Brookdale Paulin Creek

Allegation investigated: -Facility did not centrally store medications.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Wendy Trigueros, Financial Services Director. Regarding allegations about facility did not centrally store medications. Per Reporting party, on 3/28/2026 the facility was unable to locate 72 vials of morphine and facility staff (S1) contacted resident’s (R1) responsible party to request a call to be made to hospice and order more morphine, but later S1 called and said to cancel the morphine order, they found the vials at the medication room refrigerator. Also, there were concerns about medication management after they learned that antibiotics prescribed to R1 were lost for three days due to an issue with the pharmacy involving R1’s name resulting in R1 missing their prescribed medication to treat an infected wound leading to R1’s hospitalization. Continued on LIC9099C... Substantiated Continued from LIC9099... Based on records review of R1’s medical records provided by the facility, on 3/18/26 R1 was hospitalized and referred to hospice care. According to S1 confirmed that R1 was admitted to hospice on 3/18/26, there were medication changes due to R1’s health condition, on 3/19/26 S1 requested hospice to change the medication to something that R1 could take orally or have hospice to come and administer injections prescribed. On 3/20/26 S1 checked all changes and noticed that the cream had not been changed or addressed, S1 asked RN form hospice case manager if they could change the medication or schedule someone from hospice to come and apply the cream. On 3/21/26 R1’s order was sent into pharmacy for oral medication for infection. Regarding prescribed antibiotics “on hold” for three days, it was determined the issue was due to the pharmacy having wrong R1’s name and waiting on name confirmation from prescribing doctor, but the facility was in constant communication with R1’s responsible parties and R1’s physician attempting to clarify issue with R1’s name error. Regarding morphine medication, on 3/25/26 S1 received a call from their medication technician (Med Tech) stating that the morphine had not come in yet; Med tech told S1 that they called hospice, and they said that refill syringes were sent out. On 3/26/26 S1 spoke to hospice RN – case manager who informed S1 that 79 refilled syringes were sent the night before, which they had been checked in by the front desk. After S1 researched, it was found out that they were logged in and because they needed to be refrigerated the front desk put them in office fridge until someone came to pick up clinical, but clinical was not aware of the medication being dropped off, but all 79 syringes we accounted for and returned to narcotic storage in medication room. S1 ensures that after learning of this incident, the facility has changed the process of how they allow pharmacy to drop off medication, the new process instructs that the medication must be handed to a nurse or medication manager and signed for. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. Continued from LIC9099A... since they were with R1 at the hospital and they were aware of other hospitalization of R1 within that month, R1’s responsible party spent the time when they returned from hospital on getting R1’s admitted to hospice and waiting on medication changes until 3/20/26 when they informed R1’s responsible party that day of medication changes needed. Based on records review and interviews conducted by LPA with pertinent parties, LPA received conflicting information and is unable to determine that R1’s responsible party was not notified by the facility about R1’s change of condition because the facility learned via fax about R1’s change of condition at the same time as the responsible party via telephone of urine culture results from R1’s physician. A finding that the complaint allegation facility did not notify responsible party of resident change in condition is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 21-AS-20260408132257

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jun 5, 2026

Type A 87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement has not been met as evidence by: Based on records review and interviews with facility staff, licensee failed to kept refrigerated narcotics received from the pharmacy in a locked place that is not accessible to residents in care which poses an immediate risk to the health & safety of residents.the state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: Administrator to conduct staff training to ensure that staff know how to properly store centrally stored medication per regulation 87465(h)(2). Administrator to submit date of training to LPA by POC due date of 6/5/26.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Required 1 Year visit and met with Executive Director (ED), Jeff Brenner. Facility has an approved dementia care plan. There are currently 42 residents in Assisted Living area and 29 residents in Memory Care Unit for a total of 71 residents in care. There are eight residents receiving hospice care services within the approved hospice waiver. Required postings were observed. Annual fees are current. LPA/ED toured the facility which included an inspection of assisted living and memory care, all common areas, hallways, and bathrooms observed had sufficient lighting. During the walk through of the two story building including assisted living and memory care, LPA/ED noticed that garbage cans located in resident's bathrooms do not have lids, LPA had a conversation with ED regarding the importance of providing garbage cans with well-fit covers (technical advisory issued). There is a home health room located in the assisted living area. Residents rooms are furnished per regulation. LPA/ED observed the memory care unit is on a delayed egress system, which it was approved in their fire clearance. The memory care area has outdoor entrance that has a door bell that it is accessible to families who gets access to the building through them. There are evacuation chairs located at each stair. The elevators were last inspected on 3/28/25. The facility was a comfortable temperature. Passageways were free of obstructions. Cleaning products are in locked closets or on supervised and/or locked carts. Facility has a sufficient supply of cleaners, hygiene items and paper products. Multiple first aid kits were observed. A call button is located in each bathroom, LPA tested the call system in resident's rooms and staff response time was under two minutes. Continued on LIC 809-C... Continued from LIC809... LPA/ED toured the kitchen area located adjacent to the building located in the independent living building. A tour and inspection of the kitchens and dining areas were found to be clean and sanitary. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. Refrigerators and freezers were at required temperatures. Prepared and left over foods were covered and labeled. Menu includes a wide variety of foods from all of the food groups. A board in the kitchen has written instructions for residents with food allergies and restricted diets. All medications and toxins/cleaners were all locked and inaccessible to residents in care. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. During the tour, residents were observed participating in group activities in common areas. There are activities written on a board specified for both assisted living and memory care engagement. The last fire drill was conducted December 2025. The facility completes fire/emergency drills monthly. The fire alarm and sprinkler system was last inspected September 2025. Fire extinguishers were observed to be last charged on 11/2025. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected September 2025. Water temperatures measured at between 109.2 and 113.4 degrees (F) which is within acceptable range of 105 to 120 degrees F. Bathrooms have non-skid surfaces and grab bars at the toilet and shower areas. - At 10:51 AM, LPA conducted a file review of ten staff and ten residents. Residents receiving hospice services had a care plan that appears to be accurate to services being provided. All residents' care plans seems to have a person-centered approach and they are updated. Medical assessments are current and included a description of any known behavioral expression. All staff have current 1st aid/CPR certificates updated and required training hours complete. Jeff Brenner, administrator certificate 6068069740 expires on 1/17/2026. A records check found that documentation has been submitted and certificate is pending. Medications and medication records were reviewed. ED agrees to submit updated documents by 1/30/26: (LIC500) Personnel Report & Liability Insurance. No deficiencies cited today. Exit interview conducted with ED and copy of report was given.the state’s words, verbatim · CDSS document, Jan 14, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility staff financially abused resident in care.

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 10/20/25, at approximately 4:15pm, and met with Wendy Trigueros, Financial Services Director. LPA requested records on resident, R1. Wendy Trigueros, notified the LPA that the individual, R1, is not a resident of the facility. R1 is a tenant of the independent living apartment/units, and the licensed facility doesn't provide care services to the independent living tenants/units. The investigation revealed that R1 is not a resident of the residential care for the elderly licensed facility, #496803339; R1 rents an apartment in the independent living area on the property. The Department has no jurisdiction over the independent living units/apartments. Based on interviews, and information obtained during the investigation, the allegation "facility staff financially abused resident in care" is Unfounded. We have found that the complaint allegation was Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Nothe state’s words, verbatim · CDSS document, Oct 20, 2025 · control 21-AS-20251014200856

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alvisoa conducted a case management inspection and met with Administrator Jeffrey Brenner. The purpose of today's case management is to follow up on resident incident, and a suspected abuse report that was recently submitted by the facility. LPA requested R1's records, and staff records. LPA obtained requested copies. LPA obtained additional information regarding the incident/suspected abuse report. There are no deficiencies cited during today's inspection.the state’s words, verbatim · CDSS document, Sep 16, 2025

Allegation investigated: Facility is in disrepair-Elevator doesn't work, and the large dining room has leaks

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 6/17/25 at approximately 1:30pm, and met with Executive Director Associate Viola Kaake. Reporting party alleges that "facility elevator in independent living (IL) doesn't work, and the large dining room in independent living (IL) area has leaks ". LPA conducted interviews with staff, S1 and S2, and other related parties. The investigation revealed that the licensed assisted living area has no leaks in the hallways and/or in the dining room areas. LPA obtained information that the elevator has been repaired in IL, and there is a second elevator on the floorfor use as well. The independent living dining room has no leaks, but is scheduled for roof renovations needed from leaks that occurred during the rainy season. The independent living areas are not part of the licensed assisted living portion of the facility property. The Department has no jurisdiction over the "independent living" portion of the large building. Based on interviews, LPA's observations, and information obtained during the investigation, the allegations "facility elevator doesn't work, and the large dining room has leaks" are Unfounded. We have found that the complaint allegation(s) were Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Nothe state’s words, verbatim · CDSS document, Jun 17, 2025 · control 21-AS-20250610100922

Allegation investigated: Facility ceilings in the dining room are in disrepair

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 2/13/25 at approximately 9:45am, and met with Administrator Robert Alvarado. Reporting party alleges that "facility ceilings in the dining room are in disrepair". LPA toured the assisted living facility, and toured the large dining room area in the independent living portion of the building. LPA conducted interviews with staff, S1, and other related parties. The investigation revealed that the licensed assisted living area has a total of three (3) dining rooms, two of these are in the memory care area. LPA observed that none of these, three (3), dining rooms had leaks and/or openings in the ceilings. LPA observed that the large independent dining room has openings in the ceilings, and has leaks that can't be repaired till the rain stops, per interviews with staff, S1. The independent living dining room is not part of the licensed assisted living portion of the facility. The Department has no jurisdiction over the independent living dining room and/or independent living areas of the building. Based on interviews, LPA's observations, and information obtained during the investigation, the allegation "facility ceilings in the dining room are in disrepair" is Unfounded. We have found that the complaint allegation(s) was Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Nothe state’s words, verbatim · CDSS document, Feb 13, 2025 · control 21-AS-20250205085245

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alvisoa conducted a case management inspection and met with Robert Alvarado, Administrator. The purpose of today's case management was to follow up on a facility self reported resident incidents regarding medication errors. In review of records, R1 and R2 both had medication error incidents occur. Per review of records, the medication staff had in-service training on medication policies in regards to medication assistance to residents in care. Information obtained support that a violation had occurred regarding both resident incidents. This deficiency will be cited, 87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed, see LIC809D. Deficiencies cited from the California Code of Regulations, Title 22 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator Robert Alvarado. Appeal rights provided.the state’s words, verbatim · CDSS document, Feb 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 14, 2025

87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed, This requirement was not met as evidenced by: In review of records, R1 and R2 both had medication error incidents occur. Per review of records, the medication staff had in-service training on medication policies in regards to medication assistance to residents in care. Information obtained support that a violation had occurred regarding both resident incidents. This is a risk to residents health &safety.the state’s words, verbatim · CDSS document, Feb 13, 2025

Plan of correction: POC CLEARED- LICENSEE/ADMINISTRATOR HELD AN IN-SERVICE MEDICATION POLICIES TRAINING WITH MEDICATION STAFF. ADMINISTRATOR PROVIDED COPIES TO THE LPA.

Type of visit: Required - 1 Year

At approximately 8:45 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and met with Executive Director (ED), Robert Alvarado. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Fire clearance is approved for one hundred (100) non-ambulatory, of which twenty (20) may be bedridden. There is an approved hospice waiver for eighteen (18) residents. There is a large independent living population that rents apartment units on the property, these are not part of the Residential Care for the Elderly (RCFE) license. The facility has an emergency disaster plan as required. The facility has a required infection control plan. Upon arrival, LPA was informed that there were 45 residents in Assisted Living and 25 residents in Memory Care for a total of 70 residents in care. LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. At 10:10 AM LPA toured the facility with ED Robert Alvarado. The facility was observed to be clean, orderly, and at a comfortable temperature during today's visit. All common areas, hallways, and bathrooms observed by the LPA had sufficient lighting. Bathrooms observed had grab bars, and non-slip mat/flooring for bathing/showering as needed. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility offers a variety of menu options for the residents at each meal. Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products. All toxins/cleaners were locked and inaccessible to residents in care. Hot water temperatures for a sample size of 9 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. The call system was tested in two (2) resident's rooms and Caregiver response time was under one (1) minute for both instances. Continued on 809-C... ...Continued from 809 Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected 12/31/2024. Fire Department inspection was completed on 1/7/2025. There were no violations noted. All exits were observed to be unobstructed. All fire extinguishers were last serviced and tagged on 10/8/2024. The last fire drill was conducted on 12/15/2024. The facility completes fire/emergency drills monthly. At 11:45 AM, LPA conducted a sample file review of ten (10) staff members. All staff members had appropriate documentation, proof of training and current 1st Aid and CPR certification on file. LPA also conducted a sample file review for ten (10) residents. Upon review, LPA observed residents to have appropriate documentation on file including current Service Plans and Physician's Reports. All medications were locked and inaccessible to residents in care. LPA conducted a spot check of 4 memory care residents’ medications and observed all documentation and medications to be in order. During the tour, residents were observed interacting with staff in common spaces, resting in their private bedrooms, participating in various activities with Activities Director and mingling in the dining hall and common areas with family and amongst each other. Residents interact with one another in the dining area, common spaces as well as in resident private apartments. The facility provides an eclectic range of activities specified for both assisted living and memory care engagement. There is a hair/beauty salon which is open 4 days a week. There is a small vineyard and vegetable garden where residents grow grapes and various flora. Administrator/Executive Director, Robert Alvarado Administrator Certification #7017266740 is pending renewal. Application received on 8/14/2024. LPA is requesting the following documents submitted to CCLD by 2/27/2025: LIC500 - Personnel Report Copy of Current Liability Insurance No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to ED Robert Alvarado. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 29, 2025

Allegation investigated: Staff do not provide adequate activities for residents

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 4/24/24, at approximately 2:10pm, and met with Robert Alvarado Administrator/Executive Director. LPA reviewed facility records, and interviewed staff and other related parties regarding the allegation. Reporting party alleges that "staff do not provide adequate activities for residents". LPA reviewed the activity calendars for the memory care unit, for December 2023, and January 2024. LPA requested documentation showing which activities were actually held in memory care back in December 2023, and January 2024. Administrator was not able to provide completed records of activities that were actually held, provided daily to residents, in the memory care unit. The Administrator notified the LPA on 1/23/24 that there was not an activity director working at this time, and they have been trying to hire someone for the position. The caregivers in memory care have been helping when able to provide some activities to the memory care residents. Continued on LIC9099C.. Substantiated The LPA reviewed information obtained from an Agency that while on site at the facility 12/12/23, they were not doing the posted activities. They were told they were hiring someone to oversee the activities in memory care. Currently there is an activity program coordinator hired as of 1/31/24. The new activity program coordinator will be documenting all activities held daily, and documenting any changes to the activities scheduled, including posting the changes to keep all residents, and others updated as required. The Activity Program Coordinator provided copies to the LPA of how activities are being documented. Based on LPA interviews, and review of records, and information obtained, the facility had no supportive documentation to show which activities were being held and/or not being held; The facility didn't have a staff hired as the Activity Director, who was the dedicated staff person in charge of the facility's resident activity program only. The memory care unit had no accurate activity records and/or updates of the activity calendar. The investigation has revealed that the allegation of "staff do not provide adequate activities for residents " in the memory care unit, has been Substantiated. Due to the substantiation of the allegation, a citation, Planned Activities 87219(a)(f), will be cited today-see LIC9099D. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Exit interview held with the Administrator Robert Alvarado. Appeal Rights provided.the state’s words, verbatim · CDSS document, Apr 24, 2024 · control 21-AS-20240119140417

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a)(f) · Plan of correction due date: May 3, 2024

87219 (a)(f) Planned Activities- In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. The program of activities shall be written, planned in advance, kept up-to-date, and made available to all residents. This requirement was not met as evidenced by: Based on LPA's investigation, the facility had no supportive documentation to show which activities were being held and/or not being held; The facility didn't have a staff hired as the Activity Director, who was the dedicated staff person in charge of the facility's resident activity program only. The memory care unit had no accurate activity records and/or updates of the activity calendar. This is a personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2024

Plan of correction: POC CLEARED- Administrator has hired an Activity Program Coordinator as of 1/31/24; The Activity Program Coordinator is documenting daily activities held. The calendar is being kept up-to-date when activities are changed for any reason, these are posted up for residents/for all others. Activities are being held regularly in the memory care unit at this time. Activity records are being maintained as needed. Documentation, and written plan of correction was provided. POC is cleared 4/24/24.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a Case Management inspection and met with Administrator Robert Alvarado. This case management is being conducted to obtain more information on a resident incident recently reported to the Department by the facility. LPA reviewed resident (R1) incident records. Administrator provided additional information to the LPA. No deficiencies cited today.the state’s words, verbatim · CDSS document, Apr 24, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst(LPA) Alviso conducted a continued annual inspection, on 1/9/24 at approximately 2:45pm, and met Administrator Robert Alvarado. Facility has an approved dementia plan of operation. There is an approved hospice waiver for eighteen (18) residents. Fire clearance is approved for one hundred (100) non-ambulatory, of which twenty (20) may be bedridden. The facility has an emergency disaster plan as required. The facility has a required infection control plan. LPA reviewed ten (10) resident files. Records were complete. LPA reviewed ten (10) staff records. All staff have criminal record clearance as required by regulation. LPA reviewed staff training on file. Facility was observed to be clean, orderly, and at a comfortable temperature during today's visit. All common areas, hallways, and bathrooms observed by the LPA had sufficient lighting. Bathrooms observed had grab bars, and non-slip mat/flooring for bathing/showering as needed. The facility has emergency supplies, including food and water to meet requirements of the 72 hour shelter in place. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products. All medications were locked and inaccessible to residents in care. All toxins/cleaners were locked and inaccessible to residents in care. All exits were observed to be unobstructed. All fire extinguishers were serviced and tagged 10/23/23. The last fire drill was conducted 12/19/23; Facility completes fire/emergency drills monthly. Continued on LIC809C... LPA is requesting the following documents be updated and submitted by 2/9/24: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E-Emergency Disaster Plan -Submit if any changes and/or submit last page documenting annual review was completed. Infection Control Plan- Submit if any changes and/or submit letter/ page documenting annual review was completed. Copy of LIC400 Handling of Client Cash Resources, include copy of surety bond. Copy of Current Liability Insurance Copy of current Administrator Certificate No deficiencies cited today. Exit interview conducted with Administrator Robert Alvarado.the state’s words, verbatim · CDSS document, Jan 9, 2024

Allegation investigated: Staff did not provide resident transportation to medical appointments

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 12/11/2023, at approximately 9:40am, and met with Viola Kaake, Associate Executive Director (ED). Director Viola contacted Executive Director/Administrator Robert Alvarado. Administrator stated they would be arriving to the facility to meet with the LPA. LPA reviewed resident records, R1/R2, and obtained copies of requested documents, including account/financial records, admission agreements, care plan services, resident handbook regarding transportation services (obtained copy), and records on any maintenance repairs to apartment unit. LPA reviewed the facility's bus schedule, operating days and hours (obtained copy. LPA reviewed obtained information from reporting party LPA conducted interviews with staff, S1 & S3, and other related parties. Continued on LIC9099C... Unfounded The investigation revealed that the facility has a bus schedule for transportation available on specific days and hours, for Doctor Appointments, Pharmacy, and Bank as follows: Tuesday, Wednesday, and Thursday from 8:15am- 9:15am- 10:15am- 11:15am- 1:15pm- 2:15pm- with last pick-up at 3:30pm. Fridays bus schedule is 8:15am- 9:15am- 10:15am- 11:15am- with last pick-up at 12:15pm. The resident admission agreement states, Transportation- The Community will provide scheduled transportation for shopping and for other errands and planned social events in and around the local area- the facility bus schedule. The resident handbook provides additional transportation guidelines, resident handbook states "Most communities offer scheduled transportation to stores and doctor appointments within a designated service area. We can help make arrangements if you need transportation outside of our regular schedule or service area. The LPA reviewed emails and video that were related to the complaint investigation. Per review of records and information obtained, R1 had Doctor appointments that started at 8am, three times a week, and R2 provided transportation to R1 to get to the medical appointments. The facility bus schedule doesn't start before 8:15am; There was no request to the facility to help arrange other transportation, which would be at the cost of the resident. Admission agreement, resident handbook, and per emails reviewed, the transportation information was provided to all parties. There was no information supporting a violation had occurred. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation of "staff did not provide resident transportation to medical appointments" is Unfounded. The Department has found that the complaint allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted with the Administrator Robert Alvarado. No deficiencies cited. The investigation revealed that the resident apartment did have an air-conditioner that had a leak. Per record reviews, emails, and interviews with staff and other related parties. the investigation revealed that the air-conditioner had to be repaired, and a part was ordered; The facility provided a portable air-conditioner in the apartment until the unit's air conditioner was repaired. Per the investigation of records and interviews, It is unknown if the portable air-conditioner also leaked. The unit's air-conditioner was repaired when the facility received the part needed. There was differing information obtained during the investigation regarding the allegation. The investigation revealed that financial records showed that there were fees that were credited to the residents account by facility choice after discussions back and forth with other party, per records/interviews. Per investigation, there was no information obtained to support a violation occurred regarding resident care services being provided and/or fees for care charged in error. Some fees that were due to be refunded, were put to outstanding fees owed to the facility for care services and tray service. The remainder of the refund, $122.15 was provided to residents/responsible party as required. There was differing information obtained during the investigation regarding the allegation. Based on record reviews, interviews conducted, and information obtained, there is no evidence to support the violations occurred. The allegations of "facility was in disrepair, staff charged residents for services not rendered" are UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Exit interviews were conducted with Administrator Robert Alvarado No deficiencies cited.the state’s words, verbatim · CDSS document, Dec 11, 2023 · control 21-AS-20231115115708

Type of visit: Required - 1 Year

Licensing Program Analyst(LPA) Alviso conducted Required-1 Year inspection, on 12/11/23 at approximately 3:10pm, and met Administrator Robert Alvarado. Facility has an approved dementia plan of operation. There is an approved hospice waiver for eighteen (18) residents. Fire clearance is approved for one hundred (100) non-ambulatory, of which twenty (20) may be bedridden. The facility has an emergency disaster plan as required. The facility has a required infection control plan. The facility had all observed exits unobstructed. All fire extinguishers were serviced and tagged 10/23/23, as required. LPA toured the kitchen. LPA toured the memory care unit. The Department will continue this inspection at a later date.the state’s words, verbatim · CDSS document, Dec 11, 2023