Covenant Living at the Samarkand

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Case Management – Incident visit to the above-named facility. LPA met with Marjan Albert, Administrator, and explained the purpose of the visit. On 7/21/2026, CCLD received an incident report stating Staff 1 (S1) “hit” Resident 1 (R1). The purpose of today’s visit is to conduct an investigation and obtain documents pertaining to the incident. During today’s visit, LPA Kontilis conducted interviews and obtained documents pertaining to the investigation. Interviews conducted revealed the specific time and date of the incident was not determinable and there was no additional evidence obtained to verify the occurrence. Administrator Albert stated trainings are being conducted for staff members to address concerns of residents’ health and safety. Additionally, Administrator has requested mandated reporter training and abuse prevention training from the Long Term Care Ombudsman’s office for all staff. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Jul 22, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection visit at the above-named facility. Upon arrival, LPA was greeted by Marjan Albert, Administrator and Scott Bigler, Associate Executive Director and explained the purpose of the visit. The facility is a 16-acre Residential Care Facility for the Elderly (RCFE) Continuing Care Retirement Community. It consists of Independent Living, Assisted Living, and Memory Care. The skilled nursing facility is not within Community Care Licensing Division’s jurisdiction. The Independent Living section has approximately 218 private residential apartments. The Assisted Living unit has approximately 36 residential apartments. The Memory Care unit consists of a secure unit with approximately 16 apartments. The facility has a hospice waiver for 10 residents. Currently, there are five (5) residents on hospice. Resident’s activities address the “eight dimensions of holistic wellness”. These activities include but are not limited to fitness programming, life-long learning, art classes, religious studies, book clubs, technology education, spiritual programming, inter-generational opportunities with students in local schools, music appreciation and participation, outdoor games such as bocce ball, corn toss, ping pong; a Residents’ Counsel, and scenic drives to museums, parks, and cultural centers. There are four dining areas and eateries on the campus. The outdoor area consists of a 25-meter swimming pool with a jacuzzi in a locked fenced area, a gym, fitness studio, putting green, walking paths, botanical garden, coy pond, and shaded sitting areas conducive for outdoor visitations. The administrative offices consist of a two-story building with Sales & Marketing, Human Resources, Transportation, a bank, Director of Philanthropy, Business Office Specialist, Resident Life Director, and Office of Executive Administrative Assistant, Executive Director and Associate Executive Director. Please continue to 809-C, Pg 2. The facility has a daily check-in process for Residential Living residents. A daily follow-up check-in is conducted if a resident has not “checked-in”. Administrator and Associate Executive Director certificates are valid. Staff files reviewed had health screenings, current first aid certificates, and all required trainings. Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Medical Accounting Records (MARs). At approximately 2:54 pm, medication review revealed Resident 1’s (R1’s) morning medication Amlodipine 2.5mg tablet had one extra tablet and R1’s Escitalopram 5mg medication had one extra tablet. Further, LPA reviewed a self-reported incident wherein Resident 2 (R2) was “mistakenly” administered seven medications prescribed to another resident on 1/7/2026. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted. Copy of report and Appeal Rights issued via email.the state’s words, verbatim · CDSS document, Apr 28, 2026

Type of visit: Required - 1 Year

At 11:30am on 04/29/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the facility annual inspection. LPA met with Administrator, Marjan Albert, announced who he is and the reason for the visit. LPA Jeffries reviewed emergency disaster plan and infection control plan with Administrator. LPA Jeffries conducted a review of the Plan of Operations, with focus on dealing with behavior expressions, dementia and training. LPA Jeffries conducted a cursory review of staff and resident files, including medication audit of Centrally Stored Medication Records (CSMR) and Medication Administration Records (MAR). LPA Jeffries reviewed fire clearance records, and observed a passing fire inspection by Johnson Controls of North American dated 03/20/2025, showing 129 smoke detectors, 9 Carbon Monoxide Detectors, and all components of fire sprinkler detection system throughout the facility as passing. LPA Jeffries noted assorted fire extinguishers throughout the facility primed and in the green and tagged as indicating functioning. LPA Jeffries noted that the campus has a Skilled Nursing Facility approximately in the middle of the facility campus that is currently undergoing construction for a new generator, which will also support a second generator that will serve the CCLD Licensed facility buildings as well. Administrator and LPA conducted a physical tour of the facilities kitchen. LPA Jeffries noted that the facility kitchen is clean and in good repair. LPA noted that there is ample food supply of 2 days of perishable foods and 7 days of non-perishable foods in the facility kitchen. LPA Jeffries noted that the Administration building, Brandel Hall, and the dinning & Services Building were are clean and in good repair, with no exits blocked or obstructed. LPA will need more time to complete physical inspection and will return at a later date to complete entire facility inspection. EXIT INTERVIEW, REPORT READ, and REPORT PROVIDED.the state’s words, verbatim · CDSS document, Apr 29, 2025

Allegation investigated: Staff falsified residents’ medical documentation Staff billed residents for services not rendered

On 12/04/24 at 9:35 am, Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Administrator Marjan Albert and the Director of Rehabilitation, Irene Carrillo, and explained the purpose of the visit. Note, this facility has a Skilled Nursing Facility on grounds, all records pertaining to those residents was not reviewed due to Community Care Licensing (CCL) only regulates the Assisted Living and Independent Residential areas. On the allegations: Staff falsified residents’ medical documentation and Staff billed residents for services not rendered: Continued on 9099-C Unsubstantiated It was alleged by the reporting parties that staff are falsifying records when a resident is seen for Physical and/or Occupational Therapy and that the residents in care are being billed for those services. No additional information was provided by the reporting parties about the specific resident(s) who were claiming this allegation, or how the reporting party acquired the information. No contact information was provided, so CCL was unable to contact the reporting parties to obtain additional information about these allegations. To investigate the allegations, LPA Phillips conducted an initial tour of the facility on 12/07/2023, conducted a file review, acquired various documents including therapy chart notes for various residents, interviewed the Director of Nursing and Rehabilitation Director and conducted additional interviews with 2 residents. On 12/04/24 LPA Rankin returned and conducted detail interviews with the Director of Rehabilitation. During the discussion the Director explained that staff have set schedules and hours they are to work for the week, that there is a percentage of that time that must be spent in direct therapy with residents. Each morning management reviews the recorded hours and activities conducted to ensure staff are completing assigned tasks, that they able to account for staff daily activities. Additionally, the charting records have a minute account for each activity or type of therapy conducted with each resident as well as detailed notes of what was done, how many repetitions, and the progress of the resident. When therapy notes were reviewed LPA observed that the start and completion dates matched on all records and that the time stamp of when the therapist electronically signed was within the same date of when the services were provided. LPA reviewed the following dates of services 12/01/23, 12/05/23, 12/06/23, and 2/19/24. The charting system then transfers those notes, billable hours, and medical codes to the facilities system so that billing invoices can be generated. LPA noted that the minutes charted by therapists are turned into what Medicare deems a “unit” based on the medical code and the time provided for that code. At the end of the month, these records are reviewed for accuracy by the Director of Rehabilitation to ensure that what was captured by the facilities system matches the therapy recorded time/units. Continued on 9099-C During the review of these systems LPA was provided copies of invoices that are sent to Medicare, those codes, dates, and billed units were reviewed specifically for services provided to the Assisted Living residents from the therapist #1 (T1). LPA observed all records, notes, and units were consistent. A review of T1’s scheduled hours worked during the invoices reviewed were consistent with the time stamp of T1’s signature for the notes. LPA noted that T1 started with the facility early November of 2023. Director stated there was a time when T1 was spoken with, but it was due to T1 being new to the processes of the department and was stated as a one-time occurrence, but it was not in regard to any falsifying of records or billed units. When asked how staff are managed or monitored, the Director stated the following are reviewed daily: therapist notes, hours of work, and any inconsistencies in timecards. If there is a concern a 1:1 is done with staff to council them on correcting any error. LPA also interviewed Therapist #2 (T2), T2 also detailed their charting processes, record keeping, and how any issues are addressed. T2 stated if a concern is brought regarding another therapist, by family or residents, it is encouraged that they bring the concern to management. Both T2 and the Director stated there is often a cognitive element that can confuse services that were provided, or the amount of time spent in therapy. There is also the added note by both parties that some services are not “exercise” as a resident may typically understand, but more in assistance in daily living practices where a therapy is provided to residents in their living environment where therapists help them in daily practices that need to be reviewed or adjusted for the residents needs and safety. LPA interviewed 2 residents, both residents were unable to describe their therapy, but did state that the facility ensure that they are provided what is needed in a safe and timely manner. Both residents expressed that they receive good care, and that staff are attentive and that should there be an issue they or their representative are able to address those needs. Based on the investigation, there is insufficient evidence to support the claim that Staff have falsified residents’ medical documentation and that staff billed residents for services not rendered. This allegation is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 4, 2024 · control 29-AS-20231129151921

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rankin and Licensing Program Manager (LPM) Burley conducted an unannounced visit to the facility to conduct the facility annual inspection. LPA met with Scott Bigler, and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Scott Bigler. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The facility is a large CCRC campus with independent living, assisted living, and memory care. The facility is clean, safe and sanitary, and in good repair. The facility has smoke and carbon monoxide detectors functioning. Fire extinguishers were fully charged. The lighting and lamps are sufficient, and facility is well lit inside and outside for safety. The showers have non-skid flooring. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Disinfectants, cleaning solutions and poisons are inaccessible to residents. The facility has sufficient space inside and outside for activities and visiting. The facility has outdoor areas for client use with furniture and plenty of shade. The facility has telephone and internet service for resident use. Review of medication records was initiated but not completed. Due to time constraints, LPA concluded the inspection. LPA will return to continue the annual inspection at a later date. Exit interview, report read and report provided.the state’s words, verbatim · CDSS document, Apr 24, 2024