed as in place and with an inspection date of 06/08/2024. First aid kit is observed as complete with required items as observed in medication room. Medications are observed to be locked in cabinets and medication cart in the medication room. LPA reviewed resident medications at random and observed them as current. LPA observed that there are multiple fire extinguishers in place on each floor with an inspection date of 07/07/2025 smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating and air conditioning. Laundry areas are also observed as fully operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted in May 2025. Water temperature was measured at 108F in resident rooms at random and 111F in a common bathroom. Cleaning supplies are observed to be inaccessible to residents in care. Resident rooms are observed at random. LPA observed two resident rooms and both appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Continued on next page... Page 2 Resident linen supplies are observed as in place. LPA reviewed five staff files and five resident files during today's inspection and all files are observed as current. Staff are actively conducting training via Relias and it is observed as current. Administrator certificate is current expiring 01/14/2027. The following updated forms are requested to be submitted to CCLD by 09/03/2025: • Copy of facility's liability insurance • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule No citations issued. Report is reviewed with Holly and a copy is provided on this day.the state’s words, verbatim · CDSS document, Aug 27, 2025

Allegation investigated: - Staff is overcharging resident in care - Staff are not communicating with resident's POA in a timely manner

On 04/08/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to open the complaint and investigate the allegations received. LPA met with interim administrator Davina Barker and explained the purpose of today's visit. During the course of the investigation, LPA conducted interviews and reviewed documentation regarding the resident and the allegations. In regards to overcharging resident in care, it appeared to be an error in the billing system. The facility worked with the family to correct the mistake and compensate the family accordingly. In regards to no communicating with the resident's POA in a timely manner, LPA could not confirm if there was an issue regarding communication in a timely manner based on interviews and documentation observed. These allegations are unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. This report is reviewed with Davina and a copy is provided during today's visit Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 8, 2025 · control 14-AS-20250131115024

Allegation investigated: - Staff mishandled a resident medication

On 11/08/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannonced complaint investigation visit in order to deliver findings regarding the received allegation. LPA met with Joan Newman and explained the purpose of today's visit. During the investigation, LPA conducted interviews and reviewed pertinent documentation. It was discovered that the facility did not provide a medication to a resident that is prescribed. The medication was stopped being given to the resident without an order on file from the physician. The medication was stopped around February 18, 2024 through April 7, 2024. It was started again after the discovery of it not being given, but then again was stopped around April 27, 2024 thorugh August 17, 2024. The prescription for the medication was not discontinued by the physician at any point. The dosage was decreased per records reviewed, and per interviews, this may have also caused issues with the facility maintaining the medication on their medication records. The medication was not given although it was prescribed by the physician due to facility error. This allegation is substantiated. Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Substantiatedthe state’s words, verbatim · CDSS document, Nov 8, 2024 · control 14-AS-20241007215642

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Nov 9, 2024

87465(c)(2) Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This regulation has not been met as evidenced by: Based on interviews and documentation reviewed, LPA discovered that the medication was prescribed for the duration of 2024 but was stopped on two spans of time from 2/18/24 through 04/07/24 and 04/27/24 through 08/17/24 without documentation on file from the physician of the resident to discontinue.the state’s words, verbatim · CDSS document, Nov 8, 2024

Plan of correction: The facility shall develop a plan of correction addressing how this regulation will be met at all times. Plan of correction to be received by 11/09/2024.

Type of visit: Case Management - Incident

On 11/08/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident visit in response to an SOC 341 report received on 11/07/2024. LPA met with administrator Joan Newman and explained the purpose of today's visit. During today's visit LPA conducted interviews and collected pertinent documents regarding the resident. LPA also discussed the incident with the local long term care ombudsman assigned to this facility regarding the incident. Facility staff investigated the reported incident but could not come to any conclusions. The person in question as described by the resident, could not be a staff member as there are no staff matching the description of the supposed person. Male residents in the area also do not match the description provided. Facility does not have cameras in common areas of the facility. Per the facility the incident was reported to the hospice agency who then reported to the facility. As a precaution the facility has implemented a plan to assist the resident in order to prevent any issues in regards to males entering the resident's room. The facility has assigned no male staff to the resident, but if there is a male med-tech needs to visit the resident, they are to be accompanied a female care partner. The facility met with the family and they are aware and are working with the facility at this time. No further issues were discussed. No citations issued.the state’s words, verbatim · CDSS document, Nov 8, 2024

Type of visit: Case Management - Other

On 09/27/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - other visit. LPA met with Tina Pedagat Business Office Manager and explained the purpose of today's visit. During today's visit LPA Vado is requesting documentation related to complaint # 14-AS-20230804102303 regarding a resident in care at the time of the complaint investigation in 2023. LPA requested the date specific document but the facility does not have the requested record to provide to the Department regarding R1's ADL reference sheet from 06/27/2023. This poses a potential health and safety risk to residents in care. Due to the facility not having this document not being able to be found a citation is issued on this day. Citation issued on the attached LIC809D. Report is reviewed with Tina Pedagat and a copy is provided during on this day.the state’s words, verbatim · CDSS document, Sep 27, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: Oct 4, 2024

87506(e) Resident Records - Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This regulation has not been met as evidenced by: Based on recrod request, the facility is unable to provide a resident document dated 06/27/2023 that should be maintained for 3 years following the termination of service to the resident.the state’s words, verbatim · CDSS document, Sep 27, 2024

Plan of correction: The facility shall develop a plan of correction addressing how this regulation will be met at all times. Plan of correction to be received by 10/04/2024.

Type of visit: Required - 1 Year

On 08/20/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with the executive director Joan Newman and explained the purpose of today's visit. There are currently 91 residents in assisted living and 17 in memory care. LPA was allowed entry into the facility. This is a multi-level facility approved for all residents allowed to be non-ambulatory, five bedridden, and a hospice clearance for 14 residents. This facility does have a secured memory care area. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked and secured in the kitchen. Perishable and non-perishable food supplies are observed as in place. Kitchen grade fire extinguisher is observed as in place and with an inspection date of 06/08/2024. First aid kit is observed as complete with required items as observed in medication room. Medications are observed to be locked in cabinets and medication cart in the medication room. LPA reviewed resident medications at random and observed them as current. LPA observed that there are multiple fire extinguishers in place on each floor with an inspection date of 06/12/2024, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating and air conditioning. Laundry areas are also observed as fully operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 08/07/2024. Water temperature was measured at 111F in resident rooms at random. Cleaning supplies are observed to be inaccessible to residents in care. Resident rooms are observed at random. LPA observed five resident rooms and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Continued on next page... Page 2 Resident linen supplies are observed as in place. P&I monies are not handled by the facility. LPA reviewed four staff files and five resident files during today's inspection and all files are observed as current. Staff conducting via Relias and observed as current. Administrator certificate is current expiring 02/28/2025. The following updated forms are requested to be submitted to CCLD by 08/27/2024: • Copy of updated Administrator Certificate • Copy of facility's liability insurance • LIC400 Affidavit Regarding Client/Resident Cash Resources • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property or copy of lease No citations issued. Report is reviewed with Joan and a copy is provided on this day.the state’s words, verbatim · CDSS document, Aug 20, 2024

Type of visit: Office

On 6/24/24, San Bruno Regional Office conducted a non-compliance conference meeting with Executive Director, Joan Newman, Attorney Joel Goldman, Regional VPO Mark Maclaine, Director of Compliance Holly McMurry. Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Manager, April Cowan, and Licensing Program Analyst, Grace Donato. During non-compliance meeting, the following violations were discussed, 87468.1(a)(2) Personal Rights of Residents in All Facilities, 87470(b)(2) - Infection Control Requirements, 87211(a)(2) - Reporting Requirements, 87466 - Observation of Resident, 87464 - Basic Services, 87468.2(a)(4) - Additional Personal Rights of Residents in Privately Operated Facilities, 87463(a)(4) - Reappraisals. During this meeting, it was discussed, Licensee will receive more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providersthe state’s words, verbatim · CDSS document, Jun 24, 2024

Allegation investigated: - Staff are not providing medication as prescribed

LPA Jeung reviewed file for client #1 and interviewed client #1. Staff involved in incident of 1/11/24 regarding client #1 is no longer employed. According to client, medication Seroquel (Quetiapine) was not given. Based on facility Progress Notes and Medication Administration Order Tracking, on 1/11/24, the medication was not maintained and not given. Client recounted that medication staff were unable to procure medication, so he requested to be taken to hospital, where he would be given the medication. This is also documented in the Progress Notes. Client said that he received medication and returned to facility without an overnight stay. It is documented that staff ordered medication on 1/9/24, but had not received it. It cannot be determined that staff failed to administer medication as prescribed, as the electronic MAR and electronic Medication Administration Order Tracking--which reflects medications that were GIVEN--show inconsistent information for administration of Quetiapine in January 2024. Based on information obtained, including interviews with resident and staff, this allegation is determined to be unsubstantiated. Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 8, 2024 · control 14-AS-20240215114634

Allegation investigated: - Staff are financially abusing resident in care

LPA Jeung interviewed residents. Based on this investigation, which included review of client records and interviews with clients and staff, this allegation is determined to be unsubstantiated. Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur. It was alleged that female staff were "flirting" with male resident(s) to get cash tips. Although there is no proof that staff received cash tips from male residents, this was also not refuted by at least one male resident. Based on information obtained from complainant, staff and residents, this may have occurred, as an isolated incident. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 8, 2024 · control 14-AS-20240205120118

Allegation investigated: - Staff do not ensure that resident(s) are adequately fed while in care

LPA Jeung interviewed staff. Based on review of clients' records, observation of boxed meal preparations, and interviews with clients, staff and witnesses, this allegation is determined to be unsubstantiated. Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur. Dining room serves breakfast from 7 - 9am, lunch 11am - 1pm, dinner 4 - 6pm. For those who receive meals in their rooms, boxed meals are prepared by kitchen staff before regular dining room service, for pick up or delivery by caregivers; breakfast boxes are prepared and ready for delivery between 7 and 7:30 am, lunch boxes from 11 to 11:30am, and dinner boxes between 4:00 and 4:30 pm. Kitchen and dining staff do not work after 6 pm, so prepared food is not available after 6pm. Client's responsible party was provided with the cell phone number of the culinary services director to report concerns, but has not contacted him when delivered meal was not as ordered. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 8, 2024 · control 14-AS-20231127170557

Allegation investigated: - Staff failed to meet resident's needs - Resident sustained multiple falls and injuries while in care

AMENDED REPORT OF LIC9099A DATED 02/22/2024 On 03/01/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver amended LIC9099 report and deliver findings regarding the allegations listed above. LPA met with --- and explained the purpose of today's visit. During the complaint investigation it was discovered that the resident had several documented falls - March 2022, February 2023, April 2023, and May 2023. On May 29, 2023 the resident had an unwitnessed fall, and based on interviews no one knew where the staff were and no staff were present to supervise the resident. The resident suffered significant injury which resulted in hospitalization and an arm separation was as a result of the fall. April 2023 fall the resident was evaluated at the hospital and released on the same day. After multiple falls in the facility there were no reappraisals done for the resident although the facility identified the resident as a fall risk. The facility failed to reassess the resident, establish, and update safety measures to prevent falls after sustaining these multiple falls to meet the resident's needs. Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Substantiatedthe state’s words, verbatim · CDSS document, Mar 1, 2024 · control 14-AS-20230804102303

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a)(4) · Plan of correction due date: Mar 2, 2024

87463 Reappraisals - (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This regulation has not been met as evidenced by: Based on the investigation the facility failed to reassess resident who was identified as a fall risk and develop a plan of care to prevent falls and meet the resident's needs.the state’s words, verbatim · CDSS document, Mar 1, 2024

Plan of correction: The licensee shall create a plan of correction to ensure that this regulation is met at all times.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 2, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities - (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This regulation has not been met as evidenced by: Based on the investigaiton the facility did not provide care and supervision to meet the needs of a resident who was identified as a fall risk and suffered a fall on May 29, 2023 that resulted in arm separation. There was no staff to supervise and was no where to be found.the state’s words, verbatim · CDSS document, Mar 1, 2024

Plan of correction: The licensee shall create a plan of correction to ensure that this regulation is met at all times.

Allegation investigated: - Resident sustained an arm separation while in care - Resident suffered from dehydration while in care

AMENDED REPORT 03/01/2024 Based on investigation conducted by this Department--which included review of facility and medical records and interviews with staff--these allegations are determined to be substantiated. The preponderance of evidence standard has been met. Client #1 was admitted to facility's memory care unit in January 2022. Care Plan and Service Plan--signed by client's representative--were documented by facility in August 2022; high scores for care needs were noted in the areas of neurogocognitive, mobility/ambulation, toiletting and transferring. It is noted that "resident is dependent on staff for all escort needs, requires frequent supervision and oversight," and frequent status checks. In March 2023, a Care Plan detail was completed by facility staff--but not signed by client's representative; client was noted to require extensive assistance in ambulation, transferring, toileting and moderate supervision due to wandering tendencies. All staff interviewed acknowledged that client was a fall risk. Continued Substantiated According to facility records, several falls were documented--in March 2022, February 2023, April 2023. Client did not sustain any significant injuries as a result of these falls; he was evaluated at the hospital after April 2023 fall and released the same day. Client was not under direct staff supervision on 5/29/23 when he fell in the common living room of memory care unit and sustained an acute shoulder separation. Client was evaluated and treated at the hospital. On 6/27/23, client was observed to be unresponsive with low oxygen level. 9-1-1 was called and client was transported to hospital, where tests revealed he was severely dehydrated and significantly hyperglycemic. Client was admitted to ICU with severe sepsis and hypernatremia. Based on staff interviews, client missed 3 meals immediately prior to hospitalization, only one of which was documented. In addition, client was known to be always eager to eat, so his refusal to eat was unusual. Staff failed to accurately document the change in condition. report this to client's family and seek medical advice. Deficiencies of the California Code of REgulations, Title 22 are cited on a following page, as well as civil penalties of $1000-- $500 for Section 87464 Basic Services and $500 for Section 87466 Observation of Resident. Assessment of additional civil penalties is pending.the state’s words, verbatim · CDSS document, Feb 22, 2024 · control 14-AS-20230804102303

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464 · Plan of correction due date: Feb 23, 2024

87464 BASIC SERVICES - Basic services shall ... include care and supervision as defined in 87101(c)(3) and Health and Safety Code 1569.2(c), meaning the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with ADLs without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement was not met as evidenced by: Based on investigation the licensee failed to ensure adequate supervision of a client who was a fall risk by leaving resident with fall risks alone, which poses immediate health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Plan/proof of correction to be submitted to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 23, 2024

87466 OBSERVATION OF RESIDENT - The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes...are observed...such brought to the attention of the resident's physician and the resident's responsible person. This requirement was not met as evidenced by: Based on the investigation licensee failed to monitor changes in resident and failed to seek medical attention to address medical needs.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Plan/proof of correction to be sent to CCLD BY DUE DATE

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.