Wood Glen Hall

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

Allegation investigated: Staff failed to keep resident's personal information confidential. Facility does not have an adequate plan to be self-reliant for power outage.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to issue final findings on the allegations stated above. Long Term Care Ombudsman, Diane See, accompanied LPA during the visit. LPA met with Rick Olds, Administrator and explained the purpose of the visit. On 7/15/2025 from 11:00 am to 3:30 pm, LPA Kontilis conducted an initial complaint visit to obtain documents and conduct interviews with staff. On 10/1/2025 from 12:05 pm to 5:45 pm, LPA conducted a subsequent complaint visit to conduct additional interviews with staff and residents. On the allegation: Staff failed to keep a resident's personal information confidential. It was alleged that one resident asked a staff where another resident was, and the staff disclosed they were in the hospital. Staff interviewed stated they had never heard a staff member provide personal information about another resident. Administrator stated the facility policy is that staff explain to residents that they are required to Please continue to 9099-C, Pg 2. Unsubstantiated keep residents’ information private due to HIPAA. Administrator further stated staff do not typically know the specifics of where a resident is if the resident has left the community. One staff stated a resident may ask who is going to the hospital, but they would respond that they ‘do not know’. It is reasonable for a resident to ask where their friend is, and no personal or confidential information would be provided if staff stated they were in the hospital (and not at the facility). Based on the information obtained, the allegation is Unsubstantiated at this time. On the allegation: Facility does not have an adequate plan to be self-reliant for power outage. It was alleged the facility’s generator did not function during a power outage. Interim Administrator stated on 7/3/2025 they had a power outage. A staff said there was an error message on the generator. A staff called the company that manages the generator, but they were not able to send out anyone right away due to it being before a holiday, and it would be at least four hours. Interim Administrator called other companies and was able to get a temporary generator delivered within 30-40 minutes, and they tried to troubleshoot the issue with the main generator. Interim Administrator stated additional batteries, lanterns, and flashlights were ordered by the Business Office Manager. Interim Administrator stated the generator company arrived around the same time to troubleshoot. Shortly thereafter, the power came back on. One vendor was able to get the generator working but noted it was an older generator. Interim Administrator stated they kept the temporary generator in place for a few more days due to the potential for other power outages. Interim Administrator stated they were working to get quotes for a new, larger generator. It is not required that facilities have a generator on the premises but must be able to obtain one in a reasonable amount of time. The facility did have a plan to be self-reliant and found an alternative solution quickly when needed. Based on the information obtained, the allegation is Unsubstantiated at this time. Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Feb 6, 2026 · control 29-AS-20250711115955

Allegation investigated: Staff failed to assist residents with transportation needs.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to issue final findings on the allegation stated above. Long Term Care Ombudsman Diane See accompanied LPA during the visit. LPA met with Rick Olds, Administrator, and explained the purpose of the visit. On 7/8/2025 from 11:51 am to 5:00 pm, LPA Kontilis conducted an initial complaint visit to obtain documents and conduct interviews. On the allegation: Staff failed to assist residents with transportation needs. It was alleged the facility’s wheelchair transportation bus had been non-operational for more than a year during which time the facility transportation consisted of two SUV vans for approximately 5-6 passengers per van. It was alleged that on 6/28/2025 there was an outing scheduled, and a resident in a wheelchair was denied participation because their wheelchair was too large for the available transportation van. It was alleged that the resident was discouraged from attending the outing so they could accommodate ambulatory residents and/or Please continue to 9099-C, Pg 2. Substantiated residents only using walkers on the outing. During today’s visit, interviews conducted revealed Resident 1 (R1) was discouraged from attending the outing because R1’s wheelchair took up space that could accommodate additional residents. During today’s visit, Administrator stated at the onset of becoming Administrator in August 2025, Administrator recognized the need to get the facility bus up and running and promised the residents that it would be fully operable in time for the holiday season. Administrator stated a representative from the California Highway Patrol, Safety Service and Security, Coastal Division MCSU was consulted during the process which took approximately three (3) months to bring the project to fruition making the facility bus fully operable. Based on the information obtained, the allegation is Substantiated at this time and a technical violation has been issued. Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Feb 6, 2026 · control 29-AS-20250630152236

Allegation investigated: Staff are not keeping medications in their original bottle Medications are stored in resident's room without physician's authorization

At 10:05am, on 11/24/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to investigate the allegations of this complaint. LPA met with Administrator Rick Olds, announced who he was and the reason for the visit. During the visit LPA collected documents, reviewed resident files, and conducted interviews. On the allegation: Staff are not keeping medications in their original bottle. It was alleged the facility was pre-pouring medication 24 hours in advance. LPA reviewed medications and interviewed relevant staff about medication practices. Staff interviewed stated medications are not pre-poured more than 24 hours in advance. There is no regulation stating medications may not be prepared or pre-poured in advance. (Continued on LIC9099-C) Unsubstantiated Per CCLD’s Medications Guide, setting up medications no more than 24 hours in advance is an acceptable practice. Based on all interviews conducted and LPA observation, the above allegation was found to be unsubstantiated at this time. On the allegation: Medications are stored in resident's room without physician's authorization. LPA interviewed staff who indicated 21 of 49 residents store their medications in their rooms and independently self-administer medications. LPA conducted a tour of the facility and toured 7 residents’ rooms. LPA observed self-administered medications were appropriately locked in a dresser drawer provided by the facility to each resident. LPA reviewed the same residents’ files and confirmed their physician’s report indicates they can store and self-administer their medications without staff assistance. In rooms where residents’ cannot self-administer their medications, LPA observed medications are managed and stored by the facility, not accessible to the residents. Based on all interviews conducted and LPA observation, the above allegation was found to be unsubstantiated at this time. At this time no deficiencies are cited. Exit interview conducted, report signed, and report provided to the Administrator.the state’s words, verbatim · CDSS document, Nov 24, 2025 · control 29-AS-20251119090701

Allegation investigated: The facility failed to store, prepare, and serve food in a safe and healthful manner. Staff failed to follow the food menu.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to further investigate the allegations as stated above. During today’s visit, LPA met with Rick Olds, Executive Director and explained the reason for the visit. The initial visit was conducted on 7/15/2025 from 11:00 am to 3:30 pm in which LPA conducted interviews with staff, obtained documents pertaining to the investigation, and conducted a tour of the facility. During today’s visit from 12:15 pm to 4:00 pm, LPA conducted a tour of the facility and interviewed staff and residents. On the allegation, the facility failed to store, prepare, and serve food in a safe and healthful manner: At approximately 12:32 pm during a tour of the kitchen area, LPA observed all kitchen staff wearing hairnets as well as foods appropriately wrapped and marked; lunch items properly plated just prior to being served to residents in care; and, fresh fruits and vegetables properly stored in industrial sized cold storage refrigerators. Additionally, LPA reviewed menus from 9/14/2025 to today’s date, 10/1/2025. Please see 9099-C, Pg 2. Unsubstantiated During today’s visit, Staff 1 (S1) stated the facility subscribes to a “Dietician Approved Menu” program designed specifically for assisted living as well as other types of facilities for elderly individuals. S1 further stated much of the menu items are made from scratch such as the tomato bisque soup and the Mediterranean Quiche. S1 stated dining room feedback forms are placed on the dining tables and residents are encouraged to provide feedback as to the food items they like and/or dislike. S1 further stated a monthly feedback form is summarized and discussed at the Chef’s Corner Meeting held monthly. During today’s visit, interviews conducted revealed eight out of eight residents believed the nutritional value of the food was of good quality and at a “healthful” standard. Three residents stated when substitute items are requested, they are satisfied with the quality of the substitution and that it is to their liking. Five of the eight residents interviewed specifically stated they ‘liked the food’ and were provided with additional portions upon request. Two of the eight residents stated the food is too spicy at times and acknowledged that that is a personal preference. Based on the interviews conducted, records reviewed, and observations made, the allegation that the facility failed to store, prepare, and serve food in a safe and healthful manner is Unsubstantiated at this time. On the allegation, staff failed to follow the menu: During today’s visit, LPA obtained meal menus from 9/14/2025 to today’s date, 10/1/2025. During today’s visit, LPA observed today’s lunch as stated on the menu which consisted of tomato bisque soup, Mediterranean Quiche, green seedless grapes, endive salad with Parmesan cheese and fresh orange slices, and homestyle strawberry shortcake. During today’s visit, Staff 1 (S1) stated the facility subscribes to a “Dietician Approved Menu” program designed specifically for assisted living as well as other types of facilities for elderly individuals. The menus are created on a seasonal basis and items are pre-ordered based on the ingredients needed for each meal. S1 stated if a menu item needs to be revised, it is posted on the daily menu for that meal of that day. S1 further stated they ensure the items are available prior to creating the menu. During today’s visit, interviews conducted revealed seven out of eight residents stated the facility menu is followed and when substitutions are made, it is only a slight variance from the original stated menu item. Based on interviews conducted and observations made, the allegation that staff failed to follow the menu is Unsubstantiated that this time. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 29-AS-20250711115955

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

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual visit to the facility stated above. LPA was greeted by staff and explained the purpose of the visit. Administrator Rick Olds arrived shortly after LPA’s arrival. The facility is a non-profit residential care facility for the elderly. The facility is licensed for a capacity of 72 residents of which 72 can be non-ambulatory. The facility maintains a hospice waiver for 10 residents. There are currently 5 residents on hospice. The facility is maintained in conformity with State Fire Marshall regulations. The facility has smoke alarms, a sprinkler system, and a pull alarm system that is hard-wired and notifies the local fire department when activated. Fire drills and disaster emergency preparedness drills are conducted quarterly throughout the facility. The community has two vans and one pick up truck utilized for transporting residents to appointments and outings. The Administrator is present a sufficient number of hours to manage and oversee the facility. The facility consists of 63 resident rooms, a dining room, lanai, game room, library, meditation room, tea room, garden room, a computer lab, a beauty shop, a laundry room, east side patio, gardening area, and a gazebo. Throughout the facility are private sitting areas, snack stations, hydration stations, and an area for sewing/ironing. Paved walkways surround the facility are utilized by residents for daily strolls. The parking area and resident pick up/drop off area has flush curbing to assist non-ambulatory residents Meals are prepared in the main kitchen and served to residents in the dining area and in their private rooms. The facility utilizes assigned seating in the dining room for purposes of special diets and special requests. The Garden Room is available to residents for family meals and special occasions. Due to time restraints, LPA will return at a later date to continue the inspection. Exit interview conducted. No deficiencies noted. Report issued at the time of the visit.the state’s words, verbatim · CDSS document, Oct 1, 2025

Allegation investigated: Staff do not ensure resident binders are up to date. Staff are pre-pouring medications.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced 10-day complaint investigation based on the above stated allegations. LPA met with Administrator Rick Olds and explained the purpose of the visit. During today’s visit, LPA obtained documents pertaining to the allegation and conducted interviews with staff. On the allegation, “Staff do not ensure resident binders are up to date”, LPA reviewed resident records for ten (10) residents and found 10 out of 10 residents’ binders to include required documents including but not limited to emergency face sheets, dates of birth, dates of admission, Physician’s report, Resident’s care plan; Pre-Placement Appraisal and/or Re-Appraisal; and Medication Administration Record. Additionally, per facility staff, the facility is in the process of updating resident records to include recommended documents as a suggestion from a residential care consulting agency. The recommended documents are not required Please continue to 9099-C, Pg 2. Unsubstantiated per Title 22 regulations. Based on records reviewed, interviews conducted, and observations made, the allegation Staff do not ensure resident binders are up to date is Unsubstantiated at this time. On the allegation, “Staff are pre-pouring medications”, LPA Kontilis reviewed Medication Guide, Residential Care Facilities for the Elderly published by California Department of Social Services, Community Care Licensing Division, Advocacy and Technical Support, Resource Guide, TSP 2016-03 (version 8/30/2021) with administrator and staff. The medication guide specifically states, “Medications may be ‘set up’ or ‘poured’ under the following circumstances…Pour medications from the bottle directly into the individual resident’s cup/utensil to avoid touching or contaminating the medication; implement a process to ensure medication is given to the correct resident; implement procedures for situations such as medication spillage, contamination, assisting with liquid medication, interactions of medications, etc. During today’s visit, LPA Kontilis interviewed Staff 1 (S1) wherein S1 demonstrated the steps they take when popping medications prior to administering to residents in care. S1’s demonstration included precautions taken such as wearing gloves to ensure no contamination of the medication occurs. LPA observed the medication cups to have the Resident’s name, picture, and room number on each medication cup. S1 further stated if a resident needs assistance at the time of medication administration, S1 will call for additional assistance from a caregiver and/or other staff to assist. S1 stated they have worked in the facility for over a decade and has followed this procedure consistently with no history of medication errors or contaminations. Based on interviews conducted, records reviewed, and observations made, the allegation that staff are pre-pouring medications is Unsubstantiated at this time. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 29-AS-20250812091303

Allegation investigated: Licensee does not ensure staff are conducting disaster drills.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to deliver final findings based on the above-stated allegation. At the time of arrival, LPA met with Interim Administrator Jessica Hong and explained the purpose of the visit. During the investigation, LPA Kontilis conducted a visit on 6/20/2025 from 11:15 am to 4:00 pm to interview staff and obtain relevant documents. On the allegation, Licensee does not ensure staff are conducting disaster drills, Reporting Party stated concern that the facility has not conducted a fire or disaster drill within the last six months. Interviews conducted revealed that a disaster drill had not been conducted in the facility since November 2024. On 6/26/2025, an all-staff Emergency Preparedness 101 Training and Drill was conducted with all staff currently employed at the facility. The Emergency Preparedness Drill conducted on 6/26/2025 included identifying the location of the Public Announcement (PA) system and the fire panel which locates a fire. Please continue to 9099-C, Pg 2. Substantiated The drill included how the fire panel would light up and guide staff on how to read the different zones in order to locate a fire. Drill activities included placement of staff throughout the facility with one staff member posing as “the fire” and staff practiced the steps to locate “the fire” then take the appropriate action to address the emergency. Although an all-staff fire drill was conducted on 6/26/2025, it was determined that a disaster drill was not conducted in the first quarter of 2025. Based on records reviewed and interviews conducted the allegation the Licensee does not ensure staff are conducting disaster drills is Substantiated at this time. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit. Extinguisher Checks, Weather Conditions, News Predictions, Forewarning, Natural Disasters; Post Evacuation / Return Survival; and Violence in the Workplace & Active Shooter. LPA obtained a copy of the 2025 Safety Meeting Monthly Schedule during the initial visit on 6/20/2025. Staff interviews further revealed the all-staff meetings are mandatory and staff members are notified verbally via their supervisors, directors, and/or co-workers as well as notices are posted on a white board near the time clock about one week prior to the meeting. Staff stated if they are unable to attend a meeting, follow-up with the employee is conducted to brief them on the contents of the meeting. Based on interviews conducted and records reviewed revealed monthly all-staff meetings are held covering relevant topics promoting safety awareness, overall health and well-being, and open communication. Based on interviews conducted and records reviewed, the allegation Licensee does not ensure staff are receiving required training is Unsubstantiated at this time. Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Jul 8, 2025 · control 29-AS-20250618100351

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: Jul 9, 2025

§1569.695 Emergency Plans: (c) A facility shall conduct a drill at least quarterly for each shift.... This requirement is not met as evidenced by: The facility did not comply with the section cited above as a disaster drill had not been conducted between November 2024 and June 2025 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: An all-staff disaster drill "Emergency Preparedness 101" was conducted on 6/26/2025. POC cleared on this date.

Allegation investigated: Facility is unsanitary.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced 10-day complaint investigation based on the above stated allegations. LPA met with Jessica Hong, Interim Executive Director and explained the purpose of the visit. June Davila, Wellness Director and Holly Walling, Sales & Marketing Manager participated in the visit. During today’s visit, from 11:45 am to 1:10 pm, LPA conducted a tour of the facility with Interim Executive Director, Wellness Director, and Sales & Marketing Manager. Also during today’s visit, LPA obtained documents pertaining to the investigation and conducted in-person interviews. On the allegation Facility is unsanitary: The complainant’s concern was that there was a “fly trap” with trapped flies located directly above an area where food is prepared and a kitty litter box was located in Wellness Room staff bathroom posing a risk for potential contamination and/or cross contamination. Please continue to 9099-C, Pg 2. Substantiated LPA also conducted a tour of the outside of the facility with Maintenance/Housekeeping Supervisor. The facility is located in a high vegetation rural neighborhood where many of the neighboring homes have multiple fruit trees, gardens, and other varieties of vegetation. There was no evidence of rodents and/or rats, or sign of rodent/rat excrement, or rodent/rat destruction in the outside area of the facility. Further interviews conducted revealed the facility contracts with a local vendor for rat and rodent removal, pest control, termite inspection, bird control, and fumigation. The contract with the vendor includes a monthly routine visit for spraying and a more in-depth spraying every four months outside the facility. The last four-month in-depth spraying was conducted in March 2025. Interim Executive Director stated no reports of rats, rodents, insects, etc. have been reported to facility directors and if there were, it would show in the vendors’ reports. LPA reviewed pest control Invoice #501984 dated 5/6/2025 for routine spraying on the same date as invoiced from 10:52 am to 11:47 am. No note of rodents, rats, insects, etc. were noted in the invoice. Further, Interim Executive Director stated, “I have never received a report that there were rats or rodents within our facility. If there was, I would have done something about it immediately!” Based on interviews conducted and observations made, the allegation that the facility has rodents is deemed Unsubstantiated at this time. On the allegation, staff failed to maintain accurate residents' records: Complainant’s concern is residents’ charts are not being regularly updated. During today’s visit, LPA conducted staff interviews and obtained copies pertaining to the allegation. Interviews conducted revealed upon a resident's admission, each resident’s records are compiled as the “admission packet” including the resident’s face sheet, LIC602, POLST form, insurance information and Pre-Appraisal. Interviews conducted revealed each resident’s records are updated on an “as needed" basis including but not limited to medical visits, medical emergencies, and other serious illness/serious injury reports. Interviews conducted revealed Wellness Director is responsible for chart keeping and regularly updates residents’ files. Interviews conducted further revealed a “care plan” is kept for each resident in the resident’s binder. The Care Plan lists the services that are offered and the price value for each service. It is originated with the family just prior to move in and it is maintained and changed based on a resident’s need. Re-appraisals are conducted on an “as needed” basis as well as on a regular basis as a “care conference”. Wellness Director communicates with the residents and their responsibility parties on an “ongoing basis”. Record review of the documents revealed no discrepancies or inaccuracies in residents' records. Therefore, based on interviews conducted and records reviewed, the allegation Staff failed to maintain accurate residents records is deemed Unsubstantiated at this time. Due to technical difficulties, copy of report issued at the time of the visit. At approximately 11:45 am to 1:10 pm, LPA toured the facility with Interim Executive Director, Wellness Coordinator, and Sales & Marketing Manager. At approximately 11:49 am, LPA observed a fly trap/strip with dead flies attached on the strip placed above a warming station of a food service work area. LPA observed the food service area had plates with sandwiches covered with plastic wrap and a cutting board with a cutting knife and crumbs on the cutting board. At approximately 1:50 pm, LPA observed the fly trap/strip had been removed. During the tour of the facility, at approximately 11:56 am, LPA observed Staff Room 3 with mold on the wall, dirt on the carpet, and an electrical light panel lying on the floor. During the tour of the facility at approximately 12:15 pm and 12:25 pm, LPA observed two residents’ rooms to have stained and soiled carpets. At approximately 12:30 pm, LPA observed that there was no kitty litter box in the staff bathroom of the Wellness Office. Interim Executive Director stated at one time the litter box was kept in the bathroom, but upon the recommendation of Allen Flores Consulting in March 2025, it was recommended that the litter box be kept in the staff bathroom of the Wellness Office with no accessibility to residents. As of March 2025, the litter box is kept in the staff bathroom and the bathroom is kept clean on a daily basis and a staff member cares for the facility cat including feeding the cat and keeping the litter box clean. Per Interim Executive Director, the Wellness Office is inaccessible to residents in care. Based on observation and interviews conducted, the allegation that the facility is unsanitary is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted. Due to technical issues, copy of report and appeal rights issued at the time of the visit via email.the state’s words, verbatim · CDSS document, Jun 10, 2025 · control 29-AS-20250603085058

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 20, 2025

87303(a) Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above per observations made: fly trap with trapped flies, staff room with mold and dirt on the wall, and two residents’ rooms with stained and soiled carpet which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 10, 2025

Plan of correction: Administrator agrees to have carpets cleaned in Residents' rooms noted to be soiled and stained no later than POC due date. Administrator agrees to provide photos of cleaned carpets no later than POC due date.of cleaning conducted. Administrator agrees to create a Housekeeping checklist to ensure rooms are thoroughly cleaned and any issues brought to the attention of the Housekeeping Supervisor.

Type of visit: Required - 1 Year

On 10/01/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility above to conduct an unscheduled, required inspection evaluation visit. When the LPA arrived, they were greeted by Executive Director Michael Easbey, and informed them of the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This facility is a Residential Facility for the Elderly (RCFE) with an approved fire clearance capacity of seventy two (72) non-ambulatory residents, and a hospice waiver for ten (10) residents. The LPA inspected the food service area and observed that the food preparation area is staff only. Knives/sharp instruments are stored in areas inaccessible to clients. All appliances were in operable condition and looked clean/in good repair. Appliances such as microwaves, refrigerators, stoves, etc. are clean and operating properly. Food utensils, dishes, glasses, etc. are clean and in good repair with no cracks or chips. Furniture is room/resident appropriate, clean and in good repair. All rooms are appropriately furnished for their intended use such as bedrooms, dining rooms, kitchens, living rooms, game room, beauty salon, etc. Hot water temperature is maintained between 105-120 degrees Fahrenheit as per Community Care Licensing (CCL) Title 22 regulations. Outdoor activity spaces have shaded areas and furnished for outdoor use. Each resident has an adult bed with a mattress, pad, bedsprings, and pillow, which are clean and in good repair. Each bed is fitted with sheets, pillowcase, blankets, and bedspread that are clean and in good repair. Each resident has adequate dresser and closet space for clothing and other belongings that includes at least two drawers or adequate dresser space. The facility has a sufficient supply of linens to permit weekly changing or more often to always insure clean linens for residents. Equipment and supplies for resident personal hygiene is available and on site. Activity supplies are available for residents. As the facility has an approved fire clearance for a maximum of seventy-two (72) residents, there is a signal system required and observed by LPA. Refrigerators and freezers are maintained at an appropriate temperature Fahrenheit as per Community Care Licensing (CCL) regulations. Continued on 809-C Food storage and preparation areas, including pantries, cupboards, counters, etc., are clean and appropriate for food preparation. The food service area was clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The facility has an adequate amount of perishable food for residents. There is enough tableware and utensils for all clients living in the facility, and enough equipment for the storage, preparation, and service of food. A locked storage area for central storage of medications is available. Cleaning supplies are kept in areas separate from where food supplies are stored. Walls, ceilings, floors, carpeting, window screens, and areas around the facility are clean, painted and/or in good repair. There are locked storage area(s) for poisons, toxic, cleaning solutions, disinfectants, etc. Fire extinguishers and smoke detectors operate properly. Doors and passageways are unobstructed. There are no pools/bodies of water on the physical plant of the facility as observed by LPA. During the inspection, LPA did not observe any firearms that would require trigger locks, locked and inaccessible, or firing pins removed. At the time of the visit, all common areas/interior rooms of the facility were observed to be appropriately furnished, with all furniture in good condition. There are activity materials in the common areas of the facility in good repair and operating condition. The facility maintained a comfortable temperature in all areas inspected. Fireplaces on the premises are covered and inaccessible. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguishers in all buildings inspected were fully charged and serviced annually. The LPA observed required postings throughout all common spaces including Resident Personal Rights and Resident Council Rights. There is appropriate lighting in all the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, with no changes in incline requiring ramps and/or sturdy hand railings/stair chair accessibility devices. This facility is one (1) story throughout and therefore there are no stairways for residents to utilize. There are no bodies of water as observed by LPA in the outdoor area of the facility. LPA did not observe any noticeable outdoor hazards. There are two (2) outdoor courtyards accessed through the interior of the facility. The outdoor activity space is completely enclosed by facility doors and latching gates. The front outdoor area of the facility consists of a front courtyard with an open porch with tables and chairs. The designated laundry area is an unlocked room as both staff and residents are able to do laundry, with the storage of cleaning products locked and inaccessible to residents when not in use, away from food products. There was emergency food and water stored in the facility, which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to residents are kept in areas inaccessible to residents. Continued on 809-C The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms in the facility included soap, paper towels, required postings, and clean trashcans with closed lids. The facility contains both communal restrooms in the hallways as well as private restrooms in the interior of resident bedrooms. All restrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per Title 22 regulations between 105-120 degrees Fahrenheit. There are an adequate number of toilets per residents in the facility. Nightlights are installed as observed by LPA. All toilets and hand washing areas are maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences are available accommodate any physically handicapped residents who need such items. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Each resident bedroom has a bed/beds, nightstands, and lights and nightstand lamps to provide sufficient lighting. All bedrooms within the facility are for single individuals, but the bedrooms can be conjoined if there is a couple or the resident needs extra space. Each closet in all the resident rooms can store or has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assisting device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. The facility has provisioned to each resident of furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. An emergency exiting plan and emergency phone numbers are posted in an appropriate place. A current disaster and mass casualty plan maintained at the facility. First-aid supplies, which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual, are maintained. Administrator’s records, employees and resident records are maintained at the facility and available for review by the LPA as employees are hired and residents accepted into the facility. The facility complies with CCL standards for health screening, TB clearance, staff training, criminal background clearance and transfer requests. Admission agreements and needs and services (ANS) plan are maintained for each resident and/or their authorized representative. Resident records are maintained on the facility premises in a secured area. Centrally stored medications are locked in a secure area of the facility, inaccessible to residents. The facility administrator meets the qualifications as specified in Title 22 regulations with a pending certificate as of 05/28/2024. Exit interview conducted. Copy of this report provided to the facility.the state’s words, verbatim · CDSS document, Oct 1, 2024

Allegation investigated: Staff do not provide adequate food service to the residents.

At 7:45am on 05/16/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the initial investigation visit to the allegation to this complaint. LPA met with Administrator, Lordes Espinoza, announced who he is and the reason for the visit. LPA conducted interviews, collected and reviewd documents, made observations, and sampled breakfast service. As to the allegation of, "Staff do not provide adequate food service to residents". It was alleged that "the residents have complained to the director about the quality of the food". It was discovered through observations, documentation, photographs, taste sampling foods, and interviews that on 05/16/2024, LPA conducted interviews with Residents 1-12. (R1, R2, R3, etc..), 10 of 12 residents had no issues with facility food in every aspect. interviews with R11 and R12 indicated that quality of food was below their personal standard and quality. CONTINUED on LIC0900-C Unsubstantiated On 05/16/2024 LPA Jeffries interviewed facility Staff (S1-S5). In interview with S1 stated that the food service at the facility was above average and that most of the Residents had no complaints. S1 stated that they do address the food concerns with residents who do complain. Interviews of S2-S5 all felt that the food service was very good and most of the time all of the residents enjoy the quality, variety, and choice of food here at this facility. On 05/16/2024, LPA Jeffries reviewed documentation of menus for the past 30 days aw well as the up coming week, which was accurate on the day LPA visited. LPA observed alternate menu with a large variety of food choices to supplement the posted menu. LPA reviewed and collected the NutraLink, Nutricopia dietary contract with, two recent Consultant Dietitian Report Cards from January 2024 and April 2024. January and February of 2024 both scores were 89% in Food Preparation & Meal Service LPA purchased menu item meal, which was of good quality including a meat, poetry, bread and fruit. On 05/16/2024, LPA observed breakfast service, LPA noted observation of 33 resident that partook of meals with no food complaints during this service, and noted that staff clean up with 90-100% of breakfast served was consumed by residents. On 05/16/2024 at 7;50am LPA conducted a tour of the kitchen, LPA observed at least 2 days of perishable foods and at least 7 days of non perishable foods, all properly stored, and contained for alt least 51 residents,staff, and visitors. LPA collected and reviewed food vendor list. LPA noted that the facilities long time Chief retired from the facility approximately 6 weeks ago according to current administrator and has been interviewing for a new full time Chief. LPA observed Job Posting on Indeed.com for new Culinary Manager. Based on observations, interviews, documentation, photographs, food sampling, and regulations, at this time, there is not enough evidence to support the allegation of, " Staff do not provide adequate food service to the residents." and is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, May 16, 2024 · control 29-AS-20240507135620

Allegation investigated: Staff do not ensure residents are served food of good quality.

On 02/09/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility above to conduct an initial 10-Day Complaint Investigation Visit. LPA met with Administrator Lourdes Espinosa and Human Resources (HR) Shayla Sanchez, and explained the purpose of the visit. On the allegation: Staff do not ensure residents are served food of good quality. It is alleged that for the last three (3) months the quality of food has declined. The allegation states that the proteins have been overcooked and are inedible for lunch and dinner meals. Additionally, it is alleged that most of the week residents are served rice and beans and maybe a salad with their protein for the day. According to the allegation multiple residents have spoken to the Director of the Facility about the food and the reply to them is that the facility must scale back on the food budget. On 02/09/2024, LPA requested documents pertaining to the investigation, conducted observations of the pertinent areas of the facility, and interviewed both Residents and Staff members of the facility. Contd 9099-C Unsubstantiated LPA observed the dining room areas in separate sections of the facility and found the food items on the menu to be of good quality while served to residents. The facility has a main kitchen for residents of the facility off the main dining room. LPA toured the kitchen and observed the food supply. All foods observed were of good quality. There was no indication of any expired/stale food items, and all food items were stored properly at correct temperatures. During the LPA's touring of the kitchen area, policies and procedures on the handling of food were observed and food items had the dates that they were received by the facility labeled on the food product. There were no observable deficiencies in the quality of the food at the facility. On 02/09/2024, LPA interviewed residents and staff about the quality of the food and meals served in the facility. Most of the residents interviewed indicated the food was of good quality, the meat was cooked to the level of doneness ordered, there was a good variety of foods, and healthy options are available as well as “less healthy” options. Some residents interviewed stated that the food has improved during their time in the facility, and they had no complaints about the food. A minority of residents interviewed indicated they would like better quality meats and would like additional choices. All Staff members interviewed by the LPA denied stating to any resident that the facility must scale back on the food budget. LPA was provided with pertinent documentation by the facility including a facility menu, meal schedule, and resident documentation relating to any dietary restrictions if applicable. The residents have a weekly dining menu posted by the facility (Monday-Sunday) that has a lunch meal and a dinner meal daily. The LPA observed sufficient variety in the daily lunch and dinner options for residents. The residents may also fill out an alternative meal form for a lunch request and/or a dinner request if they do not want the provided daily meals. For daily breakfast options, the residents provide a documented form that they fill out for their own breakfast choice daily. These include a variety of options including cooked/non-cooked/hot/cold options. The facility works with a dietician that is the individual who creates the weekly menu schedule. The facility also posts a Resident Food Allergy/Resident Foods to Avoid Document on the bulletin board in the dining room/kitchen area which lists any resident who has dietary restrictions and needs alternative provisions. The facility has a documented written contract Agreement for Registered Dietician Consultation Services with Dietician Company, for a period of one (1) year commencing on 09/01/2023. The responsibilities of the Consultant Dietician include planning meals, maintaining standards of food selection, receiving, storage, preparation, service, safety, and security. The Consultant Dietician selects and procures food to meet optimal resident nutrition. The Consultant Dietician participates in the development and review of individual resident care plans, and provides counseling on resident nutritional needs. Continued on 9099-C The Dietician Company agreement with the facility includes weekly posting menus, daily production menus, standardized recipes, weekly purchasing guides, nutritional analysis, menu approval forms, as well as updates to maintain current regulatory and accepted standards of practice. In addition to LPA observations, interviews, and record review of the facility on 02/09/2024 for the initial complaint investigation visit, LPA had previously inspected the kitchen and food service of the facility on 10/10/2023 during a required annual facility site inspection visit. During the 10/10/2023 annual facility site inspection, The LPA inspected the kitchen/food service area and observed that all kitchen appliances were in operable condition and looked clean/in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last 7 days. Additional perishable food items were maintained on a shelf and/or an extra freezer. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation. The kitchen was clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The freezer and refrigerator were both in the appropriate temperate Fahrenheit. LPA observed enough equipment for the storage, preparation, and service of food. LPA additionally observed the preparation of meals for residents and found no observable deficiencies in the preparation of meals or quality of ingredients. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Feb 9, 2024 · control 29-AS-20240202124318