Montecito Manor

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Incident visit and met with Jolene Sicley, Administrator. The purpose of the visit was to follow up on an incident report filed by the facility on 09/21/2026. The Incident Report stated that on 09/17/2026, staff noticed that resident R1 was missing from the facility. Police located R1 and returned R1 to the facility on 09/18/2026 at 6:00 PM. The facility submitted R1's Physician's Report along with the Incident Report, and R1's Physician's Report states he/she is not able to leave the facility unassisted. On 09/21/2026, LPA Marrufo called the facility and spoke with staff S1, who stated after the facility staff noticed R1 was missing from the facility, they checked the facility surveillance footage and observed R1 had exited the facility by going over a fence. During visit, LPA Marrufo interviewed Administrator Joleen Sicley. LPA Marrufo requests that the facility submits copies of R1's original Appraisal/Needs and Services Plan, Pre-Admission Appraisal, and updated Physician's Report and updated Appraisal/Needs and Services Plan by 09/30/2026. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Jolene Sicley and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 25, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Jolene Sicley. During visit, LPA Marrufo toured the facility inside and out. LPA toured three out of three facility kitchens. The kitchens had a perishable food supply of at least two days and a non-perishable food supply of at least three days. LPA toured 12 out of 49 resident apartments. Each apartment had working lights and available bedding and clothing storage areas. LPA toured 12 resident bathrooms. The water temperatures in the bathrooms ranged from 88 F to 126 F. Eight out of the twelve inspected bathrooms had water temperatures that were below 105 F or above 120 F. Each bathroom had working lights and available soap and paper towels. LPA toured the outside area and observed the exits to be clear of obstructions. During visit, facility staff tested the smoke detection system and it functioned properly when tested. LPA Marrufo reviewed 6 resident records, including Centrally Stored Medication and Destruction Records, and found them to be complete. LPA reviewed 6 staff records. See LIC809-C for more information. Page 1 of 2. Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D page for more information. LPA Marrufo requests that the following documents be updated and copies sent to the department by 01/19/2026: LIC500 Personnel Report LIC308 Designation of Administrative Responsibility LIC400 Affidavit Regarding Client/Cash Resources Liability Insurance LIC610 Emergency Disaster Plan This report was reviewed with Administrator Jolene Sicley and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 12, 2026

Allegation investigated: Staff handle residents in a rough manner Staff does not treat residents with respect Resident's toileting needs are not being met

On 03/08/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Jolene Sicley and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings. Current census was 52. A brief interview with FDA Sicley was conducted. Allegation: Staff handle residents in a rough manner It was alleged that staff handle residents in a rough manner. During the course of this investigation LPA conducted staff and resident interviews. Based on interviews conducted with 5 staff members. 5 out of 5 staff members denied handing any residents in a rough manner. 5 out 5 of staff members deny seeing any other staff members handling any residents in a rough manner. 5 out 5 staff members also deny any reports regarding any staff members handling residents in a rough manner. An interview with 8 residents were conducted. 8 out 8 residents deny being handled in a rough manner. 8 out 8 residents deny hearing or seeing any other residents being handled in a rough manner. Based on the information gathered, it is unclear that the staff handled the residents in a rough manner. Unsubstantiated Allegation: Staff does not treat residents with respect It was alleged that staff does not treat residents with respect. During the course of this investigation, LPA conducted staff and resident interviews. Based on interviews conducted with 5 staff members, 5 out 5 staff members denied not treating the residents with respect. 5 out 5 staff members deny seeing any staff members not treating residents with respect. An interview with 8 residents were conducted. 8 out 8 deny not being treated with respect and report that they enjoy the staff at the facility. Based on the information gathered, it is unclear that the staff does not treat residents with respect. Allegation: Resident's toileting needs are not being met It was alleged that the resident’s toileting needs are not being met. During the course of this investigation, LPA conducted interviews and reviewed facility records. Based on interviews conducted, 5 out 5 staff members deny not meeting residents toileting needs. 5 out 5 staff members stated that sometimes it may be difficult to change the residents however, most of the time it is met. An interview with 8 residents were conducted. 5 out 8 residents needed assistance with toileting needs and denied that their needs were not being met. A review of the residents shower logs and daily notes were conducted. Which did not indicate if the facility did not meet resident’s toileting needs. Based on the information gathered, it was unclear of the resident’s toileting needs were not being met. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, Mar 8, 2025 · control 26-AS-20220429092911

Allegation investigated: Resident caused injury to another resident in care. Staff not providing adequate supervision to resident's. Resident developed sores while in care. Staff not providing resident with drinking water. Staff not responding to resident's emergency cord Resident is required to dispose of trash. Resident is required to clean facility commode Resident is required to purchase food. Facility does not provide supplies for resident.

On 03/08/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Adminstrator (FDA) Jolene Sicley, and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings. Current census was 52. A brief interview with FDC Sicley was conducted. Allegation: Resident caused injury to another resident in care. It was alleged that a resident cause injury to another resident in care. During the course of this investigation, LPA conducted staff and resident interviews. An interview with 5 staff members were conducted. 5 out 5 staff members deny that they have witnessed or heard that another resident caused injury to another resident in care. An interview with 8 residents were conducted. 8 of 8 residents deny that they have hurt or caused injury to another residents. 8 out 8 residents report that they have not heard or seen any residents who have hurt another residents in care. Based on the information gathered, it is unclear that the resident caused injury to another resident in care. Unsubstantiated Allegation: Staff not providing adequate supervision to resident's. It was alleged that staff are not providing adequate supervision to residents. During the course of this investigation, LPA conducted interviews and reviewed facility records. Based on interviews conducted, it was denied by 5 out 5 staff members that they do not provide adequate supervision to the residents. 5 out 5 staff members state that they able to meet the residents needs with the current staffing that they have. An interview with 8 residents were conducted. 8 out 8 residents state that they believe that they have sufficient supervision and report no issues. A review of the facilities staffing schedule was conducted. However, it was unable to use due to the time difference between the allegation and complaint finding. Based on the information gathered, it is unclear if the staff are not providing adequate supervision to residents. Allegation: Resident developed sores while in care. It was alleged that at resident developed sores while in care. During the course of this investigation, LPA conducted interviews and reviewed facility records. Based on interviews conducted, it was learned that R1 would state that they developed sores however when staff would access this resident there was no sores or indication that showed that the resident was developing a sore. In addition, LPA reviewed R1’s daily notes which showed that the staff would often do skin checks but did not find anything concerning any skin integrity issues. Based on the information gathered, it is unclear if the resident developed sores while in care. Allegation: Staff not providing resident with drinking water. It was alleged that staff do not provide residents with drinking water. During the course of this investigation LPA conducted interviews and toured the facility. An interview with 8 residents were conducted. 8 out 8 residents state that they do have access to water. 8 out 8 residents state that they did have individual water bottles, however, the facility has changed to having water that is brought by the staff members to fill out their pitchers. An interview with 6 staff members were conducted. 5 out 5 staff members state that they have implemented a new system where the facility has hydration carts on each floor that includes excess water pitchers and cups. These hydration carts are monitored by staff and are used to fill the residents personal pitcher in their rooms. 5 out 5 staff members deny that they do not provide residents with water. LPA conducted a tour of the facility, where it was observed that the facility does have 3 separate hydration carts available for residents and staff to use throughout the day. Based on the information gathered, it is unclear if the staff do not provide residents with drinking water. Allegation: Staff not responding to resident's emergency cord It was alleged that the staff are not responding to the resident’s emergency cord. During the course of this investigation, LPA conducted interviews and reviewed facility records. An interview with 5 staff members were conducted. 5 out 5 staff members deny not responding to a resident’s emergency cord. 5 out 5 staff members state that they try to get to the resident within 20 minutes. An interview with 8 residents were conducted 8 out of 8 residents state that they do not have any issues in obtaining any help when pulling their emergency cord. Based on the information gathered, it is unclear if the staff are not responding to the resident’s emergency cord. Allegation: Resident is required to dispose of trash. It was alleged that the residents are required to dispose of trash. During the course of this investigation, LPA conducted interviews with staff and residents. Based on interviews conducted it was denied by 5 staff members and 8 residents that the residents had to dispose of their own trash. Based on the information gathered, it is unclear that the resident required to dispose of trash. Allegation: Resident is required to clean facility commode It was alleged that the resident is required to clean the facility commode. During the course of this investigation, LPA conducted interviews with staff and residents. Based on interviews conducted it was denied by 5 staff and 8 residents that the resident is required to clean facility commode. Based on the information gathered, it is unclear that the resident required to dispose of trash. Allegation: Resident is required to purchase food. It was alleged that the resident is required to purchase food. During the course of this investigation, LPA conducted interviews and reviewed facility food supply. Based on interviews conducted, it was denied by 5 staff members and 8 residents that the facility requires the resident the purchase food. It was stated by 5 staff members that the residents are able to bring in any type of snacks that the facility does not have. In addition, a review of the facilities food supply was conducted which displayed a sufficient amount of food supply to meet the resident’s needs. A review of the facilities food receipts were also conducted. Based on the information gathered, it is unclear if the resident is required to purchase food. Allegation: Facility does not provide supplies for resident. It was alleged that the facility does not provide supplies for the resident. During the course of this investigation, LPA conducted interviews. It was denied by 5 staff and 8 residents that the facility does not provide supplies for the resident. Based on the information gathered, it is unclear if the facility does not provide supplies for resident. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility. Allegation: Facility has insects. It was alleged that the facility has insects. During the course of this investigation, LPA conducted interviews, reviewed facility records and toured the facility. Based on interviews conducted 5 staff and 8 residents deny that the facility has insects. Based on observation and records reviewed, it was learned that A pest control service agreement was reviewed and confirmed that on-going pest control service in place for facility. Based on the information gathered, it is unclear if the facility has insects. Allegation: Facility is unsanitary and staff do not clean facility. During the course of the investigation, LPA Pascua conducted site visits and inspected the facility. No unsanitary conditions were observed. LPA Pascua also interviewed 8 residents and 5 staff members, all of whom felt the facility is maintained in a sanitary condition and cleans on a daily basis. Based on the information gathered, it is unclear if the facility is unsanitary. Allegation: Resident is washing laundry in a sink and Facility washing machine is in disrepair. It was alleged that the resident is washing laundry in the sink. During the course of this investigation, LPA conducted interviews. Interviews conducted with 5 staff members and 8 residents denied that the resident is washing laundry in the sink and that the washing machine has been working. 5 staff members state that if one washing machine was not working, they have others that they could use. Based on the information gathered, it is unclear if the resident is washing laundry in the sink due to the facility washing machine being in disrepair. Allegation: Resident's bedding is dirty. It was alleged that the resident’s bedding is dirty. During the course of the investigation, LPA conducted interviews, and observed bedding conditions. Based on interviews conducted with 5 staff members and 8 residents it was denied that their bedding was dirty. LPA observed 8 resident beddings which did not have odor or any indication to show that the bedding was dirty. Based on the information gathered, it is unclear if the resident’s bedding is dirty. Allegation: Staff not following physician's orders. It was alleged that staff are not following physicians orders. During the course of this investigation, LPA conducted interviews in which it was denied by 5 staff members that they are not following physicians orders. An interview with 8 residents were conducted. 8 out 8 residents state that the facility does a good job in ensuring that any changes are communicated and done. Based on information gathered, it is unclear if the staff are not following physicians orders. Allegation: Resident left in a soiled diaper for a long period of time. It was alleged that the resident was left in a soiled diaper for a long period of time. During the course of this investigation, LPA conducted interviews which revealed that 5 out 5 staff members deny that they leave the resident’s in a soiled diaper for a long period of time. It was stated by all 5 staff members that they are required to change diapers as soon as they are soiled. An interview with 8 residents were conducted, who denied that they’re needs are not being met at this time. Based on the information gathered, it is unclear if the residents are left in a soiled diaper for a long time. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, Mar 8, 2025 · control 26-AS-20220318160628

Allegation investigated: Staff did not treat resident with dignity and respect. Staff made inappropriate comments to resident. Resident's personal belongings are missing. Staff opened resident's packages without permission. Staff did not note a change in resident's condition

On 03/08/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDR), Jolene Sicley and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings. Current census was 52. A brief interview with FDA Sicley was conducted. Allegation: Staff did not treat resident with dignity and respect It was alleged that staff did not treat resident with dignity and respect. the course of this investigation, LPA conducted staff and resident interviews. Based on interviews conducted with 5 staff members, 5 out 5 staff members denied not treating the residents with respect. 5 out 5 staff members deny seeing any staff members not treating residents with respect. An interview with 8 residents were conducted. 8 out 8 deny not being treated with respect and report that they enjoy the staff at the facility. Based on the information gathered, it is unclear that the staff does not treat residents with respect. Unsubstantiated Allegation: Staff made inappropriate comments to resident. It was alleged that staff made inappropriate comments to residents. During the course of this investigation, LPA conducted staff and resident interviews. Based on interviews conducted with 5 staff members, 5 out 5 staff members deny making inappropriate comments to residents. 5 out 5 staff members deny seeing any staff members speaking inappropriately to residents. An interview with 8 residents were conducted. 8 out 8 deny that staff speak to them inappropriately. Based on the information gathered, it is unclear that the staff made inappropriate comments to residents. Allegation: Resident's personal belongings are missing. It was alleged that resident’s personal belongings are missing. During the course of this investigation, this LPA reviewed facility records and conducted resident interviews. Based on interviews conducted, 8 out 8 residents state that they have not missed any important items. 1 out 8 state that they had a shirt go missing once but that something of not large importance. LPA reviewed facility records. Records show that the facility conducts inventory logs when residents are admitted to the facility and will update as needed. Based on the information gathered, it is unclear if the resident’s personal belongings have been missing. Allegation: Staff opened resident's packages without permission. It was alleged that staff opened resident’s packages without permission. During the course of this investigation, LPA conducted staff and resident interviews. Based on interviews conducted with 5 staff members, 5 out 5 staff members denied opening up resident packages. 5 out 5 staff members deny seeing any staff members open the resident’s packaging without permission. An interview with 8 residents were conducted. 8 out 8 deny that staff open their packages and have not seen anything suspicious that would indicate it. Based on the information gathered, it is unclear that the staff opened resident’s packages without permission. Allegation: Staff did not note a change in resident's condition It was alleged that staff did not note a change of resident’s condition. During the course of this investigation, LPA conducted staff and resident interviews. Based on interviews conducted it was learned that R1 was consistently demanding changes to their care plan however when changed R1 would change their mind and revert back the care plan. Many times, the facility would send the resident out to the hospital to doctors visits to check for any changes however, R1 would refuse care. In addition, LPA reviewed daily notes for R1 which document the attempts to assist R1 with their care. Based on this information gathered, it is unclear if the staff did not note a change of resident’s condition. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, Mar 8, 2025 · control 26-AS-20220323104507

Allegation investigated: Facility staff inappropriately touched resident in care

On 02/02/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Ivonne Sanchez and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current census was 53. A brief interview with FDR Sanchez was conducted. It was alleged that facility staff inappropriately touched resident in care. During the course of this investigation, LPA conducted interviews and reviewed facilty records. Based on interviews conducted it was denied by 4 out 4 staff members that they have seen or inappropriately touched a resident in care. It was also learned through interviews that it was alleged that a male inappropriately touched a resident. However it was learned through facility records that the facility does not have any staff members who are male at this time. In addition, an interview with 8 residents were conducted who deny that they have been inappropriately touched by a staff member. Based on the information gathered it is unclear if a staff member inappropriately touched a resident in care. Unsubstantiated As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, Feb 2, 2025 · control 26-AS-20241123104336

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Jolene Sicley. During visit, LPA toured the facility inside and out. LPA toured three out of three kitchen areas and food storage areas. LPA observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed locked storage areas for cleaning supplies. LPA reviewed the first aid kit during visit and found it to be complete. During visit, staff tested the centralized smoke detector system and LPA found it to function properly when tested. Staff tested carbon monoxide detectors located throughout the facility and all carbon monoxide detectors functioned properly when tested. LPA observed two bathrooms in the memory care wing and two bathrooms in the assisted living wing. Two out of two memory care bathroom sinks had water temperatures at 107 F. One of the assisted living bathrooms had a sink with water temperature at 95 F and the other assisted living bathroom sink had water temperature at 103 F. During visit, staff told LPA that two out of three facility water boilers had malfunctioned and staff were awaiting on replacement parts to be delivered and installed. Staff showed LPA invoices for the replacement parts and services that have been scheduled for the water boilers. LPA observed that all bathrooms had available soap and paper towels and working lights. See LIC809-C for more information. Page 1 of 2. LPA toured ten resident bedrooms and observed each bedroom to have available bedding and clothing storage areas and working lights. LPA toured the outside areas and observed the exits to be clear of obstructions. LPA reviewed the resident records for seven residents and found them to be complete. LPA reviewed the staff records for seven staff and found them to be complete. LPA reviewed the Centrally Stored Medication and Destruction Records and Personal and Incidental Money Logs for seven residents and found them to be complete and balanced. An Advisory Note was issued. See LIC9102 for more information. No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Administrator Jolene Sicley and a copy of this report was provided. Page 2 of 2. END REPORTthe state’s words, verbatim · CDSS document, Jan 28, 2025

Allegation investigated: Staff did not ensure resident was regularly observed for changes in physical health condition Staff did not seek medical attention for resident in a timely manner Staff did not ensure record of centrally stored medications was complete Staff do not provide water to residents

On 1/9/2025, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Assistant Manager Ivonne Sanchez and LPA explained the purpose of the visit. For the allegations of staff did not ensure resident (R1) was regularly observed for changes in physical health condition and staff did not seek medical attention for resident in a timely manner, reporting party (RP) stated that R1 had to be brought to the hospital and was found to have a UTI and was discharged. RP stated he/she visited R1 two days later, and R1 was acting different and was incapacitated again. RP stated 911 was called and R1 was again taken to the hospital. RP stated that they are concerned that staff saw R1s condition was worsening and never sought medical attention. RP stated that two weeks ago R1 was walking around and talking and now is unable to do those things because of the UTI. page 1 of 3 Unsubstantiated LPA Marrufo was able to interview RP and it was shared that R1 actually had a bad UTI that was missed, so R1 was treated like he/she was totally out of their mind because R1 has mental illness. LPA Maruufo also interviewed three staff members. S1 mentioned that he/she hasn’t noticed anyone with urinary tract infection (UTI). S1 also has observed R1 to be wanting his/her family member (F1) to be with him/her 100% of the time. When F1 leaves, R1 moves his/her arms and legs and wants to smoke, but when her F1 comes, he/she doesn’t move his/her arms or legs. S2 shared that there has not really been anything S2 have seen where a resident has a change of condition. S2 has also observed that R1 acts weird when R1s family is here. When the family is not here, R1 can get out of bed and walk to the bathroom. R1 walks and goes to the toilet by himself/herself. R1 sometimes needs a little bit of help to clean. R1 puts his/her clothes together. S3 added that R1 went into the hospital about a week ago on a Tuesday or Wednesday. R1 went to the hospital for a UTI. Staff didn’t really observe any changes in R1 before that. R1 has always been a little slouched over all the time since R1 got here. Based on records review, R1 was seen by P1, on 8/1/2023, who came to the facility to check on other residents. P1 is not R1s primary care physician. R1 was sent to the hospital due to P1s observation of R1 not looking right. R1 was sent and came back with a diagnosis of UTI. Last observation recorded in the progress notes was from 7/20/2023. Regarding the allegation of staff did not ensure record of centrally stored medications was complete, RP stated that a staff (S1) said he/she is giving R1s antibiotic but when RP looked at the medication list last Friday (8/4/2023) the antibiotic was not listed. LPA Donato reviewed the documents obtained by LPA Marrufo. It was shown in the Centrally Stored Medication and Destruction Records (CSMDR) that the start date of the antibiotic prescribed by the doctor was on 8/3/2023, it was filled by the pharmacy on 8/2/2023. page 2 of 3 During the interview, S3 mentioned that R1 came back from the hospital on Thursday night or the week before. R1 was prescribed new medications. It was an antibiotic. R1 was given the medication according to the doctor’s prescription. S3 believes it was every 8 hours. It was a capsule. For the allegation of staff do not provide water to residents, RP stated that R1 does not have access to water. RP stated when they showed up to visit, R1 was in bed and was unable to get up and did not have water anywhere within her reach. RP stated R1’s roommate also asked for water. RP stated there is a water dispenser out front but the residents cannot get to it if they can’t get out of bed. During LPA Marrufo’s interview, when asked if they did you ask staff to provide R1 with water? RP answered that yes, that has been a constant thing every day that they are there. Even the other residents there have asked RP for glasses of water. It has been different since O1 have been there. They have water that they are bringing from the kitchen. According to staff interviews, three out of three mentioned that staff provide enough water for residents. S1 mentioned that residents are provided water all the time, especially with R1. R1 asks for juice and water all the time. We give them water for all three meals per day. R1 would get more water. R1 would get water every 15-20 minutes. She asks for a lot of water. S2 also shared that for R1, he/she drinks a lot. R1 requests a lot of water. We give a pitcher by the bed. At meals, R1 would request for a large glass and put a straw because R1 would drop it all the time. R1 would drink 3 glasses of water with meals. There is a water station in the hallway. It is for all the residents. Based on interviews & records reviews, 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 violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. page 3 of 3the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 26-AS-20230807105035

Allegation investigated: Staff do not safeguard resident's personal belongings.

On 1/9/2025, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Assistant Manager Ivonne Sanchez and LPA explained the purpose of the visit. Regarding the allegation of staff do not safeguard resident's personal belongings, reporting party (RP) stated that around November 30, 2023, resident (R1) had money stolen, approximately $80. R1 also had a new jacket stolen within the last week. RP have purchased name labels, and RP sews them into all R1s clothing, however, his clothing frequently is taken and not returned. During an interview with RP, it was shared that R1 is visually impaired, so often he/she thinks things are missing. RP went and visited and looked for the $100 and jacket, but I did not find it. There is someone who lives there as well. One of the staff people told RP that R1 was showing the money to this other resident. RP said staff saw R1 showing the money. RP thought it might be a resident rather than a staff person. R1 also has lost hearing aids – one pair, wears one in each ear. The hearing aids went missing quite a while ago about a year ago. R1 reported the hearing aids missing to the facility. They said they will look and we don’t know what happened. They said they are not liable. page 1 of 2 Unsubstantiated LPA Marrufo was able to interview three staff members. S1 stated that he/she spoke with RP and RP said on R1s birthday they brought him/her money. S1 didn’t see it. S1 told RP that they should not be giving him money because he/she gives out the money to other people. R1 gives R2 money to buy sodas. When R1 has money, R1 always wants R2 to buy a soda. Sometimes we find shirts of R1 in other places and R1 gets stressed out. R1s black jacket is the one in the room. S1 have seen him with a brown jacket, that black puffy jacket, and a blue one that R1 has on right now. S1 haven’t seen R1s hearing aids. According to S2, around November 26th or 27th, the receptionist mentioned to S2 that R1 had $80 stolen. We told them we would do everything we can to investigate. We told RP in the future to not give R1 money personally but to give it to us so we can keep it in the safe. We looked at the security camera and we did not see anyone leave the room. We asked R2 if he/she took the money and he said no. We don’t know if R1 gave R2 money to go to the store. We asked R2 if he/she did and said no, but R1 does not always remember everything. S2 had never seen that black puffy jacket before. S2 has seen one with a Raiders jacket and a blue jacket and a red one. R1 had about 3-4 different ones. R1 has been missing the hearing aids for about a year. We have notified R1s family about that. R1 keeps taking them out and won’t let the staff put them on the charger. R1 would not let the staff take them out of his/her ears at night to put them on the charger. They went missing for a long time. He had not ordered new ones that I know of. LPA Marrufo also interviewed R2 and it was mentioned that R1 never gave money to buy anything for him/her. Based on records review, the jacket and money was not logged on either the Safeguard for Properties and Valuables form nor the money logged on Cash resources log. Additionally, according to the theft and loss policy of the facility, included in the admissions agreement, the facility reserves the right to review aII valuables retained by the Resident and accepts neither responsibility not liability for loss of money or valuables unless they are deposited and inventories with Montecito Manor for safekeeping. Residents are not allowed to bring in valuables. Montecito Manor requires the Responsible Party provide a complete inventory of all personal property (brought into Montecito Manor) and that no jewelry be brought in over $100 in value. Based on interviews and ecords review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Report is reviewed and copy is provided page 2 of 2the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 26-AS-20231206120806

Allegation investigated: Staff caused injury to a resident in care. Staff pushed a resident in care. Staff left residents in a soiled diaper for a long period of time. Staff does not shower the residents. Staff did not keep facility free of insects. Staff did not prevent a dog from causing injury to a resident in care. Staff is not ensuring that residents are taking prescribed medications. Staff calls residents inappropriate names.

On 1/9/2025, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Assistant Manager Ivonne Sanchez and LPA explained the purpose of the visit. Regarding the allegations of staff caused injury to a resident in care and staff pushed a resident in care, reporting party (RP) reported that there is a resident (R1) that is about 300 pounds and was observed with bruises. RP reported that R1 disclosed that he/she got pinched and pushed by the staff (S4). LPA Marrufo was able to interview RP for additional information. According to RP, when RP asked R1 why R1 has bruises on his/her arms and R1 says “S4 pushed me to the wall so I wouldn’t fall and squeezed my hand to hard.” R1 said S4 tried to hold him/her and then punched him/her. R1 says he/she is scared of S4. RP doesn’t have photos of the bruising. page 1 of 5 Unsubstantiated LPA Marrufo also interviewed R1. R1 mentioned that he/she hasn’t observed any staff pushing or pinching residents. R1 also mentioned that he/she likes S4. S4 is a very good worker here. S4 is not cruel. There were other seven interviewed. Six out of these seven residents said that they haven’t observed staff causing injury or pushed residents. One resident, R6, had memory issues and was having a hard time keeping on topic during the interview. Four out of four staff that were interviewed all answered that they have not observed any staff causing injury or bruising to residents. For the allegations of staff left residents in a soiled diaper for a long period of time and staff does not shower the residents, RP reported that the staff member S4, does not change the residents’ diapers and leaves them in a soiled diaper for three hours. RP also reported that S4 does not shower the residents. RP reported that residents are going approximately 5 days to a week in a half without getting a shower. RP added that there is a log for showers for all the residents. R1, R2, R3, R7 & R8 are the ones Licensing should look at for not being showered. When S4 works in Memory Care, S4 hardly showers anyone. Based on resident interviews, R1 mentioned that they have never left him/her in a diaper for a whole day. They at least change him/her before lunch. R1 also mentioned that he/she got just one shower over seven days ago. Then got one last night (at the time of the interview). R1 said he/she is supposed to be showered at least two times a week. R1 also mentioned that S4 is the one who does his/her showering. S4 does not drop R1 in the shower. S4 is very good and R1 respects and likes S4. R2 shared that they change him/her once in the morning, before lunch and after lunch. Before dinner and after dinner they also change him/her. R2 also mentioned that he is showered several times a week. R2 asks for showers Mondays, Wednesdays, and Fridays. Other residents who were interviewed said no if they have observed other residents left in soiled diapers and. Some residents are able to take their own showers and would request some assistance from time to time. page 2 of 5 Based on records review, R1, R2, R3, R7 & R8 have regular showers based on the logs provided. Some are also provided by S4. Regarding the allegation of staff did not keep facility free of insects, RP reported that there are cockroaches in the kitchen, and sometimes get into the resident’s food. Another co-complainant, RP2, shared that there are cockroaches everywhere, in the food that we serve, in the rooms. Based on interviews, R1 mentioned that he/she observed insects in the facility. R1 shared that the drawer (in the room) behind you (interviewer), someone pulled out the drawer and a cockroach came out. One day when R1 was having breakfast or lunch, R1 took the orange juice and turned it over to capture the bug. The bug was on the table. R4 shared that yes, he/she has seen flies. R4 probably have seen cockroaches but don’t see bugs in the meals when they are eating. R5 stated that he/she has observed bugs and cockroaches. R5 saw four cockroaches in the shower and in the dining room. R5 found a bug in his/her water but never observed a cockroach in his/her plate or food. R7 mentioned that yes, they have seen a few bugs here. They are little black ones, but they don’t seem to interfere with R7. R7 has never seen cockroaches. LPA Marrufo interviewed S5 & S6 and both mentioned that there are no bugs or cockroaches in the kitchen. However, during S7’s interview, it was mentioned that there are cockroaches. S7 said that they don't say anything because they know they will get in trouble. S7 have seen cockroaches. They are mostly in the main assisted living kitchen and the mental care kitchen. The last time S7 saw one was this morning by the stove. S7 sees them every day. There is sometimes the open trays and the cockroaches come out. Based on records review, video and photo evidence from RP shows bugs crawling from residents rooms and insects on loaves of breads that are still packed. However, on the records provided by the facility, the pest issue has been addressed. Pest control is scheduled monthly and during the time of this complaint, they added additional visits to the facility. Treatments have been made to target pests. page 3 of 5 Regarding the allegation of staff did not prevent a dog from causing injury to a resident in care, RP reported that there was a dog at the facility that jumped on a resident (R4) and caused an injury and RP reported that the injury was located on R4s left hand. LPA Marrufo interviewed R4 and mentioned that a dog was playing with R4. Most people like to play with the dog. R4 was not actually trying to play with the dog. The dog just came to R4. R4 doesn’t know how he/she got this injury but also shared that the dog caused the injury on R4s arm. R4 doesn’t know if the dog bit or scratched. R4 doesn’t remember. Staff came right away and put a tape on the bruise or my cut. It bled a little. They did not call the doctor. R4 doesn’t think they called his/her family. Staff checked on R4 the next day and changed my bandage. According to S3, there haven’t been any incidents with the dog here. The residents seem to love him. S3 knows one time the dog did a little scratch on R4. It was not really much. They were sort of rough playing with the dog at the time. S3 observed it when it happened. R4 and the dog were playing together on the couch. The dog was jumping off of R4 and scratched her. It was not big or anything. It was a light scratch. There was no bleeding. The dog scratched R4 on one of his/her arms, but don’t remember which one. After, we cleaned up the scratch and wrapped it up and asked R4 if he/she was okay. They wanted to continue play with the dog but after I told them that they should wait. For the allegation that staff is not ensuring that residents are taking prescribed medications, RP reported that there are two med techs that are not making sure that residents are taking their medications when giving medications to the residents. RP added that he/she finds medications on the floor of the resident rooms. They just drop off the medications at the residents’ table during meals and to their rooms. They just drop off the medications without making sure they have taken the medications. According to resident interviews, five out of eight mentioned that staff help them with medication and makes sure that they take them. R3, R6 and R8 has cognitive issues, R3 said that no one gives him/her medications and takes them himself/herself. R6 is not able to stay in topic and R8 said that staff don’t give them medications. page 4 of 5 During staff interviews, S1 mentioned that he/she stays with the residents until they finish taking all the medications. S1 watches to make sure they are taking each pill one at a time. There are some residents who cheek their medications. S1 asks to see inside their mouths, and they check. There aren’t any pills that are left in the resident rooms that are not consumed. S2 shared that the med techs pass out the meds individually. They wait there and wait until they finish. Some of them will open their mouth or they will wait until they open. If we see pills left behind, we will let the med tech know. S2 never see pills left in the resident rooms. S3 mentioned that the med techs watch the residents and ask them to open their mouths and lift their tongues. S3 never see any unconsumed pills left in the resident room. S4 shared that the med techs stay with the resident until the resident takes it. Sometimes the resident throws it away or hides the medication in their mouth. He/she (MedTech’s) asks to see the medication in their mouth. The MedTech leaves when he/she is sure that the residents have taken it. They need to make sure. Regarding the allegation of staff calls residents inappropriate names, RP reported that S4 calls the residents names, calls them fat, tells them they stink and needs to shower. RP added that a lot of staff have witnessed S4 call them names. The residents complain about this too. According to resident interviews, six out of eight mentioned that they haven’t observed any staff calling residents inappropriate names. R4 shared that he/she is the one who curses back at staff. Four out of four staff mentioned that they haven’t heard or seen any staff calling residents inappropriate names. Based on interviews, records review and observations, 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 violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Report is reviewed and copy is provided. page 5 of 5the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 26-AS-20230906125323

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Jolene Sicley. During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured 3 out of 3 facility kitchens. The kitchens had a perishable food supply of at least two days and a non-perishable food supply of at least 7 days. LPA toured 10 resident bedrooms and observed each bedroom to have available bedding and clothing storage areas as well as working lights. LPA toured 2 out of 2 hallway bathrooms and observed them to have available soap and paper towels and water temperature between 111-114 F. During visit, LPA Marrufo tested the facility smoke alarm system. During the test, the emergency strobe lights did not flash in any parts of the building and only a faint sound could be heard in the main lobby area. During visit, technicians visited the facility and repaired the alarm system. A second test was conducted and LPA observed strobe lights and alarm sounds in all areas of the facility building. The outdoor area was toured and the exits were found to be clear of obstructions. LPA Marrufo reviewed the Centrally Stored Medication Logs and Resident Records for 5 residents and found them to be complete. LPA reviewed staff records for 5 staff and found them to be complete. LPA reviewed the Personal and Incidental Money Log for residents R1-R3. R1 was missing $191.32, R2 did not have a Personal and Incidental Money Log but had $47 that the facility was safeguarding for R2, and R3 had $280, but R3's Personal and Incidental Money Log stated R3 was only supposed to have $98. See LIC809-C for more information. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. This report was reviewed with Administrator Jolene Sicley and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 31, 2024