Sierra Oaks of Redding

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Incident

On 09/25/2026 licensing program analyst (LPA) Marisa Chiarelli arrived unannounced to conduct a case management visit. LPA Chiarelli met with executive director Jennifer Campbell and Administrator Lisa Crow and explained the purpose of the visit. LPA Chiarelli followed up on a incident report that was sent to CCL on 09/20/2026. The incident reported as a resident eloped from the facility on 09/18/2026. On 09/25/2026 LPA Chiarelli interviewed staff. According to staff one (S1), resident one (R1) eloped from the facility on 09/18/2026 and was found later in a nearby neighborhood by their family member. S1 stated that there was only one staff member on duty in house 1 (where R1 resided). S1 stated no one knows how R1 got over the locked fence surrounding house 1. S1 stated that R1 used a strangers phone to call their family member to get them and that is how R1 was found. As part of the investigation into the incident LPA Chiarelli reviewed R1 file and there was no care plan created for when R1 was first admitted to the facility one was only created after the elopement incident. Two deficiencies is being cited on todays visit. Exit interview conducted and copy of report left with the facility.the state’s words, verbatim · CDSS document, Sep 25, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 23, 2026

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). The licensee did not comply with the section cited above as evidenced by: Record review and interviews. Staff did not prevent a resident from eloping from the facility, which causes a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2026

Plan of correction: Licensee agrees to create a care plan for R1 regarding elopement risk. Licensee will conduct an training with all staff regarding AWOL / elopement situations with residents.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Oct 23, 2026

87506(a) Resident Records...(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. The licensee did not comply with the section cited above as evidenced by: record review; R1 (resident one) does not have a care plan from when they were first admitted into the facility on 09/14/2026, which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2026

Plan of correction: Licensee will ensure that all residents files will be readily available for licensing upon their visit. Licensee will ensure R1 has updated care plan in their file along with all CCL required documentation. TSP referral will be completed.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Incident

On Sepetember 9, 2026 at 3:00 p.m. Licensing Program Analyst (LPA) Sarah Benson, conducted an unannounced case management visit and met with assistant administrator Jennifer Campbell. During today's visit the facility was toured. During todays visit LPA observed p.m. shift of three care staff and one med. tech., administrator, activities director, nurse and dietary staff. During the tour a box of pain patches was discovered in a residents room. The following deficiencies were observed (See LIC 809 D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted, a copy of the report, and appeal rights provided to administrator. Continued on LIC809D.the state’s words, verbatim · CDSS document, Sep 9, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(6) · Plan of correction due date: Oct 9, 2026

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... by compliance with the following: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above as a box of pain patches was found in the residents room. Which poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 9, 2026

Plan of correction: The administrator gave the box of pain patches to the medication technician to be stored with the residents medications during LPA's visit. The administrator will have a medication trainning for staff. The administrator will notify LPA when training is complete.

Type of visit: Office

On 09/08/2026 at 11:00 AM, licensing program analyst (LPA) Marisa Chiarelli held a meeting via TEAMS to clarify questions on the facility acquiring a new administrator. Attendees of the meeting: Lauren Crocker - Licensing program manager Marisa Chiarelli - Licensing program analyst Teresa Oliveri - LVN Pat Brown - Chief of Operations Jennifer Campbell - Executive Director Roland Murphy Facility stated they have someone to be interim administrator until Jennifer Campbell completes her administrator certification. Facility will submit documents for interim administrator to CCLD (community care licensing) by 09/11/2026. Exit interview conducted and copy of report emailed to facility.the state’s words, verbatim · CDSS document, Sep 8, 2026

Type of visit: Case Management - Deficiencies

On 08/24/2026 licensing program analyst (LPA) Marisa Chiarelli arrived at the facility unannounced to follow up on some documentation that was submitted to licensing. LPA Chiarelli met with Community Relations Director Jennifer Campbell and explained the purpose of the visit. Per documentation given to licensing, the staffing plan the facility created had a ratio of one (1) staff per eight (8) residents for houses 1 which is a memory care unit. LPA Chiarelli reviewed and confirmed with staff on today's visit that there is only one (1) caregiver for eight (8) residents which does not meet the needs of residents in care. The current census for house 1 is ten (10) residents which would mean per the facilities staffing plan would consist of two (2) caregivers on shift. There is only one (1) caregiver on shift. One deficiency is being cited on today's visit. Exit interview conducted and copy of report left with the facility.the state’s words, verbatim · CDSS document, Aug 24, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80085(b) · Plan of correction due date: Sep 8, 2026

80085(b) Personnel Requirements The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs. This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above. The licensee did not employ staff as necessary to ensure the resident care needs are taken care of. Which poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 24, 2026

Plan of correction: Licensee will hire more staff Licensee will create an updated staffing plan showing staffing ratios on the plan. Licensee will show on the staffing plan the responsibilites for med techs and caregivers.

Allegation investigated: Staff did not provide resident's records to the resident's authorized representative.

On 07/29/2026, Marisa Chiarelli, Licensing Program Analyst (LPA) arrived at the facility unannounced to open / deliver final findings regarding a complaint that was received on 07/22/2026. LPA Chiarelli met with Jennifer Campbell community services director , and explained the purpose of the visit. While investigating the allegation “Staff did not provide resident's records to the resident's authorized representative” LPA Chiarelli interviewed two staff member and the resident’s authorized representative. LPA Chiarelli was able to confirm through interviews and documentation review that there was communication between the facility and authorized representative in regard to the authorized representative requesting residents records but no documentation was provided to the authorized representative. Continued on 9099 - C Substantiated On 06/08/2026, the resident’s authorized representative sent over documentation requesting the residents records. Facility communicated with authorized representative that information on the documentation sent over needed to be corrected. On 06/11/2026 the resident’s authorized representative faxed the facility the corrected documentation. Authorized representative received confirmation from the facility the fax went through. On 06/18/2026 the resident’s authorized representative spoke with the facilities Wellness Director and confirmed resident record request. The resident’s authorized representative did contact the facility several times in June 2026 and July 2026 and on 07/15/2026 the authorized representative emailed the facilities Wellness Director but still has not received the documents as of 07/28/2026. Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.the state’s words, verbatim · CDSS document, Jul 29, 2026 · control 59-AS-20260722151443

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(1) · Plan of correction due date: Aug 5, 2026

87506(c)(1)Resident Records ..(c)All information and records obtained from or regarding residents shall be confidential…(1)…. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. Licensee did not comply with the section cited above as evidenced by: interviews and records reviews, the staff at the facility did not provide a residents authorized representative resident records that were requested, which poses a health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 29, 2026

Plan of correction: Licensee will submit requested documents to the residents authorized representative. Licensee will submit proof of correction to LPA by POC due date.

Type of visit: Case Management - Other

On 07/29/2026 licensing program analyst (LPA) Marisa Chiarelli arrived at the facility unannounced and met with Roland Murphy who is Quality assurance for Lenity the licensee for Sierra Oaks of Redding. During todays visit LPA Chiarelli requested documents related to complaint 59-AS-20260429091621 and interviewed staff. Exit interview conducted and copy of report left with the facility.the state’s words, verbatim · CDSS document, Jul 29, 2026

Allegation investigated: Facility is not allowing resident's husband to visit the resident.

On 07/22/2026, Marisa Chiarelli, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 07/14/2026 LPA Chiarelli met with Rhonda Johnson, Wellness Director, and explained the purpose of the visit. During the investigation LPA Chiarelli interviewed the administrator and they stated, originally the facility had a supervised visitation policy with resident one (R1) family member because of the incident that occurred, after speaking with the local police department and licensing, did not allow that family member back onto the property. Continued 9099 - C Substantiated Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 59-AS-20260714111656

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Jul 29, 2026

87468.1(a)(11) Residents in all residential care facilities for the elderly shall have all of the following personal rights… To have their visitors….permitted to visit privately……. The licensee did not comply with the above evidenced by: interviews, facility did not allow R1 husband to visit R1, which poses a health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 22, 2026

Plan of correction: Licensee will create a visitor policy with R1 family. Licensee will allow R1 husband to visit with R1.

Allegation investigated: Personal Rights

On 07/02/2026 licensing program analyst (LPA) Marisa Chiarelli arrived at the facility unannounced to deliver final complaint findings. LPA Chiarelli met with administrator Michael Lang and explained the purpose of the visit. On 01/05/2026 Staff one (S1) reported that they saw resident one (R1) entered into resident two’s room (R2), R2 stated to staff that R1 had touched them inappropriately. The incident was reported to the local police department. R1 was subsequently arrested by the local police department after determining that. R1 had a history of inappropriate behaviors. Between August 2025 and January 2026 it was reported by staff that R1 had inappropriately touched themselves and other residents in addition to four staff members stated that they had witnessed R1 inappropriately touch R2 at least five to six times. Substantiated Interviews with facility staff indicated that the corrective measures implemented to address R1 behaviors were insufficient and the one-to-one staffing plan that was developed for safety was not followed. Due to R1 documented pattern of inappropriate behavior toward R2 and other residents at the facility, combined with facility’s failure to implement timely and effective corrective measures, this allegation is Substantiated. One deficiency is being cited on today’s visit and an immediate $500 civil penalty is being assessed. Exit interview conducted and copy of report left with the administrator.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 59-AS-20260106100114

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jul 3, 2026

87468.2(a)(8) Additional personal rights of residents in privately operated facilities.....(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. The licensee did not comply with the section above as evidenced by: Interviews, observations and record reviews. Licensee did not ensure R2 and other residents personal rights were not violated which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: R1 has been subsequently arrested by the local police department and has been lawfully evicted from the facility. Licensee will have a training with staff. Training topics will include: Elder abuse.. How staff will handle a situation involving sexual or any forms of abuse. Licensee will complete training by 7/16/2026 and submit proof of correction to LPA by 7/16/2026.

Type of visit: POC

On 7/2/2026 licensing program analyst (LPA) Marisa Chiarelli arrived at the facility unannounced to conduct a POC (plan of correction) visit. LPA Chiarelli met with administrator Michael Lang and explained the purpose of the visit. LPA Chiarelli reviewed a POC from a deficiency that was cited on 05/21/2026. POC was originally due on 06/22/2026. Michael Lang requested an extension from LPA Chiarelli which was granted. New plan of correction due date was 6/29/2026. LPA Chiarelli reviewed all items needed for the POC and facility has cleared the POC. Exit interview conducted and copy of report left with the administrator.the state’s words, verbatim · CDSS document, Jul 2, 2026

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: POC

On 05/26/2026 licensing program analyst (LPA) Marisa Chiarelli arrived at the facility unannounced to complete a plan of correction (POC) inspection from 9099 and 9099 dated 05/21/2026. LPA Chiarelli met with administrator Michael Lang and explained the purpose of the visit. POC's corrected by documents submitted and POC visit. Deficiencies cleared. POC letters printed and provided. As a result of this visit, no deficiencies were cited. Exit interview conducted with Administrator Michael Lang and report provided.the state’s words, verbatim · CDSS document, May 26, 2026

Allegation investigated: Residents toileting needs are not being met timely due to insufficient staffing. - Substantiated Medication not being dispensed per MD orders. - Substantiated

On 05/21/2026 Licensing Program Analyst (LPA) Marisa Chiarelli arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 04/15/2026. LPA Chiarelli met with Michael Lang Administrator, and explained the purpose of the visit. During the investigation process, interviews were preformed and files were reviewed. The following documents were received and reviewed: staff roster including staff contact information, staff schedules. Substantiated complaints on 9099 - C Substantiated Facility is not following residents plan of care by removing bed alarm. – Unsubstantiated On 04/17/2026 LPA Chiarelli arrived at the facility unannounced and toured the facility. LPA Chiarelli and administrator Michael Lang toured house 1 and R1 (resident one) room. LPA Chiarelli observed that R1 had a bed alarm attached to his bed. Administrator Lang showed LPA Chiarelli how the bed alarm worked and that it was functioning properly. LPA Chiarelli reviewed R1 file and it showed that hospice documented that they placed a bed alarm on R1 bed because they were determined to be a fall risk. LPA Chiarelli did not have evidence to prove that staff were not meeting the plan for care and determine if staff had removed the bed alarm for an extended period of time or not. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated. Allegation - Medication not being dispensed per MD orders. – substantiated During the investigation LPA Chiarelli and LPA Adkison completed a medication audit and residents medications were reviewed. While medications were being reviewed it was observed that resident one R1 had two medications that had missing doses. The first medication observed for R1 was prescribed by the doctor to be taken twice daily but there were twelve (12) missing doses of the medication that were unaccounted for. In the E-MAR that the facility uses there were no notes on why the medication was unaccounted for. Allegation - Residents toileting needs are not being met timely due to insufficient staffing. – substantiated During the investigation several staff members were interviewed and records were reviewed. LPA Chiarelli interviewed a staff member that they stated that “Yes, for the past several months I have been working by myself. There usually is a med tech but they float between houses 1 and 2 and when they are at house 2, I am left alone. Most of my shifts I am the only caregiver.” LPA Chiarelli asked - Do you have any residents that need two staff to transfer them? S1 – Yes, we do. We only have a few but one of them we got a hoyer lift for, but it can be difficult to get them out of bed on my own or because we do not have enough staff we cannot lift them out of bed. We also have a resident that primarily uses a commode but if I do not have another caregiver to help me I just change their diaper, because I need a second caregiver to help me transfer them to the commode. Usually during my shift I can get my checks and diaper/depends changed completed. But for other shifts it can be difficult to get it all done. LPA Chiarelli – Do you have ever have a shortage of diapers/wipes and another incontinence items? S1 – Yes, we do. If we cannot find diapers or incontinence items, we do take them from other residents because we cannot leave residents wet or in a dirty diaper. LPA Chiarelli interviewed another staff member (S2) who worked a different shift and stated “Here is a brief from a resident that wasn't changed for three days after our AM shift ended, she had the brief on until 3/27-3/30. I think this was due to the shortage of staff. She isn't the only resident we found with the same brief on.” (Photo evidence was provided). Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.the state’s words, verbatim · CDSS document, May 21, 2026 · control 59-AS-20260415110425

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80085(b) · Plan of correction due date: May 24, 2026

80085(b) Personnel Requirements The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs. This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above. The licensee did not employ staff as necessary to ensure the resident care needs are taken care of. Which poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Licensee will create a staffing plan and show staffing ratios on the plan. Licensee will hire more staff Licensee will submit proof of correction to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 10, 2026

87465(a)(4) Incidental Medical and Dental Care.....A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following....The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based off observation, interview and record review, licensee did not ensure residents medication was not dispensed per MD orders which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Licensee will have a new training with all facilities med techs regarding medications and physicians orders. Licensee will show proof of training to LPA by POC due date.

Allegation investigated: Staff are not properly trained. - Substantiated

On 05/21/2026, Marisa Chiarelli, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 04/10/2026. LPA Chiarelli met with Michael Lang, Administrator, and explained the purpose of the visit. During the interview process, four staff persons were interviewed. The following documents were received and reviewed: Staff records Continued on 9099-C Substantiated During the investigation process staff were interviewed and incident reports were reviewed. It was alleged that a staff member handled a resident in an aggressive manner. While investigating the above LPA Chiarelli interviewed staff and the administrator. While interviewing LPA Chiarelli received conflicting statements as to what happened during the incident in question. Due to this the preponderance of evidence was not met and the above allegation is unsubstantiated. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated. During record review all the staff files that were reviewed by LPA Chiarelli did not show staff trainings. LPA Chiarelli asked administrator if there was another place where staff trainings are documented. Administrator stated that “I am not sure where the trainings are documented.” Administrator also stated that they do have staff meetings with training but could not provide documentation of them. Administrator stated that for staff trainings the facility uses Relias for trainings, which is an online training portal. In the staff files there was no documentation of Relias training. During an interview with S1. S1 stated “supposedly they were going to give us "training" but all they did was send out manager of DAs to show us how to use the dish washer and gave us a list on the things we should do but I personally don't think that's training . They also sent us a link to get out food handlers that we have to pay for.” LPA Chiarelli during in an interview with S2, S2 stated “staff are not properly trained which leads to staff questioning how to do things and when they ask their supervisors or superiors about it, they do not get the help or responses they need.” Based on investigation, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed. Exit interview conducted copy of report left with administratorthe state’s words, verbatim · CDSS document, May 21, 2026 · control 59-AS-20260410151311

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Jun 22, 2026

87411(c) Personnel Requirements ...All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This was not evidenced by: based on interviews and record reviews, licensee did not ensure all staff had documented trainings and required trainings per title 22 regulations. Which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Licensee will submit proof that all staff have had their initial and annual trainings completed (which is specified in health and safety codes sections 1569.625 and 1569.69), to LPA by POC due date.

Allegation investigated: Licensee does not ensure that there is adequate staffing to meet the needs of residents

On 05/21/2026 Licensing program analyst (LPA) Marisa Chiarelli arrived at the facility unannounced to deliver complaint findings. LPA Chiarelli met with administrator Michael Lang and explained the purpose of the visit. During the investigation staff were interviewed and records were reviewed. Continued on 9099 - C Substantiated During the interview process, staff stated that in house 1 they are short staffed and there is only one caregiver taking care of residents. LPA Chiarelli reviewed staff schedules, and it reflected that on many occasions there was only (one) 1 am or pm caregiver staffed. Due to lack of staff, staff stated that showers are delayed or not being completed and residents that need 2 caregivers to transfer them are not being moved or transferred. Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed. Deficiency is linked to complaint 59-AS-20260415110425. Exit interview conducted and copy of report given to administrator.the state’s words, verbatim · CDSS document, May 21, 2026 · control 59-AS-20260409155423

Allegation investigated: Facility did not issue full refund upon resident discharge

On 05/21/2026, Licensing program analyst Marisa Chiarelli arrived at the facility unannounced to deliver final complaint findings regarding a complaint that was received on 05/04/2026. LPA Chiarelli met with administrator Michael Lang and explained the purpose of the visit. During the investigation two persons were interviewed and records were reviewed. Continued on 9099-C Substantiated During the investigation a letter was sent to licensing from a residents power of attorney stating they had not received a full refund upon the residents move out. The resident gave a 30 day notice which was dated for 02/13/2026. Upon move out it is written within the facilities admission agreement that “a refund will be issued to the resident/responsible party within 30 days after the resident vacates the apartment, including all personal property.” The resident moved all their personal belongings/property out on 2/18/26. Power of attorney has not received a full refund, only partial which was dated 4/28/2026 which is after the 30 days. Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.the state’s words, verbatim · CDSS document, May 21, 2026 · control 59-AS-20260504131026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: May 29, 2026

1569.652(c) Health and safety code.....A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees. This was evidenced by record reviews and interviews. Power of attorney has not received full refund. Which poses an potential health, safety or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, May 21, 2026

Plan of correction: Licensee will submit a full refund to resident or residents power of attorney by POC due date. Licensee shall submit proof of full refund to LPA by POC due date.

Type of visit: Office

On 04/24/2026 at approximately 9:00 AM, an informal conference was conducted with representatives of Sierra Oaks and was held over TEAMS. The purpose of this conference was to discuss current issues at the facility. Present at the meeting was; Licensing program manager Lauren Crocker, Licensing program analyst Marisa Chiarelli, Administrator Michael Lang, Teresa Oliveri LVN, and Pat Brown representative of the licensee. Administrator was informed this Informal Conference is a meeting to discuss further issues at the facility and what licensing regulations require. The informal conference process was explained during this meeting. Issues discussed during the meeting were: - Adequate staffing - Medication errors - Staff training - Staffing goals - Reporting requirements During the Informal Conference, the facility has stated they will do the following to achieve continued and substantial compliance: - Creating a training plan for staff with a description of who will attend, when will classes be provided, topics being discussed. - Staffing goals Continued on 809 - C Facility staffing goals: - Day Shift - House 1 and 2, 1 med tech and 2 PCAs (caregivers) - Mid Shift - Houe 1 and 2, 6 staff including 1 med tech float. - Noc Shift - House 1 and 2, 1 PCA for both house and 1 med tech float. (goals for staff shifts are similar for house 3) Facility stated that they would like to make the staff in house 1 and 2 universal workers. They would like everyone cross trained so that way staff can help assist in every task in house 1 and 2. - For medication errors, Teresa stated that the facility is going to train the med techs more and have clinical meetings before shifts to better assist in duties for med techs. Administrator Lang stated that for staffing goals they would like to be at 125% and believe they can obtain that goal by end of May of 2026. To meet there 100% staffing goals administrator believed they could meet that goal by mid to late May of 2026. No deficiencies were cited during today’s Office Visit. Exit interview was conducted. A copy of the Office Visit was signed and provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 24, 2026

Type of visit: Case Management - Other

On 4/22/2026 Licensing program analyst Marisa Chiarelli and LPA Kayla Adkison came unannounced for a case management visit, met with administrator Michael Lang and explained the purpose of the visit. On today's visit LPA Chiarelli and LPA Adkison did a medication review of all three houses on the property. (see 812) On todays' visit it was observed by LPA Chiarelli and LPA Adkison that there was severalthe state’s words, verbatim · CDSS document, Apr 22, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 6, 2026

87211(a)(1) Reporting requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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.......Any incident which threatens the welfare, safety or health of any resident. Evidenced by; during medication audit/review LPA's observed several medication errors that were not reported to licensing...Which possess a potential health, safety, personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Licensee will have a training on reporting requirements for all staff by POC due date; once training has been completed licensee will submit proof of training to LPA by POC due date.

Type of visit: Case Management - Deficiencies

On 4/17/26 Licensing program analyst Marisa Chiarelli visited the facility unannounced to conduct a case management visit. LPA Chiarelli met with administrator Michael Lang and explained the purpose of the visit. LPA Chiarelli and administrator Michael Lang toured facility. Facility consists of three separate buildings; house 1, house 2 and house 3. LPA Chiarelli observed in house 1 that there was no call system in place. House 2 and 3 have a call system but in house 1 call system was not in place. During today's visit LPA Chiarelli reviewed staff records, and residents records. Exit interview conducted, several topics were discussed, copy of report left with administrator. Two type B deficiencies are being cited as of today’s visit, see 809 D for deficiencies.the state’s words, verbatim · CDSS document, Apr 17, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a)(5) · Plan of correction due date: May 1, 2026

87208(a)(5) Plan of Operation…(a)The licensee shall have and maintain a current, written definitive plan of operation for the facility…. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval……..(5) Staffing plan, qualifications and duties. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. The licensee did not submit new staffing plan to community care licensing. Which poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 17, 2026

Plan of correction: Licensee will submit any significant changes in the plan of operation to LPA by POC due date. Licensee will submit updated plan of staffing, qualifications and duties to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(i)(1) · Plan of correction due date: May 1, 2026

87303(i)(1) Maintence and operation...Facilities shall have signal system. This requirement is not met as evidenced by: Based on observation, in house 1 there is not a call system in place, which poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 17, 2026

Plan of correction: Licensee will get pendants and/or bed alarms for all residents in house 1 by POC due date. Licensee will submit a permanent plan for a call system for house 1, to LPA by POC due date..... Once permanent plan for call system for house 1 has been submitted to LPA, licensing will need to approve and submit back to licensee for implementation.

Allegation investigated: Facility did not ensure that there is adequate staffing to meet the needs of the residents in care.

On 04/03/2026, Licensing program analyst (LPA) Marisa Chiarelli, arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 03/09/2026. LPA Chiarelli met with administrator Michael Lang, and explained the purpose of the visit. During the interview process, three staff persons were interviewed and the following documents were received and reviewed: staff schedules, LIC 500, staff rosters and incident reports. Continued on 9099-C (Page 1) Substantiated Shifts for caregivers and Med techs are as follows: AM – 6am – 230pm PM – 2pm – 1030pm NOC – 10pm – 630pm During record review, it was revealed on the staff schedules provided by management at Sierra Oaks and staff that for house 2 at Sierra Oaks of Redding there were only these staff persons working, listed below: March 1st – for PM shift only one staff person, one staff person for NOC shift, and only one staff person for AM shift. March 8th – one staff person for AM shift, two staff person for PM shift, two person for NOC shift. March 15th – one staff person for PM shift, and one caregiver and med tech for NOC shift, no staff persons for AM shift were scheduled for that day. Later on, in the investigation LPA Chiarelli confirmed updated schedule that NOC shift stayed later than scheduled to help in the AM. March 22nd – one staff person for AM shift, one staff person for PM shift, and two staff persons for NOC shift. During LPA Chiarelli’s investigation three staff persons were interviewed. It was revealed and was confirmed by all staff interviewed that staff were being put on the schedule twice to show they were working in multiple houses. Staff persons who were listed twice on the schedule only worked one house not two like the schedule stated. This evidence showed that there was in fact not as many people working in multiple houses as per stated by original schedule given to LPA Chiarelli by administrator Lang when they visited the facility on 3/18/2026. Updated schedule was given to LPA Chiarelli by staff persons. Continued 9099-C (page 2) During an interview with staff one S1 stated they have been left alone with residents and were expected to work double shifts even though that was not agreed upon when they started in their position. Staff person two and three (S2 and S3) said they have also been left alone with residents and were expected to work doubles due to staffing shortage. S3 reported that they were assigned to one house and were moved to another house by management to help other staff but this meant leaving other staff alone with residents. S3 stated “When I am left alone, I cannot give residents showers because there is no one to help me do it. There are not enough staff to call for help to assist me in doing showers, so weekends showers are not done. We have two residents in house 2 that need two staff to do resident transfers and when I do not have staff to help me, I can only sit them up in bed I cannot transfer them or get them out of bed by myself. I also cannot give medications since I am not trained to give out medications.” S1 also stated: “I am not able to shower them if I am alone because that would mean I would be leaving other residents alone. I cannot do that.” Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed. (Page 3)the state’s words, verbatim · CDSS document, Apr 3, 2026 · control 59-AS-20260309160812

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80065(b) · Plan of correction due date: Apr 17, 2026

80065(b) Personnel Requirements The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs. This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above. The licensee did not employ staff as necessary to ensure the resident care needs are taken care of. Which poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: Licensee shall submit written documentation showing staffing numbers of caregivers and med techs per shift. Licensee will hire more staff. Licensee will submit all documentation to LPA by POC dute date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst K. Hiratsuka, conducted this unannounced case management visit. This visit is a health and safety check in response to four residents who were relocated to this facility yesterday from another facility. LPA observed the four residents today. LPA was able to speak to two of them. LPA toured the resident rooms. LPA was able to speak to a responsible party of one of the residents. LPA did not observe any deficiencies. No deficiencies cited.the state’s words, verbatim · CDSS document, Mar 18, 2026

Type of visit: Required - 1 Year

On 03/18/2026, Licensing Program Analyst (LPA) Marisa Chiarelli, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator Michael Lang and explained the purpose of the visit. Facility consists of three buildings. Two buildings (building 1 and 2) have locked gates (facility has waivers for locked gates for both buildings). Each building has an integrated fire alarm system and was inspected by City of Redding Fire Department on 6/11/25, copy of inspection reports given to LPA Chiarelli for facility file. Building 3 - LPA Chiarelli and administrator Lang toured building 3 together. Building three tour consisted of residents rooms, common areas, main kitchen, activity room, outdoor premises and common bathrooms. The main kitchen in building 3 supplies all the food for the kitchens in building 1 and 2. All hallways have carbon monoxide detectors and hallways have an integrated fire alarm system. LPA Chiarelli did not observe any immediate health, safety or personal rights violations during tour. Building 2 - LPA Chiarelli and administrator Lang toured building 2 together. Building two tour consisted of residents room, common areas, kitchen, outdoor premises and common bathrooms. Building 2 kitchen had snacks and met title 22 regulation requirements. All hallways have carbon monoxide detectors and hallways have an integrated fire alarm system. LPA Chiarelli did not observe any immediate health, safety or personal rights violations during tour. Building 1 - LPA Chiarelli and administrator Lang toured building 1 together. Building one tour consisted of residents room, common areas, kitchen, outdoor premises and common bathroom. All hallways have carbon monoxide detectors and hallways have an integrated fire alarm system. LPA Chiarelli did not observe any immediate health, safety or personal rights violations during tour. LPA reviewed a total of eight (8) residents' files and six (6) staff files which contained all the required documentation. Several topics were discussed. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Mar 18, 2026

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff did not comply with reporting requirements.

On 02/18/2026, Marisa Chiarelli, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 1/06/26. LPA Chiarelli met with Adminstrator Michael Lang, and explained the purpose of the visit. On 2/11/26 community care licensing received a fax that contained incident reports from 1/12/26, 1/16/26, and two incidents reports from 1/17/26. Based on incident reports dates of incident occurring and date it was submitted to CCL, the allegation “staff did not comply with reporting requirements” is Substantiated. Exit interview conducted. Copy of report given to facility. Substantiatedthe state’s words, verbatim · CDSS document, Feb 18, 2026 · control 59-AS-20260106100114

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Mar 18, 2026

87211(a)(1)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Evidenced by On 2/11/26 community care licensing received a fax that contained incident reports from 1/12/26, 1/16/26, and two incidents reports from 1/17/26. Which possess a potential health, safety, personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 18, 2026

Plan of correction: Licensee will have a meeting with all department heads to go over regulations on reporting requirements and will give proof of meeting to LPA by POC due date. Licensee will fax CCL all old incident reports that were not previously sent to CCL by POC due date.

Allegation investigated: Due to staff negligence, resident missed medications. Due to lack of supervision, resident was wedged between the bed/wall in an unsafe situation. Due to staff neglect, resident was left to lye in feces for an extended period of time.

On February 10, 2026 Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 10/10/25. LPA Benson met with Administrator Mike Lang Chief Operating Officer for Lenity Pat Brown and explained the purpose of the visit. During the interview process, staff and witnesses were interviewed. The following documents were received and reviewed: staff schedule, staff list with telephone numbers, MAR, Observation notes, Service Plan and admission agreements. Continued on LIC9099C & LIC9099D Substantiated Due to staff negligence, resident missed medications. The MAR review revealed the C medication was not administered on October first, second and seventh at 12p.m. MAR review revealed that the C medication was on administered on October sixth or ninth at 8p.m. The MAR review also revealed the C medication was not administered on October eight or ninth for 10p.m. shift, with no notations on MAR for missing medications. During the investigation with staff interviews it was reported that medication was not given as the facility had run out of oral syringes. Staff five stated we did run out of oral syringes and I used one from house three, some of the other staff didn’t know to go borrow from house three, so the medication was not given. Staff five stated there were medication technicians that were afraid to give R1 his pain medication, stating that it was too much. Staff four stated when R1’s medication was put in the computer incorrectly and medications were missed because they didn’t show up on his list of medications for R1. Staff four stated there was a few times R1 didn’t receive his medication as I was not trained in how to crush it and put it in a syringe. Record review revealed the facility was out of stock for three of the residents’ medications, one of the medication was out of stock for seven days. Record review revealed multiple medications on multiple days were not recorded as given. Substantiated. Due to lack of supervision, resident was wedged between the bed/wall in an unsafe situation. It was reported that the resident was wedged between the wall and bed moaning in pain with no care staff insight. Staff four stated R1 didn’t like his feet covered and he would kick his feet off the bed trying to get the blankets off of his feet. Staff three S3 stated I heard about that, S3 stated the bed was supposed to be up against the wall and locked. S3 stated the bed wasn’t locked because that is how R1 scooted between the bed and the wall. Staff six stated I’ve seen R1 get wedged more than once, he is trying to get to the chair. Substantiated. Due to staff neglect, resident was left to lye in feces for an extended period of time. It was reported that the resident was found with dried feces and a rash on lower extremities. During the interview process S4 stated I have witnessed poo left on the residents, but not sure if it was R1. S2 stated it should have been recorded in the care note for that day, when R1 was toileted. S3 stated one time I witnessed that R1 was soiled, and I could tell it had been for quite a while. S2 stated yes, I heard about this from another staff, saying family complained and we need to check R1 every hour or two. S4 stated hospice residents should be checked every 30 minutes when they are at end of life. S7 stated I would come to work in the morning and R1 was soiled with feces was dried on, R1’s sheets would be soaked and the place smelled. S7 stated it happened numerous times and I reported it to my supervisor. The residents care plan states R1 is incontinent of bowels and needs to be checked throughout the shift for any bowel movements. LPA was unable to perform record reviews for BMs as the facility is unable to provide the BM records. Substantiated. Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.the state’s words, verbatim · CDSS document, Feb 10, 2026 · control 59-AS-20251010084933

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 10, 2026

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation, interviews and record review, the licensee did not ensure the resident was assisted with medications. Which : poses an immediate Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 10, 2026

Plan of correction: Administrator will have a medication training with staff. Administrator will notify LPA with a copy of staff training sign in.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 10, 2026

87468.1(a)(2)(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation, interviews and record review, the licensee did not ensure the residents have safe, healthful and comfortable accommodations as the resident was wedged between the bed and wall for an unknow amount of time. Which poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 10, 2026

Plan of correction: Administrator will have a training with staff concerning the safety of accommodations for the residents. Administrator will have a training with staff concerning what is required for care notes. Administrator will notify LPA with a copy of training sign in.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Mar 10, 2026

87625(b)(3) Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: the resident was found soiled. Which poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 10, 2026

Plan of correction: Administrator will have a staff training concerning the importance of keeping residents clean and dry. Administrator will notify LPA with a copy of training sign in when completed.

Allegation investigated: Facility is making false claims with falsifying staff schedule. (Unsubstantiated)

On January 30 2026 at 9:30 a.m., Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 09/29/25. LPA Benson met with Community Relations Director Jennifer Campbell, and explained the purpose of the visit. During the interview process, interviews were performed and files were reviewed. The following documents were received and reviewed: staff list with telephone numbers, staff schedule, employee absence form, and a resident roster. Continued on 9099C Unsubstantiated Facility is making false claims with falsifying staff schedule. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. Staff stated management makes the schedule online and it shows there is a full staff with no correction to the schedule when call outs happen. It was reported that one staff was out on leave and they were still on the schedule a month later. During the investigation process, most of the people interviewed reported there has been a history with the staff schedule not being updated to reflect when the facility is short staffed. Document review of employee absence form revealed several days a week with sick calls or no shows. It was reported staff are falsifying the schedule, although the schedule is not being updated when call outs happen causing the schedule to not be current. Although the calendar is not updated there is insufficient evidence showing falsifying. Although the above allegations mentioned may have happened, or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, the findings are Unsubstantiated.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 59-AS-20250929085428

Allegation investigated: Facility does not have enough staffing to meet residents needs. (substantiated)

On January 30 2026 at 9:30 a.m., Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 09/29/25. LPA Benson met with Community Relations Director Jennifer Campbell and explained the purpose of the visit. During the interview process, interviews were performed and files were reviewed. The following documents were received and reviewed: staff list with telephone numbers, staff schedule, employee absence form, and a resident roster. Continued on 9099C & 9099D Substantiated Facility does not have enough staffing to meet residents needs. During the interview process, staff stated when a care staff finds out they are by themselves, no showers, no laundry, no two person transferring, no toileting and the facility smells from the unchanged residents when the a.m. shift comes in. It was reported the one-hour checks are not getting done when we have call outs. Staff stated I have to skip showers and laundry when we have sick calls. Staff stated I had one care giver for morning shift, for 3 days in a row, one care staff for 40 residents. Staff stated its usually during the weekends when we get staff calling off with no back up. Staff stated the residents are not changed in time, the two-hour resident checks are not completed, when two people assist is needed we can’t shower some residents. Staff stated we cannot put eyes on all of the residents in a timely manner. Document review revealed several days a week with sick calls or no shows. Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 59-AS-20250929085428

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80065(b) · Plan of correction due date: Feb 28, 2026

80065 (b) Personnel Requirements The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs. This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above. The licensee did not employ staff as necessary to ensure the resident care needs are taken care of. Which poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: The Licensee trained the staff for softwear to keep schedule currant with call outs. The Licensee is hiring more staff. The licensee has created a system for extra pay when staff cover a sick call. The Licensee will contact LPA when complete.

Allegation investigated: Facility is understaffed resulting in residents waiting for a period of time to be assisted. - UNSUBSTANTIATED

/15/2025 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a complaint investigation. LPA met with Executive Director Jacob Stevens and explained the purpose of the visit. LPA interviewed the Executive Director during the visit. LPA requested copies of the following documents: Staffing schedule for August 2025. Continued on LIC9099-C Unsubstantiated Facility is understaffed resulting in residents waiting for a period of time to be assisted. - UNSUBSTANTIATED It was reported that one staff was attending to 120 residents by themselves, which resulted in residents waiting more than an hour to be assisted. LPA reviewed staff schedule for August 2025 and found staffing to be adequate. There was never only one staff on duty. Executive Director stated that the current census is 80 residents. The number of staff on duty for the AM shift is 1 med tech and two care givers in each house for a total of 9 staff. PM shift is the same with 1 less staff in house 1. NOC has a total of seven staff for all three houses. The average wait time for staff to answer a call light is 12 minutes. It was determined that the facility had adequate staffing for the month of August 2025, and residents are not waiting an unreasonable amount of time for staff to answer call lights. This allegation is unsubstantiated. This agency has investigated the above allegation. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator Jacob Stevens.the state’s words, verbatim · CDSS document, Sep 15, 2025 · control 59-AS-20250910121441

Type of visit: Case Management - Incident

On 7-17-25 Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a case management visit. LPA met with Administrator Jacob Stevens and Nurse Susan Mosby and explained the reason for the visit. The department followed up on Incident Report (IR) sent by facility on 06-17-25 stating that resident, R1 had a fractured right femur which was diagnosed on 06/16/25. Staff reported finding R1 on the ground at 5:45am on 6-16-25 in front of recliner. Staff assisted R1 back into recliner. Staff reported that R1 spent most of the day in room in recliner. Staff reported they were unable to assist R1 out of recliner as R1 because of R1’s pain. Staff reported at 15:15 on 6-16-25 finding R1 on the ground in front of recliner again. Staff reassessed R1 at 3:30pm. Staff reported sending R1 to the hospital. R1's doctor ordered lab work and X-RAY with results of fractured right femur. Department conducted interviews with the administrator and Nurse director regarding this incident. At this time, this case is under review and the department will do follow up as needed. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Jul 17, 2025

Type of visit: Required - 1 Year

April 25, 2025 10:00 AM Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Kristine Boban, Administrator, and explained the purpose of the visit. LPA Adkison and Administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to five (5) resident rooms, common areas, six (6) bathrooms, kitchen, laundry room, activity areas and exterior courtyards. In the areas toured no immediate health, safety, or personal rights violations were observed. Five (5) staff and five (5) resident files were reviewed. Medications were reviewed and observed to be kept in a locked room out of reach from residents. The common area was clean, odor-free and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were all clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguishers were last serviced in March, 2025. Smoke detectors are all operational and were tested April, 2025. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities planned for the clients. All required postings are displayed within the facility. The facility is in compliance. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report was provided to administrator.the state’s words, verbatim · CDSS document, Apr 25, 2025

Type of visit: Case Management - Incident

On January 23, 2025 at approximately 01:30 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Sierra Oaks of Redding for the purpose of conducting a Case Management-Incident inspection. LPA met with Administrator, Kristine Boban, and was granted access into the facility. During the Case Management-Incident inspection, LPA and Administrator reviewed the incident report dated for December 16, 2024 and observed that the facility was not late in reporting but just made an error (See LIC 9102-Technical Assistance). LPA educated the Administrator on ensuring that the facility is reporting incidents in a concise fashion as outlined in Title 22 regulations. LPA toured the facility and made observations. No deficiencies were cited during today's Case Management-Incident Inspection. Exit interview was conducted and a copy of this report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Jan 23, 2025

Type of visit: Case Management - Incident

On September 24, 2024 at approximately 11:45 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Sierra Oaks of Redding for the purpose of conducting a Case Management-Incident Inspection. LPA was greeted at the door by Administrator, Kristine Boban, and was granted access into the facility. On September 16, 2024, an incident report was forwarded to the California Department of Social Services-Community Care Licensing Division reflecting a Medication Error that occurred. Administrator reported that the Caregiver gave the wrong medication to a resident. Administrator reported no adverse reactions. Responsible Party and the Physician were notified (See LIC 9102-Technical Violation). LPA educated the Administrator on the importance of ensuring that ALL residents are being given the correct medications and dosages. As of right now, the Caregiver is no longer passing medication and is in training. LPA toured the facility with the Administrator and made observations. No deficiencies were cited during today's Case Management-Incident Inspection . Exit interview was conducted and a copy of this report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Sep 24, 2024

Allegation investigated: Staff are not mitigating the spread of scabies in the facility.

On 06/18/24 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 04/03/24. LPA Gurriere met with Annie Clayton, Resident Care Director and explained the purpose of the visit. Staff are not mitigating the spread of scabies in the facility. During the interview process, the administrator was interviewed, and she provided numerous documents regarding various diagnoses of the residents. It was reported that approximately 15 residents and three staff persons at the facility developed a type of rash. Diagnoses included dermatitis, rash, and eczema in which the physicians prescribed various types of cream, medication, and showering treatment. Clothing and bedding were sanitized throughout the facility. Two residents and a resident’s family member were diagnosed with scabies, which can spread with people you have contact with. Substantiated Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.the state’s words, verbatim · CDSS document, Jun 18, 2024 · control 59-AS-20240403101714

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 25, 2024

Personal Rights - To be accorded safe, healthful, and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by the spread of scabies in the facility. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2024

Plan of correction: The administrator agrees to submit a plan of correction to the licensing agency describing how this type of violation will be corrected.

Type of visit: Required - 1 Year

On 03/12/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Kristine Boban and explained the purpose of the visit. LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, activity rooms, medication rooms, laundry rooms and common restrooms. LPA observed the facility to be clean, and odor-free. LPA observed each bathroom to have the necessary, no non-skid flooring, grab bars and/or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. LPA observed two of bathrooms have damage. LPA observed each resident bedrooms to have the required furnishings, working lights and windows with screens. LPA observed the activity rooms to be fully equip with the a plethora of supplies for the scheduled activities. LPA observed the medication room to be clean and organized, locked and inaccessible to residents in care. LPA observed the first aid kit to be completed and ready for use. LPA measured the water in several locations throughout the facility which was within the regulation range. LPA observed the laundry room to be locked which leaves the toxic chemicals inaccessible to residents. Facility has a 2-day perishable and a 7-day non-perishable amount of food. The facility had a variety of food to offer the residents. The kitchen was clean and organized. LPA observed several fire extinguishers, fire detectors, and carbon monoxide detectors thought out the facility. LPA reviewed a total of seven (5) residents' files and five (6) staff files which contained all the required documentation. Several topics were discussed. As a result of this visit, deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of this report, 809D, and appeals rights given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Mar 12, 2024

Allegation investigated: Resident sustained an injury from another resident while in care.

On 01/03/24 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 11/16/23. LPA Gurriere met with Kristine Boban, Administrator, and explained the purpose of the visit. Resident sustained an injury from another resident while in care. During the interview process, eight staff persons were interviewed. The residents were not interviewed, due to their dementia status. Documents were received and reviewed to include Physician’s Reports, Admission Agreements, Incident Reports and Medications Lists. Substantiated During the investigation, it was reported that on 10/19/23, a staff person was “shadow boxing” (pretend fighting) with Resident 1. Resident 1 then went to Resident 2 and hit him in the face. Resident 2 fell backwards and sustained an abrasion to the back of his head. Staff heard the altercation and went to the residents and separated them. Staff called emergency services and Resident 2 was sent to the hospital. While at the hospital, the resident’s abrasion was addressed and within a few hours he was sent back to the facility. The staff person that was shadow boxing was terminated from her position. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.the state’s words, verbatim · CDSS document, Jan 3, 2024 · control 59-AS-20231116090319

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.2(c) · Plan of correction due date: Jan 4, 2024

"Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement was not met as evidenced by: Based on interviews of staff persons and records reviewed, the licensee did not ensure that the resident was protected from an injury.the state’s words, verbatim · CDSS document, Jan 3, 2024

Plan of correction: The administrator agrees to provide training to staff persons regarding the facility’s protocol of caring for a dementia resident, which shall include appropriate staff interactions with the residents. Administrator shall submit names of staff persons trained and training material to the licensing agency by 01/04/24.

Allegation investigated: Staff did not report incident to responsible party

LPA Hiratsuka conducted this visit to deliver the results of the investigation above. LPA met with During the investigation the executive director, staff, and witnesses interviewed. Medical records and facility records were reviewed. Administrator admitted they did not notify the responsible party of R1 that R1 had a fall on April 4, 2023. Based on the evidence obtained, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. The following deficiency was cited per CA Code of Regulations Title 22- refer to the 9099-D. Exit interview completed and copy of report emailed to Admin. Substantiated Witness also stated R1 was not taken to activities by staff. Staff stated the R1 attended activities when R1 wanted to. Facility notes state the R1 stayed in bed a lot. Title 22 regulations does not allow for staff to force residents to participate in activities. Witness also stated they found R1 soiled each time witness visited R1. Staff stated R1 was checked on a regular basis. LPA was unable to interview R1. Due to the information gathered, LPA cannot determine the allegations: Staff not following resident care plan and Staff do not meet resident's dietary needs. LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Medical records obtained did not mention pressure injuries. LPA interviewed responsible party of R1 and the responsible party stated there were no pressure injuries treated while R1 was at the facility 2. Staff interviews stated R1 did not show any signs of trauma after a fall at the facility nor did R1 have any pressure injuries. LPA obtained a copy of medical records from two different locations, and both stated the resident had a chronic injury and did not mention any pressure injury. The medical records also stated resident did not show any sign of discomfort and had full range of motion of and wrist. This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Dec 6, 2023 · control 59-AS-20230417091208

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jan 5, 2024

Reporting Requirements - Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: 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 ... This report shall include the resident's name ,...; and disposition of the case. Based on record review, the licensee did not comply with the section cited above because staff admitted they didn't notifiy responsible party of a fall, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 6, 2023

Plan of correction: By 01/05/2024, Licensee shall submit a written plan of correction on how they shall ensure staff shall notify resident responsible parties when an incident occurs.