A Touch of Heaven

Allegation investigated: Facility did not issue refund to resident after TSO

The licensee was served a Temporary Suspension Order on March 17, 2026. All residents were moved out on March 17, 2026. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegations listed above. Therefore, the allegations above are unsubstantiated. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is going to be mailed certified to the licensee. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 4, 2026 · control 59-AS-20260318132304

Allegation investigated: Facility is in financial distress

On March 17, 2026, Licensing Program Analysts (LPAs) Ivan Avila and Marisa Chiarelli and Licensing Progam Managers (LPMs) Laura Munoz and Troy Orodonez conducted an unannounced complaint investigation visit regarding the above allegation directed by the Department. LPAs met with Justine Long and explained the purpose of the visit. Based on information obtained during the investigation, the allegation that the facility is in financial distress is substantiated. On February 20, 2026, facility staff attempted to cash their paychecks; however, the checks were returned due to insufficient funds. -----Continued on LIC9099-C----- Substantiated On or about March 6, 2026, the Chief Executive Officer (CEO) informed the Regional Office (RO) that the facility would be unable to meet payroll obligations for the upcoming payroll period scheduled for March 20, 2026. The CEO further stated that the facility would be unable to sustain operations beyond March 20, 2026 due to financial instability. On or about March 9, 2026, during an office meeting with staff and the RO, the CEO reported that the facility had sufficient food supplies to last approximately two weeks but did not have the financial resources to purchase additional food once those supplies were depleted. On March 13, 2026, during an office meeting, the CEO acknowledged that employee paychecks had bounced due to insufficient funds. The CEO also stated that third-party check-cashing services had contacted both the CEO and facility employees to report that the facility’s checks were being returned for insufficient funds and were requesting repayment of the funds issued. Based on statements made by the CEO during meetings with staff and the RO, the facility acknowledged it was unable to meet its financial obligations to sustain facility operations. Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, and the California Health and Safety Code are cited on the attached LIC9099-D. An exit interview was conducted, and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 17, 2026 · control 59-AS-20260224114018

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Mar 20, 2026

87213 Finances, requiring the licensee to maintain a financial plan that assures sufficient resources to meet operating costs for the care of residents. This requirement is not met as evidence by: Based on interviews with staff and the CEO, the licensee failed to maintain sufficient financial resources to meet operating costs necessary for the care of residents, including payroll and basic operational expenses, which poses an immediate health, safety, and personal rights risk to clients in carethe state’s words, verbatim · CDSS document, Mar 17, 2026

Plan of correction: No plan of correction required. TSO served.

Type of visit: Case Management - Legal/Non-compliance

On March 17, 2026, Licensing Program Manager (LPM) Laura Munoz and Troy Ordonez, Licensing Program Analysts (LPAs) Ivan Avila and Marisa Chiarelli along with the Local Long Term Care Ombudsman arrived unannounced at the facility to deliver a Temporary Suspension Order (TSO). The TSO shall be effective IMMEDIATELY. The Regional Office staff were met by the facility administrator, Justine Long upon arrival. The licensee, Kenneth Freel was not available during today's visit. A call was made to the licensee by LPM, Troy Ordonez at 9:48 AM, on March 17, 2026 requesting a call back. The licensee did not return the Department's call. LPMs, and LPAs conducted a tour of the facility to ensure the health and safety of resident in care. LPM Ordonez reviewed the TSO paperwork with the Administrator and served residents and responsible parties with a copy of the TSO. Upon arriving to the facility, there were 12 residents in care. By 4:00 PM., all residents were successfully relocated and no residents remained in care. The Regional Office staff ensured that the transition process was carried out in accordance with Title 22 regulations. Collaboration with the local ombudsman supported a smooth relocation for residents, safeguarding their health, safety, and personal rights throughout the process. Exit interview conducted and report providedthe state’s words, verbatim · CDSS document, Mar 17, 2026

Type of visit: Case Management - Health Checks

On March 14, 2026, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management regarding facility's financial stability and current operation. LPA met with lead medication technician (Med Tech) and explained the purpose of the visit. During today's visit, LPA and Med Tech conducted a tour of the facility. LPA observed ten residents present in the dining area, eating breakfast. LPA was informed the other three residents were in their bedrooms. LPA observed four staff working at the facility. LPA observed facility to have at least two days of perishable and seven days of nonperishable foods. LPA was informed that a big food order just recently arrived at the facility. Breakfast served during LPA's visit was biscuit and gravy with spam and eggs along with coffee, juice and tea. LPA observed residents to be clean and socializing in the common area. It was discussed about payroll, possible relocation of residents in care, and facility closure in the future. Facility updates are to be provided to LPA Avila. At this time, no deficiencies cited. Exit interview and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 14, 2026

Type of visit: Office

On Friday, March 9, 2026, at 3:30 p.m. an Office Meeting was conducted virtually via Microsoft Teams. Present were the Licensing Program Manager, Troy Ordonez, Licensing Program Manager Lauren Crocker, Licensing Program Analyst (LPA) Sarah Benson, CEO, Kenn Freel, representing Golden Years LLC, dba A Touch of Heaven and James Bird.The CEO was informed that this conference is part of the Administrative Action process. The purpose was to discuss concerns regarding the facility’s financial stability and ability to maintain continuous operations. The following was discussed during the meeting: Payroll Instability Upcoming Payroll Operational Impact’s Funding and Potential Change of Ownership/Closure procedures Closure Notification Requirements Control of Property The Department requires: Documentation of financial capacity to sustain operations and payroll. Written plan addressing payroll stability and operational continuity. Submit a copy of sixty-day notice before ending of day March 9, 2026. Provide updates to LPA Avila regarding funding efforts or potential sale of the facility. Follow up meeting March 13, 2026, at 10:00 a.m. Comply with Health and Safety Code section 1569.191 if closure or change of ownership occurs. Continued on LIC809-C The Department emphasized that resident health and safety are the top priority. Financial instability and payroll disruption create serious risks. The facility must demonstrate stable operations and reliable staffing. Failure to do so may result in administrative action.the state’s words, verbatim · CDSS document, Mar 9, 2026

Type of visit: Office

the Licensing Program Manager, Troy Ordonez, Licensing Program Manager Lauren Crocker, Licensing Program Manager Laura Munoz, Licensing Program Analyst (LPA) Sarah Benson, and the CEO, Kenn Freel, representing Golden Years LLC, dba A Touch of Heaven. The CEO was informed that this conference is part of the Administrative Action process. The purpose was to discuss concerns regarding the facility’s financial stability and ability to maintain continuous operations. The following was discussed during the meeting: Payroll Instability Upcoming Payroll Operational Impact’s Funding and Potential Change of Ownership/Closure procedures Closure Notification Requirements Required Actions. The Department requires: Documentation of financial capacity to sustain operations and payroll. Written plan addressing payroll stability and operational continuity. Email confirmation to LPA two days before March 20, 2026, verifying payroll funds are secured. Proof of sufficient food supplies for two weeks, including weekly receipts. Provide updates to LPA Avila regarding funding efforts or potential sale of the facility. Continuation of todays NCC meeting will be held March 9, 2026 at 4:00 p.m. via teams. Comply with Health and Safety Code section 1569.191 if closure or change of ownership occurs. Continued on LIC809-C The Department emphasized that resident health and safety are the top priority. Financial instability and payroll disruption create serious risks. The facility must demonstrate stable operations and reliable staffing. Failure to do so may result in administrative action. An exit interview was conducted and a copy of this report will be provided to the facility via email. A copy will be signed and returned to CCLD. A continuation of todays NCC meeting will be held March 9, 2026 at 4:00 p.m. via teams.the state’s words, verbatim · CDSS document, Mar 6, 2026

Type of visit: Case Management - Other

03/05/2026 09:50 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Justine Long and explained the purpose of the visit. Administrator could not stay for the entire visit, LPA toured the facility with staff Trish Cockrun. During the visit LPA toured the facility, conducted staff interviews, collected documents and checked the food supply. LPA obtained the following documents during the visit: Current resident roster that includes hospice status, two-person assists, residents who are currently receiving home health services, responsible party (RP) contact information for all current residents, Current staff roster with contact information including payroll staff. LPA requested the licensee submit a written plan of how they will operate the facility in the event that staff resign. LPA requested the licensee email this plan to LPA’s Knight and Avila by 03/06/2026. No deficiencies were cited during the visit. A copy of the report was provided during the visit.the state’s words, verbatim · CDSS document, Mar 5, 2026

Type of visit: Office

On Friday, February 27, 2026, an informal conference was conducted virtually via Microsoft Teams Meeting. Present in the meeting was Acting Regional Manager, Troy Ordonez, Licensing Program Analyst (LPA) Ivan Avila, and CEO, Kenneth Freel representing Golden Years LLC dba A Touch of Heaven CEO was informed that this Informal conference is a part of the Administrative Action process and that further noncompliance may result in an elevation to a formal noncompliance conference, which could lead to a referral to the Department's legal division for possible revocation of license. The purpose of today’s meeting was to discuss serious concerns regarding LLC’s financial stability and its ability to maintain continuous operations. Topic discussed: · Financial Concerns · Payroll Checks · IRS Concerns · Operational Risk to the residents and staff · Required Action- Financial Stability Plan Continued on LIC 809-C The Department stated that the primary priorities are: · Residents must remain safe. · Staff must be paid on time. · There must be no disruption in care. · Operations must continue without interruption. CEO was directed to submit a comprehensive Financial Stability Plan to the Department that includes: Payroll Confirmation Requirements: · Email confirmation to the LPA two (2) days prior to March 5, 2026, verifying payroll funds are secured. · Email confirmation to the LPA two (2) days prior to March 20, 2026, verifying payroll funds are secured. · Identification of all pay dates for the next three (3) months. · Submission of proof of payroll completion to the LPA on payday for the next three (3) months. · Email Proof and confirmation of sufficient food supplies for two weeks · Email Proof and confirmation of current week’s food receipts prior to February 28, 2026 · Email Proof and confirmation of plan with the IRS on payment requirements Contingency Plan Requirements: · Immediate email notification to the LPA if payroll funds are at risk at any time. · Identification of secured backup funding sources. · Written emergency funding strategy to ensure uninterrupted operations Continued on LIC 809-C Ongoing Monitoring by the Department · Maintain sufficient operating funds · Ensure uninterrupted food and vendor services · Ensure no staffing disruption The Department advised that failure to demonstrate immediate financial stabilization may result in further regulatory action. The licensee acknowledged the seriousness of the concerns and the requirement to ensure uninterrupted care, staffing stability, and operational continuity. The Department will continue to monitor compliance closely. No deficiencies cited. Exit interview conducted. Informal meeting concluded and a copy of report will be emailed. CEO Signature is expected to be signed and returned to LPA by close of business, February 27, 2026.the state’s words, verbatim · CDSS document, Feb 27, 2026

Allegation investigated: Staff are harassing resident in care

On December 4, 2025, Licensing Program Analyst (LPA) Ivan Avila conducted an unannounced complaint investigation visit regarding the above allegation directed by the Department. LPA Avila met with Tricia Cockrum and explained the purpose of the visit. During the investigation process, interviews and a review of records were initiated. LPA investigated the allegation, “Staff are harassing resident in care.” Based on interviews it was indicated that staff have never been observed harassing any residents. Interviews stated residents are treated with dignity and respect. Based on interviews conducted and record review, the preponderance of evidence standards has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. Findings that the complaint is Unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of the report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 4, 2025 · control 59-AS-20251015083720

Type of visit: Case Management - Other

On December 4, 2025, Licensing Program Analyst (LPA) Ivan Avila arrived at the facility to conduct a case management visit. LPA met with Med Tech Tricia Cockrum and explained the purpose of the visit. LPA arrived to obtain further information regarding a resident. During today's inspection LPA gathered information regarding an incident report that will be sent to the Department. Several topics were discussed. No deficiencies cited during today's inspection. Exit interview conducted and copy of report was provided.the state’s words, verbatim · CDSS document, Dec 4, 2025

Type of visit: Required - 1 Year

On October 15, 2025, Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to conduct a 1-year annual inspection and met with Justine Long and explained the purpose of the visit. LPA Avila and Administrator toured facility together to ensure the health and safety of residents in care. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects are stored in a locked area. Water temperature measured within the required range. Bedrooms: The LPA observed resident bedrooms furnished with at least one night stand, a bed, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. Bathrooms: The LPA observed the resident bathrooms to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene products. Common Areas: These included but are not limited to the living area, activity area, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. In the areas toured no immediate health, safety, or personal rights violations were observed. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no firearms or bodies of water on the premises. Record Review: A review of facility files was initiated. The LPA observed documentation of the Infection Control, Disaster prevention and last fire drill. Facility records are stored inaccessible to residents. The LPA reviewed five (5) staff, and five (5) resident files. All documents reviewed appeared complete and current. Medications: During the facility visit a medications review was initiated. Medications are centrally stored and locked in a cabinet inaccessible to residents in care; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record log. No errors observed during the medication review. No deficiencies cited during today's visit. Exit interview conducted and a copy of the report was providedthe state’s words, verbatim · CDSS document, Oct 15, 2025

Allegation investigated: Catheter care not being properly provided Resident belongings stolen Resident not being showered regularly

On September 15, 2025, Licensing Program Analyst (LPA), Ivan Avila conducted an unannounced complaint investigation visit regarding the above allegations directed by the Department. LPA Avila met with Administrator Justine Long and explained the purpose of the visit. During the investigation process, interviews and a review of records were initiated. LPA investigated the allegation, “Catheter care not being properly provided.” Based on interviews, staff indicated R1’s catheter gets cleaned by staff when there’s a leak. R1 has a home health agency that goes into the facility twice a week to help with R1’s catheter care. R1 stated catheter care is being properly provided. ----- Continued on LIC9099C ------ Unsubstantiated LPA investigated the allegation, “Resident belongings stolen.” Based on interviews and record review, staff indicated R1 had a wristwatch upon admission to the facility. R1 alerted staff the wristwatch was missing. Interviews stated facility staff looked for R1’s missing wristwatch and it was later found in R1’s room. LPA investigated the allegation, “Resident not being showered regularly.” Based on interviews, staff indicated that the residents receive sufficient care with bathing, grooming, and hygiene. LPA observed records documented showing R1 receiving showers and being combative with staff. R1 has declined showers but has been offered showers at later times. R1 stated they have changed their shower schedule to day shifts and has been offered showers multiple times a week. Based on interviews conducted and observations, the preponderance of evidence standards has not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. Findings that the complaint is Unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 15, 2025 · control 59-AS-20250716135350

Allegation investigated: Staff do not ensure sufficient care and supervision is being provided to resident

On 11/20/2024 Licensing Program Analyst (LPA) Ivan Avila conducted an unannounced complaint investigation visit regarding the above allegation directed by the Department. LPA met with Tricia Cockrum and explained the purpose of the visit. During the investigation process, interviews and a records review were initiated. LPA investigated the allegation, “Staff do not ensure sufficient care and supervision is being provided to resident.” Based on record review and interviews conducted, R1 had been found on the floor by staff in multiple occasions. Staff have stated it is unknown for how long R1 had been on the floor but was immediately helped back up and placed up on the bed or chair. Based on LPAs interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED. California Code of Regulations, Title 22, and the California Health and Safety Code are cited on the attached LIC9099-D. An exit interview was conducted, and a copy of the report and appeal rights were provided. Substantiated LPA investigated the allegation, “Staff did not ensure resident was accorded privacy while receiving incontinence care.” Based on interviews conducted, there was no indication that any residents or staff observed that staff did not provide privacy to resident. During residents’ interviews, residents stated that facility staff are meeting their care needs and did not express any concerns with privacy or dignity. It was noted that they did not express any issues. Although the allegations 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. An exit interview was conducted, and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Nov 20, 2024 · control 59-AS-20240805143528

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 22, 2024

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…sufficient support staff shall be employed to ensure provision of personal assistance. This requirement is not met as evidence by: Based on record review and interviews, the licensee did provide adequate care and supervision as R1 was found on the floor on multiple occasions, which posses an immediate Health, Safety, and/or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 20, 2024

Plan of correction: Facility will complete a statement of understanding regarding regulation 87411(a). Facility will submit statement of understanding via email to LPA by POC due date of 11/22/2024.

Allegation investigated: Resident fell multiple times due to staff neglect resulting in injuries

On 11/20/2024 Licensing Program Analyst (LPA) Ivan Avila conducted an unannounced complaint investigation visit regarding the above allegation directed by the Department. LPA met with Tricia Cockrum and explained the purpose of the visit. During the investigation process, interviews and a records review were initiated. LPA investigated the allegation, “Resident fell multiple times due to staff neglect resulting in injuries.” Based on record review and interviews conducted, R1 sustained multiple falls at the facility. R1 had also sustained some minor injuries. R1 had fallen from her bed after staff forgot to adjust the resident’s bedrails causing R1 to fall from the bed. Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, and the California Health and Safety Code are cited on the attached LIC9099-D. An exit interview was conducted, and a copy of the report and appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Nov 20, 2024 · control 59-AS-20240808154742

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Nov 22, 2024

87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement is not met as evidence by: Based on interviews and record review, the licensee did not comply with the section cited above as R1 required frequent observation after multiple falls that was not provided resulting in injuries, which posses an immediate Health, Safety, and/or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 20, 2024

Plan of correction: Facility will complete a statement of understanding regarding regulation 87466. Facility will submit statement of understanding via email to LPA by POC due date of 11/22/2024.

Type of visit: Required - 1 Year

On 10/15/2024 Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to conduct a 1-year annual inspection and met with Sarah Prather and explained the purpose of the visit. LPA Avila and Administrator toured facility together to ensure the health and safety of residents in care. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects are stored in a locked area. Water temperature measured at 114 degrees. Bedrooms: The LPA observed resident bedrooms furnished with at least one night stand, a bed, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. Bathrooms: The LPA observed the resident bathrooms to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene products. Common Areas: These included but are not limited to the living area, activity area, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. In the areas toured no immediate health, safety, or personal rights violations were observed. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no firearms or bodies of water on the premises. Record Review: A review of facility files was initiated. The LPA observed documentation of the Infection Control, Disaster prevention and last fire drill. Facility records are stored inaccessible to residents. The LPA reviewed four (4) staff, and four (4) resident files. All documents reviewed appeared complete and current. Medications: During the facility visit a medications review was initiated. Medications are centrally stored and locked in a cabinet inaccessible to residents in care; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record log. No errors observed during the medication review. No deficiencies cited during today's visit. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 15, 2024

Allegation investigated: Staff allege to have a relationship with a resident The resident is scared to come out and be in the facility common areas

On 07/08/2024 Licensing Program Analyst (LPA) Ivan Avila conducted an unannounced complaint investigation visit regarding the above allegations directed by the Department. LPA met with Sarah Prather and explained the purpose of the visit. During the investigation process, interviews and a records review were initiated. LPA reviewed R1s physician report, and it states R1 has a Neurocognitive Disorder known as Dementia. LPA investigated the allegation, “Staff allege to have a relationship with a resident.” Based on interviews conducted, staff stated that they never witnessed any inappropriate behavior between a staff member and a resident. R1s daughter stated that her mother suffers from dementia and has told her that staff members are there to care for her and she cannot go around saying the caregiver is her boyfriend. Interviews revealed that it is R1 that grabs ahold of the staff member and does not want to let go. ****Continued on LIC 9099-C**** Unfounded LPA investigated the allegation, “The resident is scared to come out and be in the facility common areas.” Based on interviews conducted, R1 goes out to the facility common areas. R1 has dementia and sometimes she wants to stay in her room and staff have encouraged her to go out in the common areas. R1's daughter revealed that R1 has been in the facility common areas without any issues when she visits. This agency has investigated the complaint alleging “Staff allege to have a relationship with a resident & The resident is scared to come out and be in the facility common areas.” 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 a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 8, 2024 · control 59-AS-20240611103531

Type of visit: Case Management - Incident

On 06/12/2024, Licensing Program Analyst (LPA) Ivan Avila arrived unannounced at the facility to conduct a case management visit regarding an absent without leave incident report the Department received via fax on 05/29/2024. LPA met with Administrator Sarah Prather and explained the purpose of the visit. The incident occurred on 05/29/2024 at approximately 1:30 AM when facility staff observed R1 to be missing. Facility staff conducted a search throughout the facility, and it was noted that R1 was no longer in the facility. Resident was missing for approximately 30 minutes. R1 was located later that night across the street. Based on R1's LIC 602 Physician's Report, signed on 04/03/2024, it is indicated that R1 was deemed unable to leave the facility unassisted. LPA and Administrator discussed ensuring that staff are aware which residents can leave the facility unassisted. LPA clarified that if the LIC 602 indicates resident cannot leave unassisted then the facility is to comply. Additionally, LPA and Administrator discussed that R1 is diagnosed with a Neurocognitive Disorder, Dementia, and requires close supervision. As a result of the incident, a deficiency is being cited per California Code of Regulations, Title 22, and California Health and Safety Code. The deficiency is documented on the LIC 809-D page. Exit interview conducted, a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(d) · Plan of correction due date: Jun 14, 2024

1569.312 Every facility required to be licensed...following basic services: (d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by: Based on file review and interview, the Licensee did not comply in the section cited above as resident was observed to have left the community and is unable to leave the community unassisted, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 12, 2024

Plan of correction: Facility will complete a statement of understanding regarding regulation 1569.312(d). Facility will submit statement of understanding to LPA by POC due date of 06/14/2024.