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Licensing Program Analyst (LPA) Magdaleno arrived unannounced to initiate a 10-day complaint investigation and deliver findings regarding the above allegation and met with Tava Setareki, Business Office Director Specialist (BODS). Staff did not dispose of residents records properly – Reporting Party (RP) alleges that facility did not dispose of confidential resident documentation in a secured manner. During the course of this investigation LPA reviewed records, made observations, and conducted interviews. Review of photographs submitted by RP indicated that the confidential documents of multiple residents were disposed of in standard waste containers without maintaining resident confidentiality. Further review of photographs indicated that these waste containers were dumpsters. LPA located and observed that facility dumpsters are located outside of the facility in unlocked sheds. The dumpsters themselves were similarly unlocked. Continued LIC9099C... SubstantiatedRead the full finding— CDSS inspection report, October 16, 2025 · control 21-AS-20251008092313

At approximately 09:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this faciity unannounced to conduct an investigation into the above allegations. LPA met with Activity Director Tamia Lindsay, toured the building, interviewed staff and reviewed records. Based on interviews conducted, LPA was not able to find evidence that staff did not assist resident in a timely manner. The facility call system is designed to log each call with time of activation, location and response time, however the system is not fully operational and does not log any details. The call system alerts staff in the medication room, who then relay the location and resident to the caregivers by text. LPA was informed that when staff leave the medication room, the medication technicians take turns returning every five minutes to check the call system. This occurs on all shift. Facility is undergoing a leadership change and the call system is in the process of repair or replacement. During the course ofRead the full finding— CDSS inspection report, September 22, 2025 · control 21-AS-20250909084115

At approximately 12:30PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegation. LPA met with Care Coordinator Tamara Mason, interviewed staff and toured the building. Based on interviews conducted, a staff member was reported to have been caught sleeping in a resident room in May, 2025. Staff was reprimanded and later quit employment at the facility. Facility does not allow staff to use resident rooms for their breaks or getting extra sleep. Based on interviews conducted, facility has a beauty salon for resident use. Staff do not get their hair worked on while working at the facility. LPA was not able to find evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. UnsubstantiatedRead the full finding— CDSS inspection report, August 11, 2025 · control 21-AS-20250729095017

At approximately 10:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to open an investigation into the above allegation. LPA met with Executive Director Jasmine Seiffert and reviewed records. Based on records reviewed and interviews conducted, Resident (R1) was issued an eviction notice on 06/19/2025 for refusing care and being aggressive. LPA reviewed R1's care plan and observed facility has been making updates as needed per regulation. Based on records reviewed, R1 has been refusing care and not allowing staff into their room. Facility has taken action to ensure the well-being of R1 by issuing a 30 day eviction. Facility staff have continued to attempt to provide care for R1 when they allow it. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. UnsubstantiatedRead the full finding— CDSS inspection report, July 29, 2025 · control 21-AS-20250722102044

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegations and met with Administrator, Jasmine Seiffert. During this investigation LPA made observations, conducted interviews, and reviewed records. Residents room is not clean and sanitary – Complainant alleges that upon entry to Resident (R1) room “we were met with a smell or urine and other bodily fluids that smelt like they have been lingering for a while. On top of that there was trash all over the floor, no beds were made, there was trash and dirty dishes in the sink that looked like they have been there for a while”. During this investigation LPA made observations, conducted interviews, and reviewed records. R1 room was observed to be as described above with a strong smell of urine throughout. Interviews with staff indicate that R1 has continuously refused housekeeping services. Continued LIC9099C... UnsubstantiatedRead the full finding— CDSS inspection report, July 2, 2025 · control 21-AS-20250630103354

Licensing Program Analyst (LPA) Canela arrived unannounced for the purpose of getting additional information and delivering findings to the above allegation. LPA met with Jasmine Seiffert, Executive Director. In the course of the investigation LPA reviewed records, made observations and took statements. It was alleged facility staff did not provide adequate supervision to resident in care resulting in multiple falls. LPA reviewed resident R1s file and the following was noted. R1 moved in to the facility on 8/27/2024. R1s facility service plan with R1s husband, identified R1 requiring moderate assistance with bathing, dressing, grooming and no assistance with mobility, transfers to/from bed/chair, meals; full assistance with medication and although identified as independent for mobility, R1 required escort to meals and activities. It was noted on 8/30-8/31/2024 R1 was refusing to eat, agitated and aggressive towards staff, R1s husband went to facility and picked up R1 to stay at home anRead the full finding— CDSS inspection report, March 10, 2025 · control 21-AS-20241029133104

Licensing Program Analyst (LPA) Canela arrived unannounced for the purpose of gathering additional information and delivering findings to the above allegations and met with Jasmine Seiffert, Executive Director. In the course of the investigation LPA reviewed records, made observations and took statements. It was alleged staff do not respond to call bells in a timely manner in that it has been taking about one hour to respond when residents use their pull cord for assistance. Facility was not able to pull older call records because of their system but provided records for the week LPA requested for review. Pull cord records for resident R1 showed, 14 calls were answered under 2 minutes, 11 calls were answered under 5 minutes and 14 calls were answered under 10 minutes, for the one week review. LPA did observe the facility was also answering the majority of other resident calls under 10 minutes and only 3 calls were answered 15-17 minutes, but no documentation of calls answered upto an hRead the full finding— CDSS inspection report, January 17, 2025 · control 21-AS-20241003101824

Licensing Program Analyst (LPA) Canela arrived unannounced for the purpose of continuing investigation and delivering findings to the above allegations and met with Jasmine Seiffert, Executive Director. In the course of the investigation, LPA toured facility, some resident bedrooms; obtained documents, and took statements. It was alleged Neglect/lack of supervision resulting in resident's care needs not being met and facility not kept clean and sanitary. More specifically, it was reported that R1 was found with feces all over foot & shoe; bathroom and bedding was soaked in urine. On a previous visit LPA observed resident (R1) bedroom had a very strong urine odor, the carpet had several large stains and R1's bathroom wall had a tiny smear of feces. Continue report see LIC9099-C SubstantiatedRead the full finding— CDSS inspection report, September 27, 2024 · control 21-AS-20240502095016

Licensing Program Analyst (LPA) Canela arrived unannounced for the purpose of delivering findings to the above allegations and met with Jasmine Seiffert, Executive Director. In the course of the investigation, LPA toured facility, kitchen, dining area, some resident bedrooms; obtained documents, and took statements. It was alleged that lack of care/supervision resulting in residents going AWOL. Investigation revealed the facility had placed several residents in Assisted Living (AL) bedrooms who due to their diagnoses of dementia, should have been placed in the facilities secured Memory Care unit area. Due to resident R2 and R3 not having the proper supervision or safety measures for individuals with Dementia in AL, residents R2 & R3 walked out of the facility with no supervision. It was also alleged the facility was not kept free of pests, in that mice were observed in a residents bedroom. Facility disclosed they did have an issue and as soon as they had information a mouse was observeRead the full finding— CDSS inspection report, July 23, 2024 · control 21-AS-20240129091633

Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. This investigation consisted of site visits to facility, taking statements from staff and witnesses, review of pertinent documents. The following determinations are made: Complainant alleges that R1 was exhibiting unusual behaviors on or about 10/23/2023 and that the POA for R1 and the facility staff refused to seek medical care for R1 and that R1 had a dangerously high blood pressure; Staff state that R1 refuted Complainant's claims and had a blood pressure reading that was average for R1; Blood pressure logs confirm staff statements; Chart notes indicates that R1 exhibited "confused" behavior that day which appears to be a pattern of behavior that is documented on other days in the chart; Paramedics were called and R1 was taken to medical facility and released the same day back to the facility; After visit summary report indicates R1 was evaluated for cognitive issues and mRead the full finding— CDSS inspection report, January 18, 2024 · control 21-AS-20240108143927

Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. LPA met with Administrator and discussed the disposition. During the course of this investigation statements were taken from staff and witnesses and documents were obtained and reviewed. The relative who has Power of Attorney for R1 has instructed facility staff to notify the POA in the event a visitor seeks to take R1 off the facility premises; There was a miscommunication during a recent incident involving R1 and a visitor who sought to take R1 outside while remaining on facility premises; Staff assumed that visitor was seeking to take R1 of the premises and advised visitor that the POA would need to be contacted; This resulted in the lodging of the complaint allegation; Subsequent statements from the Complainant confirms the miscommunication and complaint were result of misunderstanding and are not accurate. Based upon the statements, the allegation is UNFOUNDED, meaning tRead the full finding— CDSS inspection report, August 3, 2023 · control 21-AS-20230719125002

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Administrator and discussed the disposition. During the course of this investigation statements were taken from staff and witnesses, documents were obtained and reviewed, and five site visits made to the facility. The following determinations are made: Complainant alleges staff have left R1 in wheelchair all day which has caused R1's legs to swell; Memory Care Coordinator states R1 has lost mobility since placement in May of 2023 and that staff have encouraged R1 to engage in activities and to allow staff to elevate R1's legs; Home Health care was initiated in June of 2023 and has recommended that R1 lay down for several hours after meals to reduce stress on a pressure injury; Staff have satisfactorily complied with Home Health recommendations. Both Home Health personnel and R1's Power of Attorney Person have stated they believe that R1 is receiving appropriate cRead the full finding— CDSS inspection report, August 3, 2023 · control 21-AS-20230531082558

This complaint has been investigated through multiple site visits, statements from witnesses, and review of pertinent documents. Today, Licensing Program Analyst Leibert arrives unannounced and meets with the Administrator to discuss the findings: R1's care plan requires weekly bathing and assistance with grooming; Care notes report an incident when R1 refused to get out of bed; Shower logs fro R1 indicate R1 refused showers on 5/19,5/23,6/2,6/16; LPA Leibert sampled food service on three occasions and found food to be fresh, nourishing and warm or hot; A sampling of call response logs over a 3 day period resulted in most calls answered in less than one minute with one 9 minute response and one 10 minute response; LPA noted the facility to be clean and in good repair during 3 recent unannounced site visits; Facility has no maintenance record of repair to R1's toilet but reports a service call to clean toilet on 5/15. Although the allegations may be true, based on statements, documents,Read the full finding— CDSS inspection report, July 6, 2023 · control 21-AS-20230518170036

Licensing Program Analyst (LPA), A. Canela arrived unannounced, for the purpose of delivering findings to the above complaint listed allegations. Throughout the investigation, LPA toured the inside of this facility, made observations, requested records and gathered statements. It was alleged facility did not provide assistance with resident care needs for Dementia resident R1. It was reported R1 was observed on several occasions with their dentures full of stuck on food particles and their hair unkempt. R1 requires assistance with self care. LPA received corroborating statements not all staff provided assistance with oral care for R1. LPA also received copies of pictures that were taken, identifying the lack of daily assistance for R1. See LIC9099-C for continued report SubstantiatedRead the full finding— CDSS inspection report, February 7, 2023 · control 21-AS-20220914141115