Avella at Almaden

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Administrator, Brenda Ritter and stated the purpose of today's visit. On 07/8/2026, the Department received an Death Report for resident (R1) who was taken to the hospital on 07/03/2026 and passed away at the hospital on 07/05/2026. During today's visit, LPA Rai obtained copies of resident R1's documents including but not limited to R1's Progress Notes, Physician's Report and Appraisal/Needs and Services Plan. At this time, this case in under review and Department will conduct a follow up visit, if warranted. This report was reviewed with Administrator, Brenda Ritter and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 9, 2026

Allegation investigated: Staff took residents food away before residents finished eating.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Executive Director/Administrator, Brenda Ritter and stated the purpose of today’s visit. On 02/13/2026, the Department received a complaint with the above allegation. On 02/18/2026, the Department conducted an initial investigation at the facility. Continuation on LIC 9099-C, Page 1 of 3. Unfounded Page 2 of 3. Staff took residents’ food away before residents finished eating. It was alleged that on 01/15/2026, staff removed resident’s food away before resident was finished eating their meal in the dining room. The name of the staff or resident was not disclosed. On 02/18/2026, the Department interviewed 1 staff (S1). S1 stated they are not aware of the incident and did not hear or see this incident occur in the facility. During today’s visit, LPA Rai interviewed 8 staff (S2-S9). 7 Out of 8 staff stated they are not aware of the incident, and they did not hear or see this incident occur in the facility. Staff S4 stated they witnessed the incident occur approximately on 01/15/2026. S4 stated there was a staff (S10) who was assisting a resident to remove the plate from the dining table. S4 stated he/she heard S10 ask the resident if they were done with their meal before picking up with plate. S4 stated another staff member S11 was nearby and saw S10 remove the plate but misunderstood that S10 did not ask the resident if they were done with the meal. S4 stated she informed S11 that the resident was done with the meal and S10 had asked the resident prior to removing the plate. S4 stated S10 did the right thing by asking the resident was done with the meal before picking up the plate from the table, but S11 misunderstood the situation and thought S10 did not ask the resident and removed the plate prior to asking resident’s permission. S4 does not remember the name of the resident. S4 informed LPA Rai both S10 and S11 no longer work at the facility. During today’s visit, LPA Rai attempted to interview 13 residents (R2-R14). 9 Out of 13 residents were participating in activities in the activity room and they were not interviewed. 4 Out of 13 residents agreed to be interviewed. 4 Out of 4 residents (R2-R5) stated that this incident did not occur where staff removed resident’s food away before resident completed their meals at the dining room. 4 Out of 4 residents stated the staff will wait until the resident informs the staff they are done with the meal, or the staff will ask if they can remove the plate with their permission. 4 Out of 4 residents are satisfied with the meal service in the dining room and they appreciate the staff’s assistance during meal service. Page 3 of 3. During the course of the investigation, LPA Rai reached out to staff S10 and staff S11 but LPA Rai was not able to conducted an interview with both staff. The Department has completed the investigation of the above allegation. Based on interviews conducted and record reviews, the Department has found that the above allegation were UNFOUNDED, meaning that the allegation were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Executive Director/Administrator Brenda Ritter and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 13, 2026 · control 26-AS-20260213100732

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management - Incident visit to follow up on a visit made on 02/18/2026 regarding an Incident Report the Department received on 02/13/2026. LPA Rai met with Executive Director/Administrator, Brenda Ritter and stated the purpose of the visit. On 02/13/2026, the Department received an LIC 624 Incident Report stating on 02/12/2026, resident R1 and R2 had a physical altercation and facility staff witnessed the incident and separated both residents. During today's visit, LPA Rai interviewed 3 staff (S1-S3). LPA Rai determined this case management needs further investigation. This report was reviewed with Executive Director/Administrator, Brenda Ritter and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 13, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management visit in regards to two Death Reports received by the Department from the facility for resident R1 and R2 and deliver an immediate exclusion letter for an individual (S1) . LPA met with Interim Executive Director (ED) Brenda Ritter and stated the purpose of the visit. During today's visit, LPA Rai conducted an initial follow up on a Death Report for resident (R1). On 03/09/2026, the Department received a Death Report for resident (R1) who passed away at the facility on 03/01/2026. Based on Death Report, facility staff found resident on the floor and facility staff called 911 and paramedics arrived at the scene. During today's visit, LPA Rai obtained the following documents of R1 which include but not limited to R1's Appraisal/Needs and Services Plan, Physician's Reports and Progress Notes. At this time, this case is under review and the Department will conduct a follow up visit, if warranted. During today's visit, LPA Rai hand deliver an immediate exclusion letter for an individual (S1) who the Department determined engaged in conduct inimical as a staff in the facility. The letter was handed to the Interim Executive Director (ED) Brenda Ritter. ED stated the facilty records show S1 was not employed by the facility, therefore S1 was not present at the facility. ED stated they will ensure all staff prior to working at the facility will obtain a California clearance or a criminal record exemption. ED agreed and understood. During today's visit, LPA Rai conducted a follow up on a Death Report for resident (R2). On 6/23/2025, the Department conducted a case management visit to follow up on Incident Report/Death Report for resident (R2) who sustained an injury from an unwitnessed fall and passed away at the hospital. Continuation on LIC 809-C, Page 1 of 3. Page 2 of 3. The Department received an Incident Report for an incident which occurred on 6/20/2025 wherein R2 had an unwitnessed fall in resident's room in the Memory Care unit. R2 stated the right side of the body and head was "hurting". The facility staff called the paramedics and R2 was taken to the hospital. The Department received a Death Report wherein R2 passed away at the hospital on 6/20/2025 and the immediate cause of death is unknown. On 12/19/2025, the Department interviewed two staff (S2-S3). Two out of two staff stated the residents are checked on by staff every hour for safety, but they do not document their safety checks. S2 stated the residents in the memory care units do not have call buttons or alarm pendants and the residents will verbally call for staff if they require assistance. Two out of two staff stated resident R2 was a fall risk resident. On 12/24/2025, the Department interviewed four residents (R3-R6). Four out of four residents stated they feel safe at the facility and do not have any complaints. On 12/24/2025, the Department interviewed three staff (S4-S6). Three out of three staff stated the residents are checked on by staff every hour for safety, but they do not document their safety checks. Three out of three staff stated the resident R2 was a fall risk resident. S4 stated he/she checked on R2 the day of the incident on 6/20/2025 wherein R2 was calling for help in the room and S4 found R2 on the floor. S4 stated R2 was trying to put on clothes when R2 fell on the floor. S4 stated R2 was assessed R2 and called 911 and the paramedics transported R2 to the hospital. S4 stated R2 was checked an hour before the fall incident on 6/20/2025 and R2 was in bed sleeping. S5 stated R2 and R2’s family was recommended for a private companion but R2’s family refused. On 1/7/2025, the Department interviewed 1 staff (S6). S6 stated he/she assessed resident R2 on 6/20/2025 and found R2 on the floor of the room. S6 stated R2 complaining of pain on the right side of rib area. S6 called 911 as a response to R2’s fall. S6 stated resident R2 was a fall risk resident. On 2/2/2026, the Department interviewed physician (P1) from Santa Clara County’s office. P1 stated the rib fracture complicated R2’s underlying chronic diseases and contributed to R2’s death. P1 stated the trauma from the injury placed too much stress on R2’s body. Page 3 of 3. On 2/3/2026, the Department interviewed 1 staff (S5) to further clarify information provided on 12/24/2025. S5 stated residents are determined to be fall risk using the facility’s fall risk assessment tool. S5 stated the facility staff provided assistance with resident R2’s activities of daily living (ADLs), checked on resident R2 frequently and reassessed every time R2 has a fall. S5 stated the facility staff was concerned about R2’s fall incidents where S5 spoke to R2’s family and recommended a private caregiver but R2’s family refused due to the cost. Based on review of R2’s assessments after 11 documented falls from 5/24/2025 to 6/20/2025, the assessments would evaluate R2’s condition at the time of each incident but it did not result in documented revisions, modifications, or escalation of the care plan. According to R2’s gait analysis, R2 had a loss of balance while standing, and had decrease in muscle coordination. R2 used an assisted device and required assistance when moving from place to place. R2 was noted to be between a moderate to high fall risk. Based on review of R2’s Service Plan Report dated 4/9/2025, the report included fall prevention measures. The facility staff documented on R2’s progress notes from 5/24/2025 to 6/20/2025, R2 had 11 witnessed and unwitnessed falls in the facility. R2’s Service Plan dated 4/9/2025 remained on file and the facility staff did not update R2’s fall prevention plan after having 11 documented falls. Based on review of R2’s Death Certificate, R2’s immediate cause of death was due to a rib fracture complicating neurodegenerative disease. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Interim Executive Director (ED) Brenda Ritter and a copy of the report was provided. Appeal Rights was provided.the state’s words, verbatim · CDSS document, Mar 10, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a) · Plan of correction due date: Mar 11, 2026

87463(a)The pre-admission appraisal,..., shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition,... This requirement is not met as evidenced by: Based on record review and interviews, R2’s appraisal dated 4/9/2025 which included the fall prevention was not updated after facility staff noted significant changes of R2 having documented 11 falls from 5/24/2025 to 6/20/2025 which poses/posed an immediate health, safety or personal rights risk tothe state’s words, verbatim · CDSS document, Mar 10, 2026

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure appraisals are updated in writing which include signigficant changes in condition by POC due date. Administrator agreed and understood. (con't) persons in care.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management visit regarding the incident report received on 02/13/2025. LPA met with Debbie Teixeira and stated the purpose of the visit. The facility is licensed to serve adults age 60 and over. 250 non-ambulatory of which 12 may be bedridden. All room approved for bedridden. Dementia unit rooms 140-180, approved for delayed egress. Hospice waiver for 10. Based on the report received resident 1 and 2 (R1 and R2) were in the dining room when R2 was holding onto R1s arm tightly. Staff member witnessed the incident ad stepped in and separated R2 from R1. R1 has cognitive impairment (dementia) and was unable to provide a statement regarding the incident. R2 also has cognitive impairment and therefore was also unable to provide details of the event that occurred. R1 was not injured during the altercation. The altercation happened during dinner time on 2/12/2026. LPA collected LIC 602, physician's report, appraisal needs and services plan for R1 and R2. At this time, this case in under review and department will conduct a follow up visit , if warranted. No deficiencies were cited during today's case management visit and copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 18, 2026

Allegation investigated: Residents' needs are not being met due to insufficient staffing.

On 02/04/25 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced complaint investigation visit to deliver findings. LPA announced the purpose of the visit and met with Melissa Lummis, Business Office Manager. During visit LPA toured the memory care unit and observed residents in a circle in community area playing bingo. Memory Care Director stated the facility has increased staff to 5 per shift to assist residents in care from 4 staff per shift, except on the NOC shift has 3 staff. On 09/18/25 the department received a complaint with the above allegation. On 09/22/25 LPA conducted a 10-day complaint investigation visit and obtained pertinent documents and interviewed 7 staff and 7 residents. Page 1 of 2 Unsubstantiated Page 2 of 2 During the investigation 7 Staff (S1-S7) were interviewed and 7 Resident (R1-R7). 7 out of 7 staff stated that they provide care to residents with bathing, changing, assist with feeding and ambulating. 7 out of 7 staff stated that the Medication Technician and Assisted living staff will help when a staff member calls out sick or if the Memory Care department is short staffed. 7 out of 7 staff stated that the facility will check on residents who stay in their room every hour to see if they need assistance. During visit LPA observed staff helping residents and assisting with activities. During the investigation LPA reviewed the groupings for the residents and observed that the residents are grouped together and assigned a designated staff in memory care to give showers and change adult briefs. 7 out of 7 staff stated that Assisted Living Medication Technician will help the memory care unit if they need assistance. 7 out of 7 staff stated that there are 4 caregivers on average to cover for memory care. S1 stated that the memory care unit has 33 total residents and 4 staff per shift, sometimes there is 5 in the evening more often. S1 stated that the daily schedule is from 6:00 AM to 230 PM, 2:00 PM to 10:00pm and 10:00 PM to 6:30 AM. S1 stated that there are 2 residents who have 1 on 1 caregivers and only 1 of those provide care to the residents. 5 out of 7 staff stated residents are checked on every 2 hours and changed if soiled. 1 out of 7 staff were still in training and still shadowing but still provided care to residents with senior staff. 1 out of 7 residents stated that the facility staff provide care on time. 1 out of 7 residents stated that the facility on 1 occasion took 3 hours to change adult brief but R1 stated he/she wanted only female staff to assist with care. R1 stated the facility cleans the room every week and as needed. R1 stated that he/she likes the facility and likes the staff. Based on the interviews, observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Melissa Lummis and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 26-AS-20250918153803

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management - Incident visit in regards to an Incident Report the Department received on 1/8/2026. LPA met with The Gardens Director, Maria Chavez and stated the purpose of the visit. On 1/8/2026, the Department received an LIC 624 Incident Report stating on 12/16/2025, resident R1 left the facility unattended and facility staff were aware once they received a call from the local grocery store staff had found resident confused at their store. During today's visit, LPA Rai conducted interviews with 4 staff. LPA Rai will obtain copies of the following documents to included but not limited to R1's LIC 602A Physician's Report and R1's Appraisal/Needs and Services Plan. At this time, LPA Rai determined this case management needs further investigation. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with The Gardens Director, Maria Chavez and a copy of the report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jan 29, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Executive Director (ED) Robin Robbins and stated the purpose of today's visit. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.LPA Rai toured the facility to include at random 10 resident rooms, common areas such as activity rooms, kitchen, dining room and lobby. 10 Out of 10 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. Fire extinguisher was observed and inspected on 02/11/2025. Facility smoke detectors and carbon monoxide detectors were in working condition. The disaster drills, including fire and elopement drills were conducted on a monthly basis from January 2025 - November 2025. Facility passed the Fire Pump and Fire Alarm inspections in June 2025 and March 2025. LPA Rai reviewed facility records for 10 staff and 10 residents. LPA Rai reviewed resident medications and central stored medication records. During today's visit, LPA Rai reminded ED to submit the necessary paperwork to change the facility's administrator. ED agreed and understood. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director (ED) Robin Robbins and a copy of the report was provided. LIC 858 and LIC 859 were provided.the state’s words, verbatim · CDSS document, Dec 10, 2025

Allegation investigated: Facility staff do not treat residents with dignity and respect. Facility staff are not providing adequate food service to residents. Facility staff are not adequately supervising residents who may be a fall risk.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator and stated the purpose of today’s visit. On 5/6/2025, the Department received a complaint with the above allegations. On 5/16/2025, the Department conducted an initial investigation at the facility. On 7/3/2025, the Department conducted a follow up investigation to obtain additional information. Continuation on LIC 9099-C, Page 1 of 4. Unsubstantiated Page 2 of 4. Facility staff do not treat residents with dignity and respect. It was alleged that the facility staff are rude to the residents. On 5/16/2025, the Department interviewed one staff (S1). S1 stated he/she has not seen or heard staff being rude to residents. S1 stated he/she has not heard from other staff that staff are being rude to residents. On 7/3/2025, LPA Rai observed the memory care unit residents and staff for approximately 2 hours. LPA Rai observed staff treating residents with dignity and respect, such as addressing the residents with their preferred names, engaging them in the activity or asking for their permission when moving them to the different areas of the common room. On 7/3/2025, the Department interviewed four staff (S2-S5). Four out of four staff have not seen or heard staff being rude to residents. Three out of four staff stated he/she has not heard from other staff that staff are rude to residents. S5 stated he/she has seen a staff yell at the resident but was not able to remember if the resident was hard of hearing and why the staff was yelling at the resident. On 7/3/2025, the Department attempted to interview five residents but were not able to conduct interviews due to resident refusing to answer questions pertaining to this investigation. Facility staff are not providing adequate food service to residents. It was alleged that the facility staff will clear out resident’s plate when they are not finishing eating. On 5/16/2025, the Department interviewed one staff (S1). S1 stated the facility provides 3 meals and snacks to the residents every day. S1 stated he/she has seen servers provide meals and snacks to the residents in memory care. S1 has not seen/heard staff remove resident’s plates from residents while they were consuming the food. Page 3 of 4. On 7/3/2025, LPA Rai observed the memory care unit residents and staff for approximately 2 hours during lunch service. LPA Rai observed staff waiting for resident to finish their meals before removing the plate, cup or silverware from in front of the resident. LPA Rai observed 2 staff members assisted residents with their meals by cutting their food or feeding them the meal. On 7/3/2025, the Department interviewed four staff. Three out of four staff stated the staff will wait until the resident indicates when they are done with their meal to remove the resident’s plate. S2 stated there is one resident who requires supervision during mealtimes, but staff will assist other residents if they are not able to consume their meals themselves. S5 stated that sometimes the staff will take the plate front in front of the resident, but was not able to remember to recall the name of the staff removing the plates or the name of the resident whose plate was being taken prior to finishing their meal. On 7/3/2025, the Department attempted to interview five residents but were not able to conduct interviews due to resident refusing to answer questions pertaining to this investigation. Facility staff are not adequately supervising residents who may be a fall risk. It was alleged that the facility staff did not observe R1 on 4/25/2025 who had a fall. On 5/6/2025, Reporting Party (RP) stated there were a lot of staff observing resident during the incident including residents and staff. On 5/16/2025, the Department interviewed one staff (S1). S1 stated he/she has not seen or heard staff not supervising fall risk residents. S1 stated residents may fall in the common areas but staff are always present with the residents. On 7/3/2025, LPA Rai observed the memory care unit residents and staff for approximately 2 hours. LPA Rai observed at least 2 residents in the common areas with the residents. Page 4 of 4. On 7/3/2025, the Department interviewed four staff. Four out of four staff were not present during the incident. S3 stated the incident occurred during the shift change at 2pm. S3 stated he/she heard from another staff who stated there were no staff present to observe R1 when the incident occurred. S3 is not able to provide the name of the staff who made the comment to S3. S2 stated there was a staff member present during the incident and it is documents on R1’s progress note dated 4/25/2025. On 7/3/2025, the Department attempted to interview five residents but were not able to conduct interviews due to resident refusing to answer questions pertaining to this investigation. Based on review of LIC 625, Unusual Incident/Injury Report dated 4/25/2025 for R1, R1 was walking with the walker when tripping over another resident’s feet. Based on review of R1’s progress note dated 4/25/2025, staff S1 was present at the time of the incident and resident was assessed after incident and staff called “9-1-1” to seek medical attention. Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 26-AS-20250506150033

Type of visit: Case Management - Incident

Program Analyst (LPA) Simi Rai conducted an unannounced Case Management - Incident visit in regards to an Incident Report the Department received on 7/16/2025. LPA met with Interim Executive Director (ED) Brenda Ritter and stated the purpose of the visit. On 7/16/2025, the Department received an LIC 624 Incident Report stating resident (R1) reported hearing 2 staff yelling at a resident in the hallway. R1 was not able to identify the 2 staff and 1 resident involved. During today's visit, LPA Rai conducted interviews with 4 staff (S1-S4). Four out of the four staff stated they have not seen or heard staff yell at the residents or R1. Four out of four staff stated other residents have not notified them of staff yelling at residents. During today's visit, LPA Rai conducted interview with 1 resident (R1). R1 was not able to provide information about when the incident occurred and who was involved, both the staff or residents. R1 was not sure if the 2 "staff" members were individuals that worked at the facility or if they were visitors. R1 was not able to recall if the 2 "staff" members wear a light blue shirt, which would indicate if they were staff working at the facility. Based on review of R1's Physician Report dated 8/18/2021, R1 does not have neurocognitive disorders and R1 is able to manage own prescription medication and leave the facility unassisted. Based on review of R1's Service Plan dated 7/9/2025, R1 requires minimal assistance at night. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. The Department has completed the investigation. Based on interviews conducted and record reviews, the Department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 22, 2025

Allegation investigated: Facility staff does not allow resident to make phone calls. Facility staff witholding resident's personal check without resident's knowledge.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Business Office Director, Melissa Lummis and stated the purpose of today’s visit. On 12/13/2024, the Department received a complaint with the above allegations. On 1/7/2025, the Department conducted an initial investigation at the facility. Continuation on LIC 9099-C, Page 1 of 3. Unfounded Page 2 of 3. Facility staff does not allow resident to make phone calls. It was alleged that facility staff does not allow resident R1 to make phone calls. On 1/7/2025, the Department interviewed 7 staff (S1-S7). S3 stated R1 requested for a phone number to be blocked on her phone and S3 assisted with R1’s request. S3 stated that he/she only followed R1’s request and ensured R1’s personal rights were not violated. Five out of seven staff stated they have observed R1 with his/her personal cellphone and R1 was able to make phone calls on his/her own. On 1/7/2025, the Department interviewed 1 resident (R1). R1 stated he/she she uses her personal cellphone to make phone calls. R1 stated he/she is able to make phone calls on the cellphone. R1 stated he/she asked the facility staff help her to block phone numbers that she did not want to receive calls from in the future. R1 stated that it was his/her decision. While talking to R1, LPA Rai observed R1’s cellphone on the charger next to R1’s bed. R1’s cellphone was in working condition. R1 demonstrated how to use the cellphone and showed LPA Rai the call log of making phone calls in the past 7 days. Facility staff withholding resident’s personal check without resident’s knowledge. On 1/7/2025, the Department interviewed 7 staff (S1-S7). Five out of seven staff are not involved with residents’ finances and do not know what the facility’s policy is regarding resident’s finances. One out of seven staff do oversee the residents’ finances at the facility. S1 stated the facility does not keep residents’ personal check at the facility and if there is a check under a resident’s name, they will release it to the resident and/or resident’s responsible party. S7 stated he/she provided the personal check to the R1 on 11/24/2025 and informed R1’s responsible party W1. On 1/7/2025, the Department interviewed 1 resident (R1). R1 stated he/she does not recall a check being sent to the facility. R1 stated he/she has a financial responsible party (W1) which will assist with finances. Page 3 of 3. On 1/22/2025 and 1/24/2025, the Department attempted to reach W1 to obtain additional information but was unsuccessful. Based on review of R1’s Physician’s Report dated 7/14/2023, R1 is not able to manage own cash resources and R1’s family manages her finances. Based on review of conversations between facility staff and W1 on 11/27/2024, facility staff surrender R1’s personal check to R1 and R1’s responsible party was informed. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Business Office Director, Melissa Lummis and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 3, 2025 · control 26-AS-20241231084257

Allegation investigated: Facility staff are not answering resident's call button. Facility staff are not providing incontinence care at night to residents.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Business Office Director, Melissa Lummis and stated the purpose of today’s visit. On 4/25/2025, the Department received a complaint with the above allegations. On 5/2/2025, the Department conducted an initial investigation at the facility. Continuation on LIC 9099-C, Page 1 of 3. Unfounded Page 2 of 3. Facility staff are not answering resident’s call button. On 5/2/2025, the Department interviewed 1 staff (S1). S1 stated the call button system alerts the facility staff via pager every 5 minutes until the alert is not cleared. S1 stated the residents receiving incontinence care require facility staff to change incontinence products are often as necessary. S1 stated the facility staff will document when they have provided incontinence assistance to resident. On 7/3/2025, LPA Rai interviewed 4 staff (S1-S4). Four out of four staff stated they do not have call buttons for residents that require incontinent care. Four out of four staff stated they have not seen or heard staff not answering resident’s call button. On 7/3/2025, LPA Rai interviewed 5 residents (R1-R5). Five out of five residents refused to be interviewed during the visit. Based on review of call button report for March 2025 and April 2025, facility staff are responding to resident’s call buttons and there hasn’t been one entry where the staff did not answer to a resident’s call button request. Facility staff are not providing incontinence care at night to residents. On 5/2/2025, the Department interviewed 1 staff. S1 stated the residents receiving incontinence care require facility staff to change incontinence products are often as necessary. S1 stated the facility staff will document when they have provided incontinence assistance to resident. On 7/3/2025, LPA Rai interviewed 4 staff (S1-S4). Four out of four staff stated they have not seen or heard facility staff not provide incontinence care at night. Three out of four staff stated they have seen some residents that require attention in the morning with incontinence care, but that does not meet the resident has not been provided with incontinence care at night. Page 3 of 3. On 7/3/2025, LPA Rai interviewed 5 residents (R1-R5). Five out of five residents refused to be interviewed during the visit. Based on review of 5 random residents (R1-R5) who require incontinent care, 5 out of 5 residents received incontinent care at night in April 2025. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Business Office Director, Melissa Lummis and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 3, 2025 · control 26-AS-20250425154553

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct an case management visit to follow up on Incident Report/Death Report for resident (R1) who sustained injury from an unwitnessed fall and passed away at the hospital. LPA Rai met with Executive Director (ED) Brenda Ritter and stated the purpose of today's visit. Today, the Department received an Incident Report for an incident which occurred on 6/20/2025 wherein R1 had an unwitnessed fall in resident's room in the Memory Care unit. R1 stated the right side of the body and head was "hurting". The facility staff called the paramedics and R1 was taken to the hospital. Today, the Department received a Death Report wherein R1 passed away at the hospital on 6/20/2025 and the immediate cause of death is unknown. LPA Rai obtained copy of the following documents which included but not limited to R1's Physician's Report, Service Plan Report, Evaluation and progress notes. At this time, LPA Rai determined this case management needs further investigation. The report was reviewed with Executive Director (ED) Brenda Ritter and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 23, 2025

Allegation investigated: Facility did not maintain the fuel/diesel for back up power generator causing power outages.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Maintainence Director, Wes McKinley and stated the purpose of today’s visit. On 6/10/2024, the Department received a complaint with the above allegation. On 6/14/2024, the Department conducted an initial investigation at the facility. It was alleged the facility did not maintain the fuel/diesel for the back-up power generator causing power outages. On 4/22/2024 at approximately 12:24pm, the facility power generator had low fuel which caused a power outage. At approximately 1:23pm, the power was restored at the facility. Based on Incident Report dated 4/22/2024, the facility self-reported the incident and stated the facility was able to run normal operations. Continuation on LIC 9099-C, Page 1 of 2. Unfounded Page 2 of 2. On 4/23/2024, the Department had conducted a wellness check visit and observed no issues which posed a health, safety, or personal rights risks to persons in care. LPA Rai interviewed the Maintenance Director (MD). MD stated the third-party vendor was responsible for maintaining the fuel/diesel for the back-up power generator. On 3/7/2025, LPA Rai reviewed documents provided by the third-party vendor stating the facility was not responsible of the power generator and their company was responsible for the low fuel which caused the power outage. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Maintainence Director, Wes McKinley and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 7, 2025 · control 26-AS-20240610163702

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Corey Miller . During the visit, ADM stated the Assisted living has 135 residents and memory care has 31 residents. LPA explained the purpose of the visit. LPA toured all 4 floors of the facility inside out with ADM which included the Activity rooms, kitchen, dining room and restrooms. LPA randomly inspected the following assisted living resident bedrooms: 216, 301, 303, 313, 327,403 The staff area of the facility was also inspected. LPA also randomly inspected the following bedrooms in the facility memory care unit; 141, 144, 147, 163. LPA tested delayed egress, which activated when pushed. The front and back of the facility was inspected. There was no obstruction to block the walkways. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F. LPA tested hot water temperature in 4 random resident bedroom, which measured to range from 114 to 116 degrees F. Fire extinguisher was serviced in November 2, 2024. The facility's last sprinkler system inspection was completed on September 2024. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on October 7, 2024. LPA reviewed facility records for 5 staff and 5 residents. LPA reviewed 5 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff and 4 residents. Page 1 Out 2. LPA requested copies of the following documents be sent to LPA: 1.LIC 308, Designation of Administrative Responsibility 2.LIC400, Affidavit Regarding Client/Resident Cash Resources 3. Liability Insurance 4. Qualifications of Administrator (Certificate) 5. Please review your facility program for updates (incorporating new laws and/or regulations) LPA provided Dementia Care and RCFE regulation updates flyer. No deficiencies cited during today's visit. This report was reviewed with Administrator Corey Miller and a copy of the signed report was provided. Page 2 Out of 2. END OF REPORT.the state’s words, verbatim · CDSS document, Dec 19, 2024

Allegation investigated: Facility staff gave resident expired medication. Facility staff are not properly dispensing medications to residents. Facility staff are not properly managing residents' medications. Facility staff are not ensuring that residents are adequately fed.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Executive Director, Corey Miller and stated the purpose of today’s visit. On 1/26/2023, the Department received a complaint with the above allegations. On 1/31/2023, the Department conducted an initial investigation at the facility. Continuation on LIC 9099-C, Page 1 of 4. Unsubstantiated Page 2 of 4. Facility staff gave resident expired medication. It was alleged the medication carts which stored the resident’s medication had expired medication. On 1/31/2023, the LPA observed the medications in the medication cart and did not observe expired medications. On 12/16/2024, LPA Rai interviewed 3 staff (S1-S3) who were working at the facility during the time of the complaint was received on 1/26/2023. Three of three staff stated they have not seen or heard of residents being administered expired medication. S3 stated the Medication Technicians administer the medications and S3 has seen the Medication Technicians follow the facility’s police on administering medications to the residents. On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation. Facility staff are not properly dispensing medication to residents. It was alleged Medication Technicians (Med-Tech) would leave the resident’s medication on the tables, assessable to residents. On 1/31/2023, the Department interviewed S3 who was designated to administer medication to residents. S3 stated Assisted Living residents came to Medication Room to administer medications and MedTech would deliver to Memory Care residents. On 1/31/2023, the LPA observed the resident rooms and dining rooms. LPA did not observe medications left on the table. On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation. Page 3 of 4. On 12/16/2024, LPA Rai interviewed 3 staff (S1-S3) who were working at the facility during the time of the complaint was received on 1/26/2023. Three of three staff stated they have not seen or heard of staff not properly dispensing medication to residents. All three staff stated they have not seen resident’s medication on table or counters accessible to residents. S3 stated the Medication Technicians administer the medications to the resident directly and they observe the resident taking the medication. S3 stated the Medication Technicians note residents that refuse medication as well. S3 has seen the Medication Technicians follow the facility’s police on administering medications to the residents. Facility staff are not properly managing resident’s medications. It was alleged the Medication Administered Record (MAR) was incorrect, the medication was logged as administered, but the medication was refused or left in the medication cart. On 1/31/2023, the Department interviewed 3 staff members (S1-S3). Two staff did not answer questions related to this allegation. S3 stated everything was documents correctly in the MAR. S3 stated staff would try three times if resident refused to take medications. S3 stated when resident refused to take medication, it was reported to the Director and resident’s physician. On 1/31/2023, the LPA observed the medications in the medication cart and did not note any issues wherein the MAR was incorrect. Facility staff are not ensuring that residents are adequately fed. It was alleged resident R1 and R2 did not receive the assistance feeding lunch due to be short staffed, so the residents were not fed lunch. On 1/31/2023, the Department interviewed 3 staff members. One out of three staff stated all residents received and were fed meals. S1 stated there are dedication caregivers to help residents for the meals and there is no shortage of facility staff at the time. Page 4 of 4. On 1/31/2023, the Department interviewed 3 residents (R1-R3). R1 stated he/she always had meals in the dining room. LPA observed a designated caregiver with R1. R2 was not able to speak with LPA due to language barrier. R3 stated all the residents eat meals in the dining room and receive their full meals. On 1/31/2023, the LPA observed the resident rooms and dining rooms. LPA did not observe meals left on the table unconsumed. Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Executive Director, Corey Miller and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 26-AS-20230126091157

Allegation investigated: Facility billed resident for services not rendered. Staff did not adhere to resident's dietary restrictions.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Executive Director, Corey Miller and stated the purpose of today’s visit. On 6/14/2023 the Department received a complaint with the above allegations. On 6/23/2023, the Department conducted an initial investigation at the facility. Continuation on LIC 9099-C, Page 1 of 3. Unfounded Page 2 of 3. Facility billed resident for services not rendered. It was alleged resident R1 moved out of the facility in 4/30/2023 and was billed for rent and care services in May 2023 and R1 made payment on 9/8/2023. On 6/23/2023, the Department interviewed 4 staff, including the ED1 that was part of the facility at that time. ED1 stated the facility will bill the month prior, in this case, R1 was billed in April 2023 for May 2023 services. ED1 stated once they receive a 30 -day notice of resident moving out, then they reimbursement the payment from the day the resident moves out from the facility. Based on review of R1’s Admission Agreement signed on 7/28/2021 by Facility Representative and R1’s Power of Attorney, on page 10 of 44 under “Refund of Prepaid Monthly Fee, “You or your legal representative shall receive the refund on the date you move out of the Community and vacate your Unit…provided you submit a written request to us to receive such refund on that date at least five (5) days before your scheduled move-out date. Otherwise, you or your legal representative shall receive such refund within seven (7) days from the day you leave the Community, and your Unit is vacated.”. Based on R1’s invoice dated 6/1/2023, payment history is summarized so show R1 was billed for rent and care services on 5/1/2023 but it was reversed, and credit was due to R1. Based on Outgoing Payments Report for R1, R1 was reimbursed the payment on 5/9/2023, 1 day after payment was made on 5/8/2023. Staff did not adhere to resident’s dietary restrictions. It was alleged resident R1 physician order resident to be served bite-size food and there were 5 meals that resident was served whole meat servings which were not cut up into bite size. On 6/23/2023, the Department interviewed 4 staff, including the ED that was part of the facility at that time. Four out of four staff stated the facility staff follow the resident’s physician’s order for diet order and ensure meals are served as order by resident’s physician. Page 2 of 3. Staff did not assist resident with dental hygiene. It was alleged the staff did not assist resident R1 brushing R1’s teeth before going to bed and in the morning. On 6/23/2023, the Department interviewed 4 staff, including the ED that was part of the facility at that time. Four out of four staff stated residents are assessed if they are independent or need assistance with ADLs (Activities of Daily Living), which includes dental hygiene assistance. Three out of four staff work directly with R1 and all three staff stated they will remind R1 to brush teeth in the morning and in the evening. Based on review of 6 of R1’s Functional Needs Assessments from (9/2/2021- 11/16/2022), R1 had a change of condition and on 11/2/2022 and 11/16/2022, it was indicated R1 requires stand-by/remind assistance twice a day where RSA (Resident Service Assistant) will remind resident to brush teeth each morning and evening and ensure the task is complete prior to leaving resident. Facility did not follow residents Needs and Services Plan. It was alleged R1’s Needs and Services Plan indicated dental hygiene and diet plan which the facility staff did not follow. On 6/23/2023, the Department interviewed 4 staff, including the ED that was part of the facility at that time. Three out of four staff work directly with R1 and all three staff stated they will remind R1 to brush teeth in the morning and in the evening and ensure no salt is added to R1’s meals. S3 and S4 stated they will chop up the food when they assess the food item may be difficult for resident to cut themselves. S3 stated they will ask the manager to have the resident’s doctor assess the resident if they observe residents having difficulty with their current dietary needs. Based on review of R1’s dietary plan on Needs and Service Plan which indicated R1 did not require dietary needs and eating assistance. Based on review of R1’s dental hygiene plan on Needs and Service Plan, R1 requires stand-by/remind assistance twice a day where RSA (Resident Service Assistant) will remind resident to brush teeth each morning and evening and ensure the task is complete prior to leaving resident. Page 3 of 3. Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided. Page 3 of 3. Based on review of R1’s Physician’s Report dated 8/4/2021, R1’s special diet was “NAS” which is an abbreviation for “no added salt”. The physician’s report does not indicate the resident was to be served bite-size food. Based on review of R1’s initial Functional Needs Assessments on 07/21/2021 to most recent Functional Needs Assessment 11/16/2022, R1 did not require dietary needs, eating assistance or assistive/adaptive devices. All 6 Functional Needs Assessments were reviewed and signed by R1’s Power of Attorney. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 26-AS-20230614142535

Allegation investigated: Facility staff does not check resident for incontience care. Facility staff forgot to serve a meal to resident. Resident was wearing the same clothing for at least 24 hours. Facility did not provide snacks prior to supplemental fee for snacks. Facility did not ensure resident safety, resulting in resident sustaining an injury. Facility does not have adequate staffing to meet the resident's needs.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Executive Director, Corey Miller and stated the purpose of today’s visit. On 9/7/2023, the Department received a complaint with the above allegations. On 9/14/2023, the Department conducted an initial investigation at the facility. Continuation on LIC 9099-C, Page 1 of 5. Unsubstantiated Page 2 of 5. Facility does not check resident for incontinence care. It was alleged the resident’s undergarments were not changed for more than 6 hours while resident had visitors and resident was on 2-hour status checks for incontinence care. On 9/14/2023, the Department interviewed two staff (S1&S3) who provides care and supervision to R1. S1 stated the facility staff do hourly check on all residents to check on the status of the resident, including if the resident requires incontinence care. Two out of two staff stated R1 requires incontinence care and R2’s incontinence products are changed every 2 hours as necessary. On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation. Based on review of R1’s Care Plan dated 1/20/2023, R1 needed assistance with incontinence care wherein used products would need to be disposed every shift. Based on review of R1’s Functional Needs Assessment dated 11/24/2021, R1 needs assistance in the morning and night to change the hygiene pad. Facility staff forgot to serve a meal to resident. It was alleged the resident was not served a meal while resident had a visitor from 3pm-9pm. It was alleged when facility staff was asked about serving the meal to resident, they stated they forgot to give the resident the meal. On 9/14/2023, the Department interviewed two staff (S1&S3) who provides care and supervision to R1. S1 stated R1 needs assistance with meals. S1 stated the facility staff monitor residents who receive meals in their rooms and resident was provided a meal tray during dinner service. Two out of two staff stated they track R1’s food service when food tray was provided to R1. Page 3 of 5. Based on review of R1’s meal tray tracker, the staff noted R1 required meal tray service during dinner time on 9/5/2023. Based on progress notes for R1 from 9/6/2023 – 9/11/2023, staff recorded providing incontinence care to R1 at least once per shift. On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation. Resident was wearing the same clothing for at least 24 hours. It was alleged the facility staff did not change a resident’s clothes wherein resident was wearing the same clothes two days in a row. On 9/14/2023, the Department interviewed two staff (S1&S3) who provides care and supervision to R1. S1 stated R1 has night gowns and staff change R1 in bed. S1 is not aware why R1 was not changed in the evening. S3 stated R1 is not changed when R1’s clothes are clean. S3 stated R1 does not refuse to be changed, so there shouldn’t be a reason why R1 was not changed. On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation. Facility did not provide snacks prior to supplemental fee for snacks. On 9/14/2023, the Department interviewed the Administrator (ADM) who was in charge of the facility during the time of the complaint. ADM stated the facility changed its billing system when the new partnership took effect. ADM stated the facility is not charging extra for snacks and it has always been included in the meals. Page 4 of 5. On 9/14/2023, the Department interviewed three staff (S1-S3). Three out of three staff stated the staff provide snacks to the residents and there are snacks available to residents at all times which include granola bars, graham crackers, and cookies. Three out of three staff stated the facility staff have always provided snacks to the residents. On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation. Facility did not ensure resident safety, resulting in resident sustaining an injury. It was alleged resident sustained bruises due to impact and resident is bedridden and cannot move hands or head. On 9/14/2023, the Department interviewed the Administrator (ADM) who was in charge of the facility during the time of the complaint. ADM stated the resident has unknown behaviors which may have contributed to the injury. On 9/14/2023, the Department interviewed two staff (S1&S3) who provides care and supervision to R1. Two of two staff stated he/she is not aware of R1’s bruises. S1 stated R1 will move around in the bed so staff including S1 place blankets and pillows around R1’s head and hands, so R1 does not sustain bruising from the half-bed rails. Two out of two staff stated they did not see or hear staff physically hurt R1. Based on review of R1’s Care Plan dated 1/20/2023, R1’s skin assessment is not provided wherein skin issues are not documents. Based on review of R1’s Functional Needs Assessment dated 11/24/2021, R1’s skin assessment and/or skin issues were not documented. Page 5 of 5. Facility does not have adequate staff facility to meet the resident’s needs. It was alleged the facility is short staffed and they do not have enough staff in the building. On 9/14/2023, the Department interviewed the Administrator (ADM) who was in charge of the facility during the time of the complaint. ADM stated the facility staffing is set according to the needs and assessment of the residents. ADM stated resident (R1) is the only resident in Memory Care that needs 2-person assistance, and they have enough staff in the building to provide the resident’s needs. On 9/14/2023, the Department interviewed three staff (S1-S3). S1 stated the facility has enough staff, but the staff communicating to management about resident’s changing needs so the assessment can reflect the resident’s needs. S1 stated the staff need to ensure the assessment correctly reflects the needs of the resident, so management can ensure this is adequate staffing at the facility. S3 stated there have been once or twice he/she recalls when there was one care staff during nocturnal (NOC) shift but there is always one Med-Tech to assist the care staff during NOC shift. Based on review of staff schedule for Memory Care unit from July 2023 - September 2023, there is at least 2-3 care staff and 1 Medication Technician present during each shift for morning shift (6am – 2pm), 2 – 3 care staff and 1 Medication Technician present during each shift for afternoon shift (2pm – 10pm), and 1 -2 care staff and 1 Medication Technician present during nocturnal (NOC) shift (10pm-6am). Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Executive Director, Corey Miller and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 26-AS-20230907100701

Allegation investigated: . Residents in care sustained unexplained skin injuries 2. Residents in care sustained multiple falls while in care 3. Staff did not ensure resident's room was kept free of hazards 4. Staff did not safeguard resident's personal clothing items 5. Staff leave medications unattended at the reach of residents in care 6. Residents in care are not provided activities/ 7.Staff forgot to serve meals to residents in care 8. Snacks were not made available to residents in care 9. Staff do not ensure passageways are kept free of obstructions 10. Staff were not present at the facility during their night time shift

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Executive Director, Corey Miller and stated the purpose of today’s visit. On 12/7/2023, the Department received a complaint with the above allegations. On 12/15/2023, the Department conducted an initial investigation at the facility. Continuation on LIC 9099-C, Page 1 of 8. Unfounded Page 2 of 8. Residents in care sustained unexplained skin injured. It was alleged an unidentified resident sustained a questionable skin injury during an unknown date and time. On 12/15/2023, LPA Rai interview two staff (S1-S2). Two out of two staff stated they did not have knowledge of a resident who sustained a skin injury in the past three months. Two out of two staff stated the staff will submit Incident Reports for any injuries sustained to the residents. On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Three out of three staff stated did not have knowledge of a resident who sustained a skin injury during October 2023 – December 2023. On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation. On 12/16/2024, LPA Rai reviewed at random 3 resident files. LPA Rai reviewed R1-R3’s Physician’s Reports, Appraisal/Needs and Services Plan and Progress Notes. LPA Rai did not observe any note stating resident sustained a skin injury. Based on review of Incident Reports received from October 2023 - December 2023, LPA Rai reviewed 20 Incident Reports and 0 out of 20 reports were related to resident sustaining a questionable skin injury. Residents in care sustained multiple falls while in care. It was alleged an unidentified resident had multiple falls at the facility which led to hospitalization during an unknown date and time. On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of resident having multiple falls which lead to hospitalization. Two out of the two staff stated the staff will submit Incident Reports for any injuries sustained to the residents. Page 3 of 8. On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Three out of three staff stated they did not have knowledge of a resident having multiple falls which lead to hospitalization. Three of three staff cannot recall any incidents which caused resident to go to the hospital. On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation. On 12/16/2024, LPA Rai reviewed at random 3 resident files. LPA Rai reviewed R1-R3’s Physician’s Reports, Appraisal/Needs and Services Plan and Progress Notes. LPA Rai did not observe any note stating resident sustained an injury after having multiple falls. Based on review of Incident Reports received from October 2023 – December 2023, LPA Rai reviewed 20 incident Reports and 3 out of 20 reports were related to resident being hospitalized. Out of the 3 reports, 0 reports were related to hospitalized due to repeated falls. Staff did not ensure resident’s room was kept free of hazards. It was alleged an unidentified resident had a broken vase in the room and the facility staff did not remove the pieces of glass during an unknown date and time. On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of resident’s room was not kept free of hazards. Two out of the two staff stated the staff will submit work order if the resident’s room need to be cleaned of hazards. S1 reviewed work orders placed from October 2023 – December 2023 and they were not related to issues related to cleaning a broken vase in resident’s room. On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Two out of three staff stated they did not have knowledge of a resident’s room had a broken vase. S3 stated he/she remembers an incident with a broken vase but is not sure which resident it involved and if staff removed the broken case from the room in a timely manner. Page 4 of 8. On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation. Staff did not safeguard resident’s personal clothing items. It was alleged an unidentified resident had incontinence products still attached to the clothing placed in the laundry. On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of resident’s incontinence products attached to resident’s clothing placed in laundry. On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Two out of three staff stated they did not have knowledge of resident’s incontinence products attached to resident’s clothing placed in laundry. S3 stated he/she is aware of issues wherein residents would confuse the waste basket and the laundry basket, but S3 has not seen or heard staff place incontinence products still attached to the clothing in the laundry. Three of three staff stated they have not seen or heard staff place incontinence products still attached to the clothing in the laundry. On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation. Staff leave medications unattended at the reach of residents in care. It was alleged an unidentified resident’s medications were left in the resident’s room during an unknown date and time. On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of resident’s medications were left in resident’s room unattended. Two out of the two staff stated they have no heard or seen staff leave medications in resident’s room unattended. Page 5 of 8. On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Three out of three staff stated they did not have knowledge of resident’s medications were left in resident’s room unattended. Three out of the three staff stated they have no heard or seen staff leave medications in resident’s room unattended. On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation. Residents in care are not provided activities. It was alleged facility staff were not conducting activities in the activity room. On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of resident having multiple falls which lead to hospitalization. Two out of the two staff stated the staff will submit Incident Reports for any injuries sustained to the residents. On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Three out of three staff stated they did not have knowledge of a resident having multiple falls which lead to hospitalization. Three of three staff cannot recall any incidents which caused resident to go to the hospital. On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation. Based on review of activity calendar for October 2023 – December 2023, there were at least 13 activities per week listed on Memory Care activity calendar. The activities included but not limited to religious events, exercise classes, scenic drives, and movie nights. Snacks were not made available to residents in care. It was alleged residents were not given snacks. Page 6 of 8. On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of residents were not given snacks. Two out of the two staff stated the staff will give snacks before lunch and after lunch to the residents and the residents have the right to refuse to eat the snacks. On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Three out of three staff stated they did not have knowledge of residents were not given snacks. Three out of the three staff stated the staff will give snacks before lunch and after lunch to the residents and the residents have the right to refuse to eat the snacks. S3 stated there have been a delay of residents receiving the snacks due to the kitchen staff being occupied but the residents will be given to residents before lunch or dinner service. On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation. Staff forgot to serve meals to residents in care. It was alleged facility staff did not serve or provide meals to residents in their rooms. On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of staff not serving or providing means to residents in their rooms. Two out of the two staff stated the staff are aware of which residents will eat meals in their rooms and they provide the meals and help assist residents with feeding as well. On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Three out of three staff stated they did not have knowledge of staff not serving or providing means to residents in their rooms. Three out of the three staff stated the staff are aware of which residents will eat meals in their rooms. All three staff stated they have not seen or heard staff not providing meals to residents in their room. On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation. Page 7 of 8. Staff do not ensure passageways are kept free of obstructions. It was alleged the passageways in the facility are free of obstruction. On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of passageways in the facility not free of obstruction. S1 reviewed work orders placed from October 2023 – December 2023 and they were not related to issues related to passageways not free of obstruction. On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Three out of three staff stated they did not have knowledge of passageways in the facility not free of obstruction. Three of three staff cannot recall any incidents wherein the passageways were not free of obstruction. On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation. Based on review of work orders from October 2023- December 2023, 0 work orders were related to passageways were obstructed or blocked. Staff were not present at the facility during their nighttime shift. It was alleged there was no staff present at the facility during nocturnal (NOC) shift. On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of an incident where nocturnal (NOC) shift care staff were not present at the facility, and no one was available to assist the residents from 10pm to 6am. S1 stated there is always coverage of staff on all three shifts, at least 1 Medication Technician and 1 care staff during the NOC shift. On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Three out of three staff stated they did not have knowledge of an incident where nocturnal (NOC) shift care staff were not present at the facility, and no one was available to assist the residents from 10pm to 6am. S4 stated there is always coverage of staff on all three shifts, at least 1 Medication Technician and 1 care staff during the NOC shift. Page 8 of 8. On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation. Based on review of facility’s NOC shift caregiver “punch-in” times from October 2023 – December 2023, LPA Rai observed at least 1-2 caregivers and 1 Medication Technician on duty that were present at the facility who “punched-in” at approximately 10pm and “punched-out” at approximately 6am. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Executive Director, Corey Miller and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 26-AS-20231207104032

Allegation investigated: Facility did not submit Death Report for a resident. Facility did not submit Incident Reports for positive COVID-19 cases. Facility did not maintain to cool rooms to a comfortable range between 78 degrees F and 85 degrees F.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Executive Director, Corey Miller and stated the purpose of today’s visit. On 6/10/2024, the Department received a complaint with the above allegations. On 6/14/2024, the Department conducted an initial investigation at the facility. Continuation on LIC 9099-C, Page 1 out of 3. Unfounded Page 2 of 3. Facility did not submit Death Report It was alleged the facility did not submit a Death Report for a resident (R1) who passed away at the facility. Based on record review of Death Reports submitted by the facility to the Department, facility did submit the Death Report for R1 in a timely manner. Facility did not submit Incident Reports for positive COVID-19 cases. It was alleged the facility did not submit Incident Reports to the Department for residents who tested positive for COVID-19. Based on record review of Incident Reports submitted by the facility to the Department from January 2024 - June 2024, facility did submit the Incident Report for COVID-19 positive cases at the facility and report the cases to the local Public Health Department. Facility did not maintain to cool rooms to a comfortable range between 78 degrees F and 85 degrees F. It was alleged the resident (R2) was not able to adjust the thermostat to the room and the common room. On 6/14/2024, LPA Rai toured the facility, LPA Rai observed the temperature in the common areas to include the restaurant, lounge, hallways, and activity room, and randomly two resident rooms including R2’s room. LPA Rai observed the temperatures were within 78 degrees F and 85 degrees F. LPA Rai observed the thermostat in the common areas and resident rooms wherein staff and residents may adjust the temperature. Page 3 of 3. On 6/14/2024, the Department interviewed 1 staff (S1). S1 stated there weren’t any issues with the central cooling and heating unit. S1 stated he/she did not hear or observe any issues with the temperature in the facility. S1 stated the residents are able to adjust their own apartment temperatures but the system is capable to maintain the temperatures between 78 degrees F and 85 degrees F. On 6/14/2024, the Department interviewed 7 residents (R1-R7). Seven out of seven residents stated they did not have issues with the thermostat located in their room and the common room. Seven out of seven residents stated they were able to adjust the temperature of their room. R2 demonstrated how to change the temperature in the common room and adjust the temperature in R2’s room. On 12/16/2024, LPA Rai reviewed work orders for R2’s room from April 2024 – June 2024 and two out of two work order did not pertain to R2’s thermostat not working in R2’s room. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 26-AS-20240610163702

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.

Allegation investigated: Lack of staff supervision resulting in resident injury. Facility is understaffed.

Licensing Program Analysts (LPAs) Simi Rai and Marcella Tarin conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Executive Director, Corey Miller and stated the purpose of today’s visit. On 10/18/2022, the Department received a complaint with the above allegations. On 10/28/2022, the Department conducted an initial investigation at the facility. On 10/18/2022, resident (R1) was assessed at Kaiser Emergency Room due to unexplained bumps and scratches appearing on R1's head. It was alleged the facility staff was under staffed and unable to supervision R1 which resulted in R1 sustaining injury to the head. Continuation on LIC 9099-C, Page 1 of 2. Unsubstantiated Page 2 of 2. On 10/21/2022, the Department interviewed Paramedic 1 (P1) who responded on the 911 call made on 10/18/2022. Paramedic 1 stated he/she assessed resident (R1) and the bumps and scratches on R1's head did not indicate R1 had a fall. P1 stated R1 has neurocognitive impairment and R1 was not aware of current surroundings or recall the facility's name. On 9/18/2024, LPAs interviewed 3 staff (S1-S3) that were working with resident R1 during the time of the complaint. Three of of three staff stated they do not remember the incident on 10/18/2022. Two of the three staff stated R1 would have seizure-like behaviors where R1 would injury themselves during an episode and would be unbalanced when walking with walker around the facility. Two of the three staff stated they are not aware of any other residents or staff that would try to physically hurt R1. Three out of three staff stated they are not sure if the facility was under staffed at the time and they are not sure if the lack of supervision would cause resident to be injured. Three of the three staff stated all residents were checked every hour or every other hour for safety checks and the facility staff do not provide 1:1 care to R1 in October 2022. Based on review of R1's Physician's Report dated 3/15/2022, R1 had neurocognitive impairment wherein R1 was confused and disoriented and needed assistance with some Activities of Daily Living (ADLs). Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 18, 2024 · control 26-AS-20221018164411

Allegation investigated: Facility did not address water leak in resident's room.

Licensing Program Analysts (LPAs) Simi Rai and Marcella Tarin conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Executive Director, Corey Miller and stated the purpose of today’s visit. On 07/08/2024, the Department received a complaint with the above allegation. On 07/16/2024, the Department conducted an initial investigation at the facility. On 07/05/2024, resident R1 discovered water in R1's room. It was alleged the facility did not address the water leak in resident's room. Continuation on LIC 9099-C, Page 1 of 2. Unfounded Page 2 of 2. On 7/16/2024, LPA Rai interviewed Maintainence Director (MD) Wes McKinley. MD stated his department received work order on 07/05/2024 regarding a water leak in R1's room and bathroom. MD stated his team addressed the issue the next day 07/06/2024 and followed up on 07/07/2024. On 7/26/2024, LPA Rai interviewed resident R1. R1 stated the water was leaking from the roof to the floor on 7/5/2024. R1 stated facility staff responded the same day with the care staff drying the floor and submitting a work order on R1's behalf. R1 stated the maintenance staff responded the next day 7/6/2024 and resolved the issue on 7/7/2024. Based on review of work order form 07/05/2024 to 07/09/2024, facility staff created work order for the day of the incident on 7/5/2024 and the maintainence staff did respond to the work order on 7/6/2024, 7/7/2024 and 7/9/2024. The Department has completed the investigation of the above allegation. Based on interviews conducted and record reviews, the Department has found that the above allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 18, 2024 · control 26-AS-20240708094345

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Simi Rai conducted a case management visit to do a wellness check after power was restored at the facility. LPA Rai met with Executive Director, Corey Miller and stated the purpose of the visit. LPA Rai interviewed Maintenance Director (MD) Wesley McKinley. The power went back online on June 28th, 2024 and no issues to report. PG&E and City of San Jose has conducted inspections and the facility passed the inspections. The maintainence team will conduct weekly and monthly checks on the facility's generator and power grid. LPA Rai toured the facility and observed the facility's electrical grid and observe the power generator was removed from the premise. LPA Rai observed random resident rooms and observed the room temperature within range, functioning lights and fridge/freezer in working condition. No deficiencies were cited at this time as per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Corey Miller and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 16, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management visit and met Maintainence Director (MD) Wes McKinley. The purpose of the visit was to conduct a health and wellness check after the facility notified the Department that the facility had two incidents on 4/14/2024 and 4/22/2024 wherein the facility was out of power. Per LIC 624 Unusual Incident/Injury Report for incident dated 4/14/2024, at 6am a surge of power caused a building wide power outage and by 11:45am a power generator was installed to resume power for the facility. Per report, the facility was able to run normal operations. Per LIC 624 Unusual Incident/Injury Report for incident dated 4/22/2024 at 12:24pm, the generator had low fuel which caused a power outage and power was restored at 1:23pm. Per report, the facility was able to run normal operations. During visit, LPA Rai observed the outside area, behind the facility were the power surge occurred and the area was fenced off. LPA Rai observed the power generator providing power to the facility. MD stated the electrical team is currently investigating the cause of the power outage and the facility is able to function with the generator. MD stated during the two incidents, there were no issues with the water temperatures and room temperatures. Operations were able to run as normal. LPA observed the medication room and staff are able to administer medications to residents. The facility has internet access. LPA Rai interviewed Angel Bustos, Resident Services Director (RSD). RSD stated during the two incidents, there were no issues with medication administration. Hospice agency was notified for 1 resident under Hospice services. RSD stated there are 3 residents that require oxygen administration and oxygen tanks are available for emergency. RSD stated there were no hospitalization caused by the two power outage incidents. Continue LIC 809-C, Page 1 of 2. Page 2 of 2. LPA toured the facility kitchen and observed emergency food and water supplies. LPA observed freezer and fridge in working condition and observed 2 days of perishable foods and 7 days of non perishable foods. LPA Rai observed the emergency food supply and water supply. LPA Rai interviewed Debbie Teixiera, Dining Service Director (DSD). DSD stated the power outage did not cause a disruption in meals served to the residents and there was a food truck on stand by to provide food for residents. LPA observed 3 resident rooms and water temperature and room temperature was within range. The facility will provide an update on when repairs will be made and where facility will no longer need power generator and the facility's power will go online. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Maintainence Director, Wes McKinley and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 23, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Simi Rai conducted a case management visit to do a wellness check after power was restored at the facility. LPA Rai met with Interim Executive Director, Brenda Ritter and stated the purpose of the visit. LPA Rai interviewed Maintenance Director (MD) Wesley McKinley. The power went back online on March 6th, 2024 and no issues to report. PG&E and City of San Jose has conducted inspections and the facility passed the inspections. The maintainence team will conduct weekly and monthly checks on the facility's generator and power grid. LPA Rai toured the facility and observed the facility's electrical grid and observe the power generator was removed from the premise. LPA Rai observed random resident rooms and observed the room temperature within range, functioning lights and fridge/freezer in working condition. No deficiencies were cited at this time as per California Code of Regulations, Title 22. This report was reviewed with Interim Executive Director, Brenda Ritter and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 4, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to follow up on the Type A and Type B deficiencies cited on 1/11/2024. LPA Rai met with Resident Care Director (RCD) Angel Bustos and stated the purpose of today's visit. During visit, LPA Rai toured the Memory Care Unit along with Memory Care Director, Leann Marquez and Resident Services Coordinator, Jacque Bercellano. LPA Rai observed the common bathrooms and resident rooms unlocked and accessible for residents. LPA Rai observed the In-Service training for "Public Restroom Accessibility" dated 1/12/2024, "Keeping Apartment Doors and Public Restroom Unlocked at All Times" dated 1/12/2024, and "Logging of Medications in Centrally Stored Medication and Destruction Record" dated 1/26/2024. LPA Rai observed the weight log for Assisted Living residents initiated for January 2024. LPA Rai observed a printed copy of the Monthly Weight Report and RCD stated a printed copy of the Weight Log for all residents is in a dedicated binder in the Medication Room. LPA Rai observed R1's updated Physician's Report dated 1/26/2024. LPA Rai met with Maintenance Director, Wes McKinley, who stated the repairs on the facility's electrical system is on schedule. Facility will continue to provide updated to the Department. On 1/19/2023, the Department checked the room and water temperatures of the following residents (R2-R4). LPAs observed the room temperature measures from 68F to 74F and water temperature measures from 109F to 116F. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Resident Care Director, Angel Bustos and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 26, 2024

Type of visit: Case Management - Other

On 1/19/2024 Licensing Program Analysts (LPAs) Steve Chang and Mita Partoza, conducted an unannounced case management visit to follow up on the recent power outage. LPAs met with interim program director (IPD) Cheryl Grace. IPD called the maintenance director (MD) Wesley McKinley to explain their current situation. MD stated - the facility has a temporary generator that is functioning. The current generator is able to sustain and provide the power that is needed to provide the basic services and necessity for the health. safety and well being of the residents. medical equipment, kitchen function, alarm system, lighting, water heating and elevator. LPAs toured the following areas kitchen, medication room, food storage and supply, and resident rooms . LPAs observed that the facility is working at it's full capacity without any interruption to services and temperatures are maintained accordingly, refrigerator is at 40F and freezer is at 0F and has sufficient food supplies. LPAS checked the room and water and temperature of the following residents (R1-R3). LPAs found that the water and room temperature measures from 68F to 74F and for water temperature measures from 109F to 116F LPAs interviewed R1 to R3 and noted concerns expressed by the residents. page 1 of 2 continued page 2 (LIC 809-C) continued from page 1 No deficiencies are noted for today's visit. Exit interview was conducted with IPD Cheryl Grace. This report was reviewed and provided to IPD for signature and a hard copy was provided. page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Jan 19, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct a continuation of the annual inspection from 1/9/2024 and met with Interim Executive Director, Brenda Ritter. LPA Rai continued the annual inspection with Angel Bustos, Resident Service Director and Patty Cuzia (RDH) Regional Director of Health Services. LPA Rai toured the kitchen and dining room. LPA Rai observed 2 days of perishable food supply and 7 days of non-perishable food supply. LPA Rai observed a delivery of water gallons during visit and facility had water supply in the pantry, emergency supply closet and kitchen. LPA Rai observed daily temperature log of refrigerator and freezer. During visit, LPA Rai continued to review 5 resident files. LPA Rai observed 5 out of 5 resident files not including weight log. Resident Services Director (RSD) Angel Bustos stated the resident files do not have weight log and the staff are not monitoring Assisting Living resident's weight at this time. RSD stated the facility did order and received a weight machine which will accommodate a wheelchair therefore the facility will initiate weight log for Assisted Living residents. RSD stated the facility recently took over as managing group from the previous managing group and the current facility will honor all Admission Agreements signed by residents and resident's families from the previous managing group. RDH stated the new residents signing under the facility will have new admission agreements reflecting the name of the facility. During a random review/audit of Assisted Living resident's medication bottle and LIC 622 Centrally Stored Medication and Destruction Record. LPA Rai along with RSD and Resident Care Coordinator (RCC) counted the tablets from the medication bottles, 4 out of 4 medications prescribed to R1 was given as prescribed by the doctor, but the medication count was not correct. Continuation on LIC 809-C, Page 1 of 3. Page 2 of 3. During a random review/audit of Memory Care resident's medication bottle and LIC 622 Centrally Stored Medication and Destruction Record. LPA Rai along with RSD and RCC counted the tablets from the medication bottles, 7 out of 8 medications prescribed to R2 was given as prescribed by the doctor, but the medication count was not correct. LPA Rai reviewed R2's medical assessment which was conducted on 12/2/2022 and the facility did not have an annual medical assessment on file as R2 has a Dementia diagnosis. RSD stated they were aware in November 2023 of R2 missing annual medical assessment but have not received a medical assessment from R2's physician. During interview with Staff 1 and Staff 2, 2 staff stated residents are given medications prescribed by physician which was reflected on R1-R2's electronic Medication Administration Record (MAR), but the staff do not log the destruction of medication, therefore the count of the medications is not accurate. RSD stated the facility staff will conduct a mandatory in-service to train the staff of medication administration, including accurate record keeping. On 1/9/2024, LPA Rai observed the water temperatures of the resident bathroom sinks in Memory Care and Assisted Living rooms. 9 out of 9 resident bathroom sinks water temperatures ranged from 120.9F - 130.3 F, which is higher than as stated in regulation where the water temperatures for personal use shall be between 105F-120F. IED stated the water heater was not affected during the power outage and the facility continued to have hot water. During visit, LPA Rai observed the common bathrooms located in the Memory Care unit were locked. LPA Rai observed the resident bedrooms located in Memory Care unit were locked. RSA stated resident would use the bathroom and throw excess toilet paper in the bathroom and clog the toilet. RSA stated the resident would go into other resident's bedrooms. RSD and RDH were present during conversation. RDH informed LPA Rai the facility does not have a policy stating the common bathrooms and resident bedrooms in Memory Care unit shall be locked and RDH will ensure the facility staff are not locking the common bathrooms and resident rooms in Memory Care unit. RSD, RDH, RCC and Memory Care Director, Leann Marquez agreed and understood the facility shall not lock the common bathrooms and resident rooms to substitute staff supervision in Memory Care unit. Page 3 of 3. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. Technical Violation was provided. Exit interview was conducted with Angel Bustos, Resident Service Director and Patty Cuzia (RDH) Regional Director of Health Services and agreed and understood the report. A copy of this report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jan 11, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Jan 18, 2024

87465 Incidental Medical and Dental Care (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by: Based on record review and interview, R1-R2's records of centrally stored medication were inaccurate which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: RSD stated the facility will conduct a mandatory in-service with all staff administering medications and plan of action is submitted by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87466 · Plan of correction due date: Jan 18, 2024

87466 Observation of the Resident ...When changes such as unusual weight gains or losses ... are observed, the licensee shall ensure that such changes are documented... This requirement is not met as evidenced by: Based on record review, LPA did not observe weight log in residents' file in Assisted Living, RSD stated the staff do not observe resident's weight which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: RSD stated the facility will initiate weight log with new weight scale which accommadates residents with wheelchair and plan of action is submitted by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jan 12, 2024

87303 Maintenance and Operation (e)(2) ...Hot water temperature controls shall be maintained ... the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement is not met as evidenced by: Based on observation, LPA observed 9 out of 9 resident bathroom sinks with hot water temperatures ranging from 120.9F - 130.3F which poses/posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: RDH stated Maintenance Director will follow up with water temperatures in resident rooms to ensure it is within regulation and plan of action will be submitted by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(2) · Plan of correction due date: Jan 12, 2024

87468.1 Personal Rights of Residents in All Facilities (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interview and record review, IED and RSA stated the bedrooms and bathrooms were locked in the Memory Care Department and residents needs to ask staff to open the doors which poses/posed an immediate health, safety or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: RDH stated the staff should not lock common bathroom and resident rooms and staff training will be provided and plan of action will be submitted by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Jan 18, 2024

87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment... This requirement is not met as evidenced by: Based on record review of R2's file, R2 did not have an updated annual medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: RSD stated R2's physician has been faxed in November 2023 and staff faxed the physician again today 1/11/2024. RSD will submit a plan of action by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct an annual visit and met with Interim Executive Director (IED) Brenda Ritter. During visit, LPA toured the inside and outside of the facility. LPA observed a back-up generator placed on the side of the facility which is in use during visit and will be used until the generator on the premise is under repair. LPA observed the facilty common rooms and resident room temperatures to be noted at 70-74 degrees Fahrenheit. While the facility is using the back-up generator, the facility will submit daily updates of the facilty and any changes occurring during this time. The facility common bathrooms had available soap, paper towels, and trash cans with lids. The showers had grab bars and textured floors with shower chairs. Fire extinguisher were observed and were inspected on March 2023. LPA inspected 8 random rooms and occupied resident rooms had available bedding, drawers, and functioning lights. LPA will return another day to complete annual inspection. This report was reviewed with Interim Executive Director (IED) Brenda Ritter. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 9, 2024

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) David Marrufo and Steve Chang conducted an unannounced Case Management visit and met Executive Director (ED) Brenda Ritter. The purpose of the visit was to conduct a health and wellness check after the facility notified the Department that the facility had been out of electrical power since 01/06/2024. During visit, LPAs toured the facility kitchen and observed emergency food and water supplies. LPAs observed that a food vendor was at the facility providing meals for residents. LPAs observed the medication room and medication staff showed LPAs the online medication system that staff still had access to in order to administer medications. The facility still had internet access. The medication room staff showed LPAs the resident medication records that could be used in case the internet became inaccessible. Staff stated 2 out of 2 residents on hospice had had their hospice agency notified of the power outage. ED stated residents had been provided with flashlights, lamps, and blankets. ED stated 36 residents had elected to stay with family members while the power was out at the facility. ED stated one resident who required oxygen had been moved temporarily with family. LPAs conducted wellness checks with residents who were sitting in the lobby area. During visit, the backup generator began to fully provide power to the facility at around 6:30 PM. LPAs requested that a Plan of Action be submitted within 24 hours. During visit, facility staff created an LIC624 Unusual Incident Report on LPA Marrufo's computer. A copy of the LIC624 report was provided during visit. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with ED Brenda Ritter and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 8, 2024