Dominican Oaks

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator (ADM) Amy Saulnier. ADM states the facility has 42 clients. LPA toured the interior of the facility with the ADM. LPA toured the first floor (Assisted Living) in wings C and D (as shown on the facility sketch) with ADM to include but not limited to the kitchen, resident rooms, dining area, and resident activity areas. All exit and passageways were free and clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the refrigerator temperature at 34 F and Freezer at 0 F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. LPA observed the facility to be clean, safe, sanitary and in good repair. The smoke detectors were last inspected by a third party vendor on 2/3/2026 and passed inspection. Fire extinguishers were last serviced on 09/25/25. The facility emergency drill log was reviewed. The facility's last drill was conducted on 3/4/2026. Page 1 of 2 LPA toured 10 resident rooms. All 10 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 10 resident bathrooms. All 10 resident bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperature in 10 resident bathrooms with a range of 108.1 F to 118.4 F. LPA reviewed 5 residents records. LPA reviewed 5 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s) with ADM and Staff S2 and S3. During review, LPA observed R1 had one medication not listed on the CSDMR. Upon further review, S2 and S3 were unable to find a physician's order for the medication. S2 and S3 found that the medication belonged to R1's spouse (also a resident), who had a physician's order for the medication. S2 and S3 stated the medication was not given to R1. S2 states the medication was not documented on R1's spouse's CSMDR when received in December 2025. A deficiency is being issued. LPA reviewed 5 staff records. A deficiency is being cited during today's visit per California Code of Regulations Title 22. See LIC809D. An exit interview was conducted with Administrator (ADM) Amy Saulnier and a signed copy of this report and appeals rights were provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, May 27, 2026

Allegation investigated: Staff did not maintain a comfortable temperature for resident. Staff did not ensure resident’s right to participate in care decisions. Staff did not ensure resident was treated with dignity and respect. Staff did not follow infection control protocols.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint investigation visit and met with Administrator (ADM) Amy Saulnier. LPA stated the purpose of the visit. On 12/18/2025 the Department received a complaint with the above allegations. On 12/22/2025, LPA David Marrufo conducted the initial complaint investigation visit and interviewed 5 Staff (S1 to S5) and 4 Residents (R1 to R4). 5 Out of 5 staff state residents have a thermostat in his/her own room and can adjust room temperature to their preference. S1 states he/she checks room temperatures during a resident room check. 4 out 4 Residents (R1 to R4) state he/she has a thermostat in his/her room and he/she can adjust to his/her preference. Page 1 of 3 Unfounded On 12/22/2025 LPA Marrufo inspected 3 random residents rooms and took the temperature measurements with a range from 71.6F to 86F. Staff did not ensure resident’s right to participate in care decisions. On 12/22/2025, LPA David Maruffo interviewed 5 Staff (S1 to S5) and 4 Residents (R1 to R4). 5 Out of 5 staff state residents participate in his/her care decisions. 4 Out of 4 Residents (R1 to R4) state he/she participates in his/her own care decisions. R2 states that the facility moved him/her into the ‘basement’ without explanation. R2 resides on the first level of the facility in Assisted Living. Review of the facility sketch, the facility does not have a basement. Based on review of R2’s physicians report dated 6/5/2024, for Capacity for Self-Care, R2 does not require assistance with bathing, toileting, dressing, feeding and can manager his/her own cash resources. Review of R1's Admission Agreement dated 7/1/2024, R2 moved into the facility on 7/1/2024 in Independent Living. Staff did not ensure resident was treated with dignity and respect. On 12/22/2025, LPA David Maruffo interviewed 5 Staff (S1 to S5) and 4 Residents (R1 to R4). 5 Out of 5 staff state residents are treated with dignity and respect. 3 Out of 4 Residents (R1 to R4) state staff treat him/her with dignity and respect. R2 states “I am a shock to many residents and staff.” R2 did not provide additional information regarding this statement. On 2/6/2026 the Department reviewed 4 staff training records for 2025, and observed training topics to include but not limited to patients rights and safety, residents rights, and infection control. Staff did not follow infection control protocols. On 12/22/2025, LPA David Maruffo interviewed 5 Staff (S1 to S5) and 4 Residents (R1 to R4). 5 Out of 5 staff state he/she is following infection control protocols, such as wearing gloves when providing care to residents. 4 Out of 4 Residents (R1 to R4) state staff are following infection control protocols, and wear gloves when providing care to residents. Page 2 of 3 On 2/6/2026 the Department reviewed 4 staff training records for 2025, and observed training topics to include but not limited to patients rights and safety, residents rights, and infection control. This agency has investigated the complaint alleging staff did not maintain a comfortable temperature for resident, staff did not ensure resident’s right to participate in care decisions. staff did not ensure resident was treated with dignity and respect. Staff did not follow infection control protocols. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Administrator Amy Saulnier and a copy of this report was provided. Page 3 of 3 END OF REPORTthe state’s words, verbatim · CDSS document, Feb 6, 2026 · control 26-AS-20251218155721

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management Visit to follow up on the death of Resident R1 on 9/14/2025. LPA met with Administrator (ADM) Amy Saulnier. LPA stated the purpose of the visit. On 9/18/2025 the Department received an incident report. The incident report stated "On 9/14/2025, a fellow resident reported to staff that another resident was on the ground in the hallway corridor. Staff responded immediately and found the resident on the floor. Staff contacted 911 and stayed with the resident until EMS paramedics arrived and determined the resident was no longer breathing and had no pulse after medical evaluation." The incident report states Licensing, local law enforcement and R1's family were informed. During visit, LPA obtained the following copies to include but not limited to physician's report and service plan, and Medication Administration Record (MAR). LPA requested the facility to provide a copy of R1's Death Certificate once it becomes available. LPA determined this case management needs further investigation. No deficiencies cited during today's visit. This report was reviewed with ADM Amy Saulnier and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 19, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator (ADM) Amy Saulnier. ADM states the facility has 47 clients. LPA toured the exterior and interior of the facility with the ADM. LPA toured the first floor (Assisted Living) with ADM to include but not limited to the kitchen, resident rooms, dining area, and resident activity areas. All exit and passageways were free and clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the refrigerator temperature at 37 degrees F and Freezer at 0 degrees F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. The facility was equipped with smoke and carbon monoxide detectors. The smoke detectors were last serviced on 11/20/2024. Fire extinguishers were last serviced on 10/2/2024. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was on 3/20/2025. Page 1 of 2. LPA toured 10 resident rooms. All 10 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 10 resident bathrooms. All 10 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperature in 10 resident bathrooms with a range of 112.2 degrees F to 118.2 degrees F. LPA reviewed 5 residents records. LPA reviewed 5 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPA observed 5 Out of 5 CSMDRs had incorrect dates for "Date Filled" sections for medications. ADM stated staff are writing dates when the medications are received instead of the "Date Filled" on the medication label. LPA stated per Title 22 regulations, the Licensee is responsible for assuring that a record of centrally stored medication is maintained and includes the date filled. ADM stated understanding of Title 22 regulations. A Technical Violation was issued. LPA reviewed 5 staff records. No deficiencies were cited during today's visit per California Code of Regulations Title 22. A Technical Violation was issued, see LIC9120 for additional information. An exit interview was conducted with Administrator Amy Saulnier and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, May 14, 2025

Type of visit: Case Management - Other

On 4/23/2025, Licensing Program Analyst (LPA) Grace Donato conducted an an unannounced case management visit to deliver a copy of amended report from 1/22/2025. LPA met with facility Administrator Amy Saulnier (ADM) and explained the purpose of the visit. During the visit, LPA interviewed residents and additional staff members. An amended report was delivered in reference to complaint #26-AS-20220616104145. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Apr 23, 2025

Allegation investigated: Facility has an outbreak of COVID-19 Facility is not following the proper protocol for COVID-19 Insufficient staffing to meet resident's needs Facility did not meet reporting requirements

***This Is an amended report *** On 1/22/2025 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit at the facility. LPA met with facility Administrator Amy Saulnier (ADM) and explained the purpose of the visit. For the allegations of facility has an outbreak of COVID-19 and facility did not meet reporting requirements, reporting party (RP) stated that currently there are 4 residents who were tested positive for COVID-19. According to records review, the facility has sent out memos to residents regarding covid infections. It was also stated in one of the memos that the infections came from outside the facility. Also on these memos, it was stated that the facility is also consulting with Santa Cruz Health Services Agency (SCHSA) regarding recommendations against COVID-19. There was no incident reports submitted to Licensing at this time since as of this complaint was filed the residents who were infected were from the Independent Living side of the facility. Regarding the allegation of Facility is not following the proper protocol for COVID-19, RP stated that the facility is not following the proper protocol for COVID-19, and they are not taking any precautions for COVID-19. Those residents who were tested positive for COVID-19 are being exposed to other residents and the facility’s administration keeps telling everyone that’s ok. Based on interview with ADM, during this time, if there were residents who have tested positive, they are isolated in the rooms. The doors have signs and guides for donning and doffing of PPEs and carts where PPEs are stored. There were no common activities, no communal dining. According to S1, there were no cases of covid in the assisted living side of the facility. Although the testing still happens at least 3 times a week. Testing is done on the 3rd, 5th and 7th day. S2 also shared that residents and staff are tested regularly and aside from the signage outside the rooms there are also signs inside the residents’ rooms. Unsubstantiated LPA was able to interview residents and additional staff. R1, R2 and R3 all said that during this time there was a lockdown, and they are mostly in their rooms. R1 stated that staff did extra cleaning and they are tested every week. Food is delivered to rooms. R2 shared that the facility handled the outbreak very well. They get updates on cases, the meals are delivered although not the same as when you dine in the dining area. R3 mentioned that they had to stay and the room and not wander around. Food was good, there were a lot of fruits and vegetables. Based on the records reviewed, the memos released since May 2022 has constant updates regarding testing’s and how many residents and staff have tested positive. In the memo’s provided, there were also constant recommendations regarding masking, social distancing and sanitizing. Regarding the allegation of insufficient staffing to meet resident's needs, RP stated that due to the lack of staffing the residents have to wait for extended periods to get their food and drinks. According to the ADM, around this time, the residents have all meals delivered to the doors since there is no communal dining service. If there are staff who got sick, managers and ADM steps in to help facilitate meal delivery to residents in their rooms. Due to melas being delivered, some residents do have to wait. There’s a different starting point for meal delivery each time so that there is balance in the wait time for all residents. Also, if the residents are positive, the staff who delivers would still take time donning PPEs before entering the room. S1 mentioned that meal deliveries have happened since the first lock down. The meals are delivered by two persons for each floor. Meals are in a hot cart with ticket numbers that says what the resident ordered for their meal. When there are call outs on-call staff will be called otherwise it’s the managers who will help cover. S2 also added that sometimes the residents do wonder about the food but understands that it might take while since everyone has the food delivered. S3 shared that there was enough staff to help in the kitchen. They already have a system in place so food was delivered as fast as they can to residents during this time. S4 also shared that staffing is short sometimes but work wise its fine. There are sections assigned to staff but they still talk to each other if anyone needs help or support. S4 also shared that residents do understand that it takes a while for food to arrive. S3 and S4 both mentioned that in cases where help is needed, the dishwashers, maintenance, managers and the chef step in to help so that the food gets delivered to residents on time. During the resident interviews, R1 mentioned they do have to wait a little bit but it was understandable and you learn to have patience. Staff are always there if R1 needs anything. If it is critical they are at the door right away but if its non-urgent R1 waits a bit. R2 didn’t find any issues with staffing, feels like there was enough staff to help them with their needs. R3 said they get to choose food from the menu provided. There were also enough staff and they are good in responding when R3 pulls the help button. Based on interviews and records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Jan 22, 2025 · control 26-AS-20220616104145

Allegation investigated: Staff speaks inappropriately to a resident Staff do not ensure that a resident's toileting needs are met Staff do not ensure that residents are served food of good quality

LPA Marrufo conducted an unannounced complaint investigation visit and met with Administrator Amy Saulnier. On 06/19/2024, the Department received a complaint with the above allegations. On 06/28/2024, LPA Simi Rai conducted an initial complaint investigation visit. LPA Marrufo conducted additional complaint investigation visits on 08/01/2024 and 10/29/2024. During the investigation, LPA Marrufo obtained a copy of resident and facility records and interviewed staff, residents, and a resident’s family member. During interview on 08/01/2024, resident R1 stated that staff S1 would tell R1 to pick fallen items from the ground himself/herself and that R1 was “the bottom of the barrel.” See LIC9099-C for more information. Page 1 of 5. Unsubstantiated During interview on 08/01/2024, S1 stated to have never spoken inappropriately to R1. Staff S2 and S4-S6 stated to have never observed S1 speak inappropriately to R1. During interview on 10/18/2024, S3 stated that R1 complained to S3 that R1 asked S1 to pick up an item from the floor and S1 refused. During visits on 08/01/2024 and 10/29/2024, LPA Marrufo interviewed an additional 13 residents. 1 out of 13 interviewed residents stated to have observed a staff speak inappropriately to residents but did not provide the name of the staff. 12 out of 13 interviewed residents stated to have not observed staff speak inappropriately to residents. Family Member FM1 stated in a written statement to LPA Marrufo on 07/21/2024 that on 03/13/2024, S1 left R1 on the toilet, left R1’s room, and told R1 to call S1. During interview on 10/21/2024, resident R1 stated that S1 assisted R1 to the toilet and while R1 was on the toilet, S1 told R1 that S1 had to go to another apartment and would be right back. R1 stated that R1 was left alone on the toilet for approximately 10 minutes. R1 stated S1 returned to R1 and assisted R1 off the toilet. R1 stated to not remember if there were more times S1 left R1 on the toilet. R1’s Physician’s Report completed on 02/09/2023 states R1 is able to care for his/her own toileting needs with assistance and states R1 is ambulatory. R1’s Physician’s Report completed on 05/06/2024 states R1 is not able to care for his/her own toileting needs and states R1 is non-ambulatory. R1’s Physician’s Report completed on 10/08/2024 states R1 is able to care for his/her own toileting needs and states R1 is ambulatory. Page 2 of 5. The Toileting Section on page 14 of the Employee Handbook states, “1. Escort the resident to the toilet. Provide transfer assistance as necessary. Provide privacy. 2. If appropriate and safe, step out of the bathroom. a. If your community uses call lights be sure it is within the resident’s reach. b. If not, stay nearby so the resident may call out to you when he/she is finished. c. Never leave a resident alone on the toilet for a long period of time.” During visit on 10/29/2024, LPA toured R1’s living unit. LPA observed emergency pull cords in R1’s bathroom near R1’s toilet and in R1’s bedroom. LPA observed R1 was not wearing an emergency pendant necklace. R1 stated not to own an emergency pendant necklace. LPA Marrufo pulled the emergency pull cord in R1’s bathroom and a staff responded to the pull cord in 2 minutes and 25 seconds. LPA Marrufo obtained a copy of the Assisted Living Residential Care Conference that S2 wrote on 03/12/2023. The document records a conference between S2, FM1, and R1. The document Comments section states, “Explained that staff are task oriented and will be able to provide care at scheduled times + as needed. Also, explained that wait periods are not unusual, as staff are trained to complete the task they are involved with before moving on to another resident request. Wait periods could range from 5min-30minutes. Res. acknowledged + seemed to accept that there may be times when [R1] will be on [R1’s] own and staff will come to provide care on a schedule established upon move-in. Informed [R1] and [FM1] that we do not have a large staff to provide 1:1 companion care or extended periods of time to complete resident tasks outside of bathing, dressing, toileting, + escorts.” R1’s Family Member (FM1) sent LPA Marrufo an email on 07/21/2024 stating that FM1 spoke with staff S2 on 02/20/2024. FM1 stated that S2 stated that staff are allowed to leave a resident on the toilet and leave the apartment. FM1 stated S2 stated that staff are not going to wait 20 minutes for a resident to defecate. During interview on 08/01/2024, S1 stated to have never left R1 on the toilet for a long period of time. S1 stated the staff are not supposed to do that. Page 3 of 5. During interview on 08/01/2024, staff S4 stated that R1 complained to S4 that S1 left R1 on the bathroom. S4 stated to have reported R1’s complaint to S4’s supervisor and management. During interview on 08/01/2024, S2 stated that R1 reported that R1 was left on the toilet for a long time, but S2 did not witness the incident. S2 stated that S1 stated to have told R1 that S1 needed to step out and would come back and that R1 agreed to have S1 leave. S2 stated to not recall why S1 stated S1 needed to step out. During interview on 10/01/2024, staff S1 stated to have never left R1 on the toilet and walked out of R1’s apartment. S1 stated to have only stepped out of R1’s bathroom when R1 requested privacy. S1 stated S1 would stay outside R1’s bathroom door and would enter the bathroom again when R1 told S1 that R1 was ready for S1 to enter the bathroom again. During interview on 10/18/2024, staff S3 stated that R1 told S3 that S1 told R1 that S1 was busy and left R1 on the toilet for more than half an hour. S3 stated to have remembered at least three other times that R1 told S3 that S1 left R3 on the toilet. S3 stated that when S3 has assisted R1 on the toilet and received a call to assist another resident, S3 has called another staff to assist the other resident. S3 stated to have never left R1’s apartment while R1 was on the toilet. During interview on 10/21/2024, FM1 stated to have been walking towards R1’s apartment and came across S1 in the hallway to R1’s apartment. FM1 stated that S1 told FM1 that R1 was on the toilet and it way “okay” for S1 to leave to go next door to help a neighboring resident. During visits on 08/01/2024 and 10/29/2024, LPA Marrufo interviewed 13 additional residents. 5 out of 13 interviewed residents stated to have no need for toileting assistance from staff. 7 out of 13 interviewed residents stated that staff ensure their toileting needs are met. 1 out of 13 interviewed residents stated that staff have left him/her on the toilet for 10 minutes before returning to continue assisting the resident on the toilet. The resident stated that the staff who left him/her was not S1. Page 4 of 5. LPA Marrufo obtained facility invoices for purchases of fruits and vegetables for the following dates: 04/24/2024, 05/01/2024, 06/05/2024, and 06/24-28/2024. On 08/01/2024, LPA Marrufo observed meal services and interviewed 14 residents. 12 out of 14 interviewed residents stated to like the food at the facility. 2 out of 14 interviewed residents stated to not like the food at the facility. 12 out of 14 interviewed residents stated to have never been served spoiled fruits or vegetables. 2 out of 14 interviewed residents stated to have been served spoiled fruits or vegetables. LPA did not observe any foods that did not appear to be of good quality during meal service, including spoiled fruits or vegetables. LPA toured the facility kitchen and observed the food supplies, including the supplies of fruits and vegetables in the walk-in refrigerator. On 08/01/2024, LPA interviewed 5 staff. 5 out of 5 interviewed staff stated that the food is of good quality, and they have never observed staff be served spoiled fruits or vegetables. On 10/29/2024, LPA Marrufo interviewed 7 additional residents. 6 out of 7 interviewed residents stated that they think the facility food is of good quality. 1 out of 7 interviewed residents stated he/she thinks the facility food is not of good quality. 7 out of 7 interviewed residents stated to have not been served spoiled fruits or vegetables. An Advisory Note was issued. See LIC9102 for more information. Based on information from interviews conducted with staff, residents, and a family member of a resident, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22 This report was reviewed with Administrator Amy Saulnier and a copy of this report was provided. Page 5 of 5. END REPORT.the state’s words, verbatim · CDSS document, Nov 6, 2024 · control 26-AS-20240619144408

Allegation investigated: Staff are not providing adequate food service to residents Facility not following infection controls Staff are not providing adequate housekeeping services to resident Facility flooring is in disrepair

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator (ADM) Amy Saulnier. On 09/04/2024, the Department received a complaint with the above allegations. LPA Marrufo conducted an initial complaint investigation on 09/04/2024 and another complaint investigation visit on 10/29/2024. LPA Marrufo interviewed a total of 17 residents on 09/04/2024, 10/29/2024, and 11/06/2024. 8 out of 17 interviewed residents stated that the staff are not providing food of adequate quality. 9 out of 17 interviewed residents stated that the staff are providing food of adequate quality. See LIC9099-C for more information. Page 1 of 4. Unsubstantiated 14 out of 17 interviewed residents stated the facility staff deliver the food service on time. 1 out of 17 residents stated that the quality of the food service varies and another 1 out of 17 interviewed residents stated that the food service could improve. LPA Marrufo interviewed a total of 6 staff on 09/04/2024, 10/29/2024, and 11/06/2024. 6 out of 6 interviewed staff stated the staff provide food of adequate quality and provide adequate food service to residents. During visit on 09/04/2024, LPA Marrufo observed meal preparation in the facility kitchen, meal service in the resident dinning room, and food supplies in the facility refrigerator and food storage areas. LPA Marrufo did not observe any food that appeared to be rotten, spoiled, or of inadequate quality. LPA Marrufo obtained copies of letters that ADM sent to facility residents on 05/03/2024, 05/06/2024, and 05/16/2024. The letters state that due to COVID outbreaks, communal dinning and activities would be suspended. The letters from 05/03/2024 and 05/06/2024 request that residents stay home if they are experience symptoms. The letter from 05/16/2024 requests that residents who feel ill call the front desk and ask for COVID tests and informs residents that positive residents are required to complete a 10-day isolation pre guidance from the Department of Public Health. LPA Marrufo interviewed a total of 17 residents on 09/04/2024, 10/29/2024, and 11/06/2024. 15 out of 17 interviewed residents stated that the facility is following infection controls. 1 out of 17 residents stated to have not lived in an assisted living apartment at the facility while there was a COVID outbreak at the facility and another 1 out of 17 residents stated that staff wipe down surfaces but could not remember if staff notify residents of COVID outbreaks. LPA Marrufo interviewed a total of 6 staff on 09/04/2024, 10/29/2024, and 11/06/2024. On 11/06/2024, LPA Marrufo interviewed staff S1, the facility Infection Control Specialist. 6 out of 6 staff stated that facility staff follow infection control protocols, including notifying residents of COVID outbreaks, wiping down surfaces, and using Personal Protective Equipment (PPE). Page 2 of 4. S1, the Infection Control Specialist, stated to review and update the Infection Control Plan at least once a year and as needed, ensure staff receive all necessary infection control training, train staff to perform proper hand hygiene, ensure that staff have appropriate personal protective equipment available, and train staff to use personal protective equipment correctly. During visit, LPA Marrufo observed the facility PPE supply, including gloves, masks, quarantine carts, and cleaning supplies. LPA observed handwashing posters in the bathroom, above the staff time-card machine, and in the medication room. LPA Marrufo observed PPE donning and doffing instructional posters in the medication room and in the quarantine carts. LPA Marrufo obtained copies of staff infection control training conducted from 06-09/2024. LPA Marrufo obtained a copy of a letter sent from staff S2, Grounds Manager, to facility residents on 08/22/2024. The letter states that beginning 08/27/2024 and continuing throughout the week, community exterior washing activity would begin and would be conducted by an external contractor. The letter states, “residents will be expected to remove all plants, ornamental figurines or furniture which blocks personnel from easily obtaining access to your patio area. If these items are not moved out of the way, your patio slider doors will not get cleaned.” A letter printed on green paper that S2 sent to some of the community on 08/27/2024 states that, “If you are receiving this Green memo, your apartment will require contractor escorting services by the Dominican Oaks Maintenance Department to access your patio slider window for cleaning.” The letter does not state any requirements of residents to move any personal belongings away from their glass sliding doors. LPA Marrufo interviewed a total of 6 staff on 09/04/2024, 10/29/2024, and 11/06/2024. 3 out of 6 interviewed staff stated to have assisted residents by moving their personal belongings away from the sliding glass door to allow for the door to be cleaned. 2 out of 2 interviewed staff stated that residents are notified that personal belongings need to be moved away from the sliding glass door so they can be cleaned. Page 3 of 4. In addition, LPA Marrufo interviewed S2 on 11/06/2024. S2 stated to have advised contracted window cleaners to not move residents’ personal belongings due to concerns of the contracted window cleaners being liable for any damage to residents’ personal property. S2 stated that if residents need assistance in moving their personal belongings from their glass sliding windows, then they could call the front desk and request for facility staff to move the personal belongings for them. LPA Marrufo interviewed a total of 17 residents on 09/04/2024, 10/29/2024, and 11/06/2024. 14 out of 17 residents stated to have not had any issues with their personal belongings preventing their glass sliding doors from being cleaned. 1 out of 17 residents stated to not remember, another 1 out of 17 residents stated to have not lived in the assisted living area long enough to have a window cleaning, and another 1 out of 17 residents stated to not know. LPA Marrufo interviewed a total of 17 residents on 09/04/2024, 10/29/2024, and 11/06/2024. 16 out of 17 interviewed residents stated to have not observed their flooring in disrepair. 1 out of 17 interviewed residents stated to not be able to remember if his/her flooring has been in disrepair. LPA Marrufo interviewed a total of 6 staff on 09/04/2024, 10/29/2024, and 11/06/2024. 6 out of 6 interviewed staff stated to not have observed a resident’s floor in disrepair. S2 stated that when transition barriers between the tile floors and the carpets inside resident rooms are damaged, a work order is placed and a contractor repairs or replaces them. LPA Marrufo obtained a copy of a work order for an Assisted Living apartment unit for a re-installed transition strip between the kitchen and hallway. The work order was created on 04/17/2024 and the transition strip was repaired on the same day. During visit, LPA observed the floors of 13 resident living units. LPA did not observe any signs of damage to the floors, including to the transition barriers between the tile floor and the carpet. Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. No deficiencies were cited under California Code of Regulations Title 22. This report was reviewed with Administrator Amy Saulnier and a copy of this report was provided. Page 4 of 4. END REPORT.the state’s words, verbatim · CDSS document, Nov 6, 2024 · control 26-AS-20240904130824

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Front Desk Manager, Brenda Barber. The facility currently has a COVID-19 outbreak and residents are in isolation. 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. The temperature of 4 refrigerators were observed at 35-40 degree Fahrenheit (F), and the temperature of freezer was -3-0 degree F. LPA observed additional food supply areas and secured areas for cleaning supplies. There were posters above the kitchen sinks stating the water temperature may be above 120 degrees F. LPA Rai toured 3 resident bedrooms. The water temperature in the bathroom sinks ranged from 111.7 degrees F - 117.1 degrees F. Resident apartment bathrooms were observed with grab bars and non-skid pads. The window and patio door screens were clean and in good repair. The room temperatures were between 68 degrees F - 71 degrees F. Fire extinguisher was observed and inspected on 9/18/2023. Facility fire alarm was inspected on 9/28/2023 and 12/5/2023. The last disaster drill was conducted on 1/5/2024. Facility staff could not produce disaster drills conducted after 1/5/2024. Carbon monoxide detectors are located in the boiler room and facility kitchen. LPA Rai reviewed facility records for 3 staff and 3 residents. 3 Out of 3 staff files did not contain job application form or Personnel Record form. LPA Rai reviewed resident medications and central stored medication records. Medications rooms and medication carts were observed locked. The facility did not report 3 cases COVID-19 within 7 day window for reporting requirements. Deficiencies were cited per California Code of Regulations, Title 22, please see LIC-809D. This report was reviewed with Front Desk Manager, Brenda Barber and a copy of this report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, May 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a) · Plan of correction due date: May 17, 2024

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by: Based on record review and interview, 3 out of 3 staff files do not contain Application/Personnel Record which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: Manager stated to submit a written plan of action understanding regulation and will ensure staff files are complete by POC due date. Manager agreed and understood.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: May 17, 2024

87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. Based on record review and interview, 3 COVID-19 cases were not reported within the 7 day window which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: Manager stated to submit a written plan of action understanding regulation and will ensure COVID-19 cases are reported to the Deparment in a timely manner by POC due date. Manager agreed and understood.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: May 17, 2024

1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. This requirement is not met as evidenced by: Based on interview and record reivew, facility staff were not able to produce diaster drills conducted after 1/5/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 10, 2024

Plan of correction: Manager stated to submit a written plan of action understanding regulation and will ensure disaster drills are conducted at least quarterly by POC due date. Manager agreed and understood.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit and met with Administrator (ADM) Amy Saulnier. LPA toured the facility inside and out with ADM including library, activity rooms, dinning rooms, kitchen, laundry rooms, public restrooms and resident apartments. ADM stated the facility has 47 residents in assisted living unit and 153 residents in independent living unit. License, Administrator Certificate, and personal right posters were observed posted at entrance. 5 resident files and 5 staff files were reviewed. 2 out of 5 resident files were incomplete. Room temperature was measured at 69 degree F, and hot water temperature was measured at 117 degree F. The temperature of refrigerator was 40 degree F, and the temperature of freezer was 0 degree F. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Fire extinguishers were serviced on 09/18/2023. The facility was equipped with fire alarm system. Carbon monoxide detector was only observed at kitchen. Fire alarm and smoke detectors were tested by ADM, and were working fine. Medications rooms and medication carts were observed locked. Two resident rooms emergency signal alert systems were tested and staff responded in 2 minutes. Resident apartment bathrooms were observed with grab bars and non-skid pads. Oxygen use poster was observed posted on the resident apartment door for oxygen administration resident. LPA toured the back yard of the facility. No obstruction was observed blocking the walkways. ADM stated the last time for the emergency and fire drill was conducted on10/27/2023. Exit interview was conducted with ADM. Deficiencies noted for today's inspections. LIC809-D was attached. The report was provided to ADM for signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Jan 11, 2024