Clearwater at Sonoma Hills

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to conduct a case management visit. LPA met with Shannon Lish, Memory Services Director (MSD). On 9/3/26 Community Care Licensing (CCL) received a Suspected Abuse report (SOC341) from facility. Facility staff (S1) were made aware of abuse by the police. Suspected abuser is unknown. (R1). On 9/2/26 in the evening, R1 reported to their visiting family member that they had been abused. R1's family member immediately reported the allegation of abuse to S1. Facility immediately interviewed R1 and started an internal investigation. During visit, LPA conducted interviews and received documents. No citations issued during this visit. Exit interview conducted with MSD and a copy of this report given.the state’s words, verbatim · CDSS document, Sep 3, 2026

Allegation investigated: Administration staff did not provide resident with full written disclosure of preadmission fee charges and refund conditions

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 6/15/26 at approximately 9:00am, and met with Administrator/Executive Director James Homer. Reporting party alleges "administration staff did not provide resident with full written disclosure of preadmission fee charges and refund conditions". LPA reviewed resident (R1) records regarding preadmission fees paid prior to moving into the facility. Resident was assessed by facility staff for appropriate care needs/services, but the resident/responsible party decided to not admit the resident into care. Responsible party (RP) requested a refund on 5/18/26 of preadmission fees paid on 5/8/26 in the amount of $8455.00; Facility notified RP that it would take approximately 30 days for the refund. Continued on LIC9099C.. Substantiated Per review of records obtained from the facility, there was no record of facility providing RP, when RP paid the $8455.00, a required written general statement describing all costs associated with the preadmission fee charges and stating that the preadmission fee is refundable, and describing conditions for the refund. Per investigation the above allegation is substantiated. Deficiency will be cited, 87507(g)(3)(C)(1) Admission Agreements- Any fee that is charged prior to or after admission, shall be clearly specified. If a licensee charges a preadmission fee, the licensee must provide the applicant or his or her representative with a written general statement describing all costs associated with the preadmission fee charges and stating that he preadmission fee is refundable, and describing conditions for the refund, 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. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with the Administrator James Homer. Appeal Rights provided to the Administrator.the state’s words, verbatim · CDSS document, Jun 15, 2026 · control 21-AS-20260609125941

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(3)(C)(1) · Plan of correction due date: Jul 15, 2026

87507(g)(3)(C)(1) Admission Agreements- Any fee that is charged prior to or after admission, shall be clearly specified. If a licensee charges a preadmission fee, the licensee must provide the applicant or his or her representative with a written general statement describing all costs associated with the preadmission fee charges and stating that the preadmission fee is refundable, and describing conditions for the refund. This requirement was not met as evidenced by: Per review of records obtained from the facility, there was no record of facility providing RP, when RP paid the $8455.00, a required written general statement describing all costs associated with the preadmission fee charges and stating that the preadmission fee is refundable, and describing conditions for the refund. This is a risk to residents personal rights.the state’s words, verbatim · CDSS document, Jun 15, 2026

Plan of correction: Licensee/Administrator to ensure preadmission fees obtained from residents/potential residents , that there has been provided a written general statement describing all costs associated with the preadmission fee charges and stating that the preadmission fee is refundable, and describing conditions for the refund, as required. Please submit how the facility will ensure compliance with this regulation regarding preadmission fees/charges as required, POC due 7/15/26.

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.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Alviso conducted a Required- 1 Year visit, on 4/1/26 at approximately 9:45am, and met with James Homer, Administrator. Fire clearance is approved for one hundred fourteen (114) non-ambulatory, of which six (6) may be bedridden. Facility's delayed egress and secured perimeter is approved by the local fire department. Facility has an approved dementia plan of operation. There is an approved hospice waiver for eighteen (18) residents. Facility has an infection control plan as required. The facility has a required emergency and disaster plan. LPA reviewed ten (10) resident files, including medication records. All medications were stored appropriately, and locked up making them inaccessible to residents, and all others that do not handle/assist with medications. LPA toured the facility with the Administrator. All exits were free and clear of any obstructions; All walkways and paths were free and clear of obstructions. Hot water was measured in AL at 115.3 degrees Fahrenheit on the 2nd floor and 114.2 degrees Fahrenheit on the 1st floor, all readings were within regulation; Hot water was measured in memory care unit at 118.3 degrees Fahrenheit, which is within regulation. Fire extinguishers were serviced and tagged as required. All laundry rooms were clean and orderly, in AL and memory care. Facility had a sufficient supply of food, perishable and non-perishable. Emergency supplies, and emergency disaster supplies were sufficient during today's inspection. Continued on LIC809C... There was sufficient observed lighting throughout all common areas, hallways, bathrooms, and resident rooms, that were observed, during the inspection. LPA is requesting the following documents be updated and submitted by 5/1/26: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E- Emergency Disaster Plan (review and update as needed/required-no changes submit copy of review page- If changes submit copy of plan) Infection Control Plan (review and update as needed/required-no changes submit copy of review page- If changes submit copy of plan) LIC400- Handling of Client Cash Resources -All facilities must complete the form (include copy of surety bond if handling cash) Current Liability Insurance Resident Roster LPA still needs to review staff training, and emergency disaster plan/and training, and review conducted emergency drills; The annual inspection will be continued at a later date.the state’s words, verbatim · CDSS document, Apr 1, 2026

Allegation investigated: Staff misrepresented financial terms under resident's admission agreement. Staff used coercive practices to influence resident's admission decisions Staff did not allow resident’s representative access to resident records.

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 1/8/26 at approximately 10:15am, and met with Administrator/Executive Director James Homer. LPA spoke with the Marketing Director Hollie Schuze during the inspection. Reporting party alleges "staff misrepresented financial terms under resident's admission agreement, staff used coercive practices to influence resident's admission decisions, staff did not allow resident’s representative access to resident records". LPA reviewed resident R1's records, including admission agreement, and receipts from charges/fees R1 paid to the facility. LPA obtained and reviewed facility records related to the pre-admission and admission of R1, including email correspondence. LPA conducted interviews with staff, and other related parties. The investigation revealed that there is no other individual legally responsible for the resident, R1 is responsible for themselves. Continued on LIC9099C... Unsubstantiated R1 signed their admission agreement, after a review of the contract with the facility's staff, prior to moving into the facility. The facility requires admission contracts/agreements be reviewed, completed, and signed by resident (s), legal representative or a responsible party, prior to being allowed to move in to the facility unit, including moving personal belongings into the facility. R1 paid a fee of $8000 to hold a unit, the holding fee was equal to the required community fee, which is paid upon move-in along with monthly rent, and care fees. Per review of records, the holding fee paid by R1's finances, became the required community fee, upon R1's signing of the admission agreement/contract. If R1 had decided to not sign a contract and enter the facility as a resident, the holding fee would have been refunded per facility policy. R1's records are confidential, and the records are available to the resident, who is responsible for themselves and/or the legal responsible party (s). The resident responsible for themselves, may give their written consent that "another party" may be provided their confidential records. Until a written consent is provided by the resident/R1 the facility will maintain resident R1's records private and confidential from other parties. Per investigation, there was differing information obtained regarding the allegations; There was no information obtained to support violations had occurred regarding the allegations of "staff misrepresented financial terms under resident's admission agreement, staff used coercive practices to influence resident's admission decisions, staff did not allow resident’s representative access to resident records." Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations are Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies cited. Exit interview was conducted with the Executive Director James Homer.the state’s words, verbatim · CDSS document, Jan 8, 2026 · control 21-AS-20251220114331

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra conducted a case management inspection-Other and met with Executive Director, James Homer. The purpose of the case management visit is to ensure that staff (S1) is not present or working at the facility. An immediate exclusion letter dated October 30, 2025 was provided to the administrator. Per Administrator, S1 is listed as on-call staff, but administrator informed LPA that they are not present at the facility at this moment. LPA has advised the Administrator to disassociate S1 from their roster and remove them from their personnel roster (LIC 500). No deficiencies cited during today's inspection.the state’s words, verbatim · CDSS document, Oct 30, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alviso conducted a case management inspection, on 8/20/2025 at approximately 9:40am, and met with Executive Director, James Homer. This case management is to review resident incidents' of R1 AWOLs/wandering away from the facility. LPA reviewed resident, R!, records, and obtained additional information on incidents. R1 resides in assisted living area of the building. Resident R1 who uses a four wheeled walker that has a wander-guard attached to it. Wander-guard is to alert facility staff if resident wanders out of any exit door/gate. R1 is not to be in the community/out of the facility unsupervised per medical assessment, and review of resident records. R1 exited and AWOL the facility without staff’s knowledge on 8/14/25, 8/2/25, 6/6/25, and 5/8/25. On 8/14/25 , resident wandered away and an individual saw R1 and contacted the Police. Staff had not located R1 and called 911; R1 was returned to the community by the Police department. On 8/2/25 R1 was not in their room when staff came to take them to their dinner meal, staff searched inside and outside the facility, when a staff observed R1 walking into the front entrance of the building on their own. On 6/6/25 R1 exited the facility without staff’s knowledge, R1 was observed outside by the trash cans/dumpster by a maintenance staff who was arriving to work. Staff parked their vehicle and went and found R1 sitting in a staff’s parked car. Facility staff redirected R1 back into the facility. On 5/8/25 staff found R1 wandering around outside the facility. Regulation Reappraisals- 87463, this shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. Behavioral expression, as defined in Section 87101, Definitions, that may result in harm to self or others, such as unsafe wandering, elopement, hallucinations, lacking in hazard awareness, or lacking in impulse control Continued on LIC809C.. Facility is to update the resident's care plan after the reappraisal as needed. R1's care plan shall meet resident's current needs, and all health & safety hazards need to be addressed in the care plan, ensuring sufficient staffing to meet these identified needs. Per record reviews, R1 does not reside in memory care, and staff are to ensure all resident's needs are met, including behavior of wandering away from the facility. R1 does have a wander-guard on their walker they use to ambulate but has continued to awol the facility without staff's knowledge and/or supervision. Per record review, The Department was not in receipt of R1’s AWOL incidents that occurred on 5/8/25 and 6/6/25; This is a required report, per regulations. The following deficiencies will be cited, LIC809D. 87463(g)(j) Reappraisals-The licensee shall ensure corresponding changes are made in the care and supervision provided to the resident. The licensee shall evaluate staffing needs to ensure that there is a sufficient number of direct care staff, as specified in Section 87411, Personnel Requirements – General, to support each resident's physical, social, emotional, safety and health care needs, as identified in their current appraisal. 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: 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. The following deficiencies were cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation and/or Health & Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with the Administrator James Homer. Appeal rights provided.the state’s words, verbatim · CDSS document, Aug 20, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(g)(1) · Plan of correction due date: Aug 20, 2025

87463(g)(j) Reappraisals-The licensee shall ensure corresponding changes are made in the care and supervision provided to the resident. The licensee shall evaluate staffing needs to ensure that there is a sufficient number of direct care staff, as specified in Section 87411, Personnel Requirements – General, to support each resident's physical, social, emotional, safety and health care needs, as identified in their current appraisal. Per review of records, R1 is not to be in the community/out of the facility unsupervised per medical assessment, and review of resident records. R1 exited and AWOL the facility without staff’s knowledge on 8/14/25, 8/2/25, 6/6/25, and 5/8/25. This is a risk to health & safety of resident in care.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: Licensee to ensure that R1's care plan reflects current needs of the resident, and ensure sufficienting staffing at all times to ensure all R1's needs are met, including not exiting the building without staff's knowledge and supervision. Submit how the facility plans to meet R1's current needs, including their wandering/awol behavior, helping to ensure R1's health & safety. Proof of correction to be submitted by 8/25/25. POC due by 8/21/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)- · Plan of correction due date: Sep 5, 2025

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: 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 Per record review, The Department was not in receipt of R1’s AWOL incidents that occurred on 5/8/25 and 6/6/25. This is a risk to personal rights and/or health & safety of resident in care..the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: Licensee to ensure all resident incidents are reported as required per regulations. Submit incident reports on R1 of AWOL occurrences on 6/6/25, and 5/8/25. Submit plan of future compliance with this regulation. POC due 9/5/25.

Allegation investigated: Staff are mismanaging resident's medication and not providing it to the resident as prescribed

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 6/25/25 at approximately 9:40am, and met with Administrator/Executive Director James Homer and Health Services Director Eadgitha Waken. Reporting party alleges "staff are mismanaging resident's medication and not providing it to the resident as prescribed". LPA reviewed resident's (R1) records, medication records, care plan, assessments, and financial records on care plan fees. LPA obtained copies of resident (R1) records as requested. LPA obtained a copy of notice of fees regarding care plan levels, and medication assistance costs, letter dated 3/31/25. The 3/31/25 letter of new fee structure for assisted living and memory support was mailed out to all resident responsible parties, per Administrator. LPA interviewed staff, S1, and S2, and other related parties. The investigation revealed that R1's medication prescribed for mood and anxiety had been changed by the Physician, dosage was changed to three pills a day to be given at dinner time, approximately 4/9/25. R1 received their last dose of the medication on 4/19/25, per medication MAR review. Continued on LIC9099C.. Substantiated Continued from LIC9099, dated 6/25/25.. The medication assistant staff didn't refill the medication as required. Resident R1 was not provided the medication as prescribed from 4/20/25 through 5/24/25, per medication MAR review. The medication was refilled/obtained, and resident was provided the medication as ordered on 5/25/25; R1 missed a total of "35" days of the prescribed medication order, per review of records and conducted interviews. Sufficient information has been obtained to support that a violation had occurred. Per review of records, including medication records, facility records, and interviews with staff and other parties, the allegation "staff are mismanaging resident's medication and not providing it to the resident as prescribed" is substantiated. This deficiency will be cited, 87465(a)(4) Incidental Medical and Dental Care, 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. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with the Administrator James Homer. Appeal Rights provided to the Administrator.the state’s words, verbatim · CDSS document, Jun 25, 2025 · control 21-AS-20250602102129

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 26, 2025

87465(a)(4) Incidental Medical and Dental Care-The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Per review of records, R1 received last dose of the medication 4/19/25. The medication assistant staff didn't refill the medication as required. Resident R1 was not provided the medication as prescribed from 4/20/25 through 5/24/25, per medication MAR review. The medication was refilled/obtained, and resident was provided the medication as ordered on 5/25/25; R1 missed a total of "35" days of the prescribed medication, per review of records and conducted interviews. This is a health & safety risk to the resident (s) in care.the state’s words, verbatim · CDSS document, Jun 25, 2025

Plan of correction: CORRECTED/POC CLEARED. BY HEALTH SERVICES DIRECTOR HELD AN IN-SERVICE MEDICATION TRAINING WITH ALL MEDICATION ASSISTANCE STAFF. ADMINISTRATION STAFF INSTITUTED A WEEKLY AUDIT TO HELP ENSURE ALL MEDICATIONS ARE REFILLED AS REQUIRED, AND ALL MEDICATIONS ARE PROVIDED AS PRESCRIBED TO RESIDENTS IN CARE.

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPA) Alviso conducted a continued annual visit, on 6/25/25, at approximately 12:30pm, and met with James Homer, Administrator. Facility has an approved dementia plan of operation. There is an approved hospice waiver for eighteen (18) residents. Facility has an infection control plan as required. The facility has a required emergency & disaster plan. Fire clearance is approved for one hundred fourteen (114) non-ambulatory, of which six (6) may be bedridden. LPA reviewed six (6) resident files. All files were complete. LPA reviewed six (6) staff files. All staff had criminal record clearance as required. LPA reviewed staff training. Per file reviews, staff S1 and S4 lack required first aid. This deficiency will be cited, 87411(C)(1) Personnel Requirements -General, see LIC809D. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiency (s) by due date (s), may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with the Administrator James Homer Appeal Rights Provided.the state’s words, verbatim · CDSS document, Jun 25, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Alviso conducted a Required- 1 Year visit, on 324/25, at approximately 2:00pm, and met with James Homer, Administrator. Facility has an approved dementia plan of operation. There is an approved hospice waiver for eighteen (18) residents. Facility has an infection control plan as required. The facility has a required emergency & disaster plan. Fire clearance is approved for one hundred fourteen (114) non-ambulatory, of which six (6) may be bedridden. LPA reviewed staff files. LPA toured the facility with the Administrator James Homer. Hot water was measured at 115.5 degrees Fahrenheit. All exits were free and clear of obstruction. All stairwells had the required evacuation chair, and user instructions posted. All required postings were up and visible to all residents, visitors, and staff. Facility has required emergency "72 hour shelter in place" supplies. Medications were centrally stored and locked in the assisted living area and in the memory care area. LPA observed that each medication room has a refrigerator for storing refrigerated medications. Food supply was observed to be sufficient. LPA is requesting the following documents be updated and submitted by 4/24/25: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required) Infection Control Plan (ensure to review and update as needed/required) Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Copy of Current Liability Insurance Continued on LIC809C During today's inspection the LPA observed the following deficiency: LPA observed open commercial size boxes/bags of chocolate chips, pancake mix, walnuts, horchata drink mix, and jello pudding mix, open in the kitchen/pantry with no means to close the packages securely in order to prevent them from potential contamination. The Administrator and the Kitchen Chef discarded the items during the kitchen inspection. LPA obtained pictures for the file. This deficiency will be cited, 87555(b)(9)- General Food Service Requirements- The following food service requirements shall apply: Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service, see LIC809D. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiency (s) by due date (s), may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with the Administrator James Homer Appeal Rights Provided. LPA will continue the annual inspection at a later date.the state’s words, verbatim · CDSS document, Mar 24, 2025

Allegation investigated: Lack of supervision resulted in resident sustaining an unwitnessed fall Staff are not assisting resident with incontinence care and/or assisting resident with a toileting schedule Staff are not ensuring resident(s) has clean clothing Staff are not assisting resident(s) with hygiene care

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 10/3/2024 at approximately 9:00am, and met with Executive Director James Homer, and Health Services Director/LVN Janice Foster. LPA reviewed resident (R1) records, including medical documentation, and facility records. LPA conducted interviews with staff (S2, S3, S4, S5), and with other related parties. LPA obtained conflicting information regarding allegations of "lack of supervision resulted in resident sustaining an unwitnessed fall, staff are not assisting resident with incontinence care and/or assisting resident with a toileting schedule, staff are not ensuring resident(s) has clean clothing, staff are not assisting resident(s) with hygiene care". Per record reviews and interviews, the investigation revealed that R1 had a care plan in place, and the resident was on a shower schedule, and a laundry schedule. R1 would be offered their shower multiple times, and most times they could get them to shower, even if being combative about it. When resident continued to refuse a shower, it would be noted, and followed up on the next shift and/or shower provided the next day. Hygiene care, including showering, brushing teeth, cleaning/grooming as needed for a resident. Per review of records, Continued on LIC9099C... Unsubstantiated R1 was provided hygiene care regularly, including brushing their teeth, cleaning their face/body as needed. Per review of records, and staff interviews, R1 was toileted and cleaned and changed as needed, every one-two hours minimum, most times every hour. Soiled clothing and linens are to be taken to the laundry room daily and washed; Besides the washing machines in the memory care unit, staff also uses the two larger laundry rooms in the main facility, in assisted living as needed. All other dirty laundry is done weekly per the schedule. If laundry is done by a family member/responsible party staff stated it is by their choice, it is not required of them. Per record reviews, R1 had two (2) unwitnessed falls, on 1/3/24 & 4/29/24. No serious injuries sustained after assessments were done by staff. R1 was not a one to one staffed resident; R1 can ambulate on their own when wanting to, and residents are not restrained in assisted living and/or memory care from moving about freely. Staff provide checks on resident's in their rooms as needed. Staff supervise and monitor groups of residents as needed, and only residents that are one to one have a staff with them at the specified times per their care plans. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations "lack of supervision resulted in resident sustaining an unwitnessed fall, staff are not assisting resident with incontinence care and/or assisting resident with a toileting schedule, staff are not ensuring resident(s) has clean clothing, staff are not assisting resident(s) with hygiene care” are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies cited. Exit interview was conducted with the Executive Director James Homer.the state’s words, verbatim · CDSS document, Oct 3, 2024 · control 21-AS-20240604084835

Allegation investigated: Residents laundry not being done due to a broken washing machine Facility did not seek timely medical

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 10/3/2024 at approximately 9:00am, and met with Executive Director James Homer, and Health Services Director/LVN Janice Foster. LPA toured the facility, including the memory care unit; LPA reviewed resident (R1) records, including medical documentation, and reviewed facility records. LPA conducted interviews with staff (S2, S3, S4, S5, S6), and with other related parties. LPA obtained conflicting information regarding allegations of "residents laundry not being done due to a broken washing machine, and facility did not seek timely medical". Per record reviews and interviews, the investigation revealed that R1 had a care plan in place, and the resident was on a shower schedule, and a laundry schedule. Per interviews with staff (S2) the memory care machines are currently both working well. Approximately six months ago one of the machines had to have the lock lid switch replaced, when the lid closed it would lock and immediately unlock which prevented the load from washing. The part was ordered and the machine was out of use until repaired, but the second washing machine still worked. The facility also has two larger laundry rooms in the assisted living area that staff can use to wash laundry loads as needed for the memory care residents. Continued on LIC9099C... Unsubstantiated The facility was never not able to wash laundry, as the facility has multiple washing machines. Staff interviewed (S3, S4, S5, S6) stated that memory care residents soiled clothing and/or linens are pulled each day as needed, and washed and dried that day. All other dirty laundry is done by the laundry schedule, a specified day in the week for each resident group. Per investigation, it is unknown if there was some laundry that wasn't washed as needed by staff and/or if dirty laundry was mixed in with clean clothes by a resident. S2 stated that no staff purchases laundry soap because we have the eco lab soap bags attached that will automatically put soap in the washing machine to wash the load. If a resident wants to use a different laundry soap they may purchase other detergent and use that instead. No staff in AL or memory care are ever required to purchase soap/detergent to wash any of the resident/facility laundry. Per record reviews and interviews, R1 didn't have any infections and/or observed need; Per interviews and record reviews, R1 was provided assistance if needed with toileting. R1's room had already been vacated, and no odors were noted and/or observed in the room when inspected. Per record reviews, and interviews, from move-in, R1 would wander around when getting up in the night; R1 would take everything in their room and move it onto the floor, and into the hallway. Staff would put everything back and redirect the resident as needed. Resident didn't have any diagnosed urinary tract infections while residing in the facility per record reviews and interviews. Per interviews, there were no observed symptoms and/or foul urine odor of a possible infection. Per investigation and review of records, including medical records, it is unknown if R1 had started an infection prior to leaving the facility and/or if the resident started it after moving out of the facility. There was no information obtained to support that violations had occurred regarding the allegations reported. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations "residents laundry not being done due to a broken washing machine, and facility did not seek timely medical” are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies cited. Exit interview was conducted with the Executive Director James Homer.the state’s words, verbatim · CDSS document, Oct 3, 2024 · control 21-AS-20240917161619

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alviso conducted a case management inspection, on 10/3/2024 at approximately 1:27pm, and met with Executive Director, James Homer, and Health Services Director (HSD), LVN Janice Foster. LPA reviewed resident incident with HSD Janice Foster. Per report and interviews, the administration staff reviewed facility video surveillance which showed staff (S4) grabbing a resident's (R1) hand aggressively to stop them from exiting. Resident had a fall during this incident, and was hospitalized. Staff (S4) was put on immediate suspension; and was terminated by administration staff due to the incident. The Department did receive an SOC341 suspected abuse report from the facility. Police report information case number obtained. The LPA will obtain additional information regarding the above incident. No deficiencies cited today.the state’s words, verbatim · CDSS document, Oct 3, 2024

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs), Alviso and Loera, conducted a case management visit, on 9/3/24 at approximately 1:00pm, and met with Health Services Director Janice Foster. The case management is being conducted to amend the complaint report dated 8/29/24. The amended report was left with the Health Services Director. No deficiencies cited on today. Exit interview conducted with the Health Services Director.the state’s words, verbatim · CDSS document, Sep 3, 2024

Allegation investigated: Staff neglect led to resident sustaining unstageable pressure injuries Staff did not rotate resident as instructed by hospice care staff Staff did not ensure resident was adequately fed Staff left resident in soiled clothing for extended periods Staff did not provide a safe environment for resident Staff handled resident in a rough manner Staff made inappropriate comment toward resident Staff mismanaged resident’s medication Staff did not ensure resident was involved in activities Staff did not provide resident’s authorized representative with resident’s records

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 8/29/2024 at approximately 9:40am, and met with Interim Administrator Paul Gozon, and Health Services Director/LVN CA Licensed Janice Foster. LPA reviewed resident (R1) records, including medical documentation, hospice records, and facility records. LPA conducted interviews with staff (S1,S2,S3), and conducted interviews with other related parties. Per record reviews, hospice record reviews, and conducted interviews, the investigation revealed that staff stated resident was being turned/rotated as required by care plan/hospice plan. R1 was receiving hospice care services, this included care for the pressure injuries. LPA reviewed hospice progress notes regarding all visits to the facility to provide care, and there were no noted issues and/or concerns regarding staff care and/or neglect. Per record reviews, R1 moved in 4/16, and went on hospice care 5/10, resident had a care plan in place, which included a hospice care plan from the hospice agency. Per interviews, and review of records, R1 had several pressure injuries develop and that were diagnosed to be at different stages, including stage 3/stage 4/unstageable. Review of records found no medical documentation stating how these occurred and/or that they were due to neglect or abuse. R1 needed to be turned to ensure position changes, taking pressure off the pressure injuries and other areas of the body. "Amended" This is an amended version of the original report created on 8/29/24. Continued on LIC9099C.. Unsubstantiated Staff interviewed stated R1 was turned as needed. Per record reviews and interviews, R1 would refuse food/meals, and other times may eat a little of food offered. R1's diet was changed, Dr. ordered a special diet /pureed diet for R1 due to swallowing concerns and care needs. Review of records and interviews, it was found that R1 could become aggressive when staff would provide care services, such as incontinent care, and bathing/showers, but staff would provide needed care and sometimes with help from another staff, including hospice staff. Per records, staff requested a shower chair for R1, and responsible party provided one to use for. Staff interviewed stated R1 was provided hygiene care, which included dressing R1 as needed. R1 did join in activities when wanting to and staff stated they offered activities to R1 who would join if wanting to do so. As R1 declined, activities were offered as resident wanted to and/or more of a one to one, playing music, looking at pictures, talking with the resident, interacting with them, if resident was willing. Per interviews, staff deny neglecting R1 and their care needs. Staff stated they provided documents of R1 to responsible party that facility handles and charts. In summary, Director of Quality Assurance for Hospice by the Bay, stated to the LPA that Hospice staff provided care services to R1, and there are no documented issues and/or concerns filed in hospice records by hospice staff. Hospice staff had no reason to report any concerns to Department of Social Services and/or law enforcement regarding R1's care at the facility. There was no information obtained to support a violation had occurred regarding the allegations. Per interviews, staff record reviews, and facility record reviews, staff (S4) denied speaking to residents in an inappropriate manner. Staff denied handling resident's roughly when providing care services at any time. S4 stated they are trained to handle medications and assist residents with medications as needed/ordered. S4 stated they have never discontinued a residents medication. If a resident refuses their medication, it is documented and required parties are notified. Facility has required medication assistance policies, including medication discontinue orders, and refusal of medications/missed medications.There was no information obtained to support a violation had occurred regarding the allegations. The investigation found that there was differing information from interviews conducted, records reviewed, medical documentation, including hospice records, and information provided by the reporting party. There was no information obtained to support violations had occurred regarding the allegations. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation "staff neglect led to resident sustaining unstageable pressure injuries, staff did not rotate resident as instructed by hospice care staff, staff did not ensure resident was adequately fed, staff left resident in soiled clothing for extended periods, staff did not provide a safe environment for resident, staff handled resident in a rough manner, staff made inappropriate comment toward resident, staff mismanaged resident’s medication, staff did not ensure resident was involved in activities, staff did not provide resident’s authorized representative with resident’s records" are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies cited.Exit interview was conducted with the Administrator Paul Gozon. "Amended" This is an amended version of the original report created on 8/29/24.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 21-AS-20240429095831

Allegation investigated: Staff force residents to take showers.

Licensing Program Analysts (LPAs), Alviso and Florio, conducted a complaint inspection, on 4/17/24 at approximately 8:40am, and met with Administrator Janna O'Sullivan, and Health Services Director Janice Foster. LPAs requested facility records, including staff and resident files. LPAs reviewed all records. LPAs interviewed staff, and other related parties regarding the allegation. The reporting party (RP) alleges "staff force residents to take showers." The investigation revealed that resident (R1) has a care plan that includes assistance with showers. Resident is on a shower schedule, but per interviews R1 refuses many times to take their showers regularly and/or as scheduled; Per interviews, staff will offer R1 their shower, and if refused, the staff will come back after a short time and ask R1 again. Staff deny forcing any residents to take a shower, per interviews. The investigation found that there was differing information obtained per records, interviews, and per information provided by the reporting party. There was no information obtained to support a violation had occurred regarding the allegation. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation "Staff force residents to take showers." is 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. Nothe state’s words, verbatim · CDSS document, Apr 17, 2024 · control 21-AS-20240301093451

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs), Alviso and Florio, conducted a case management-other inspection, on 4/17/24 at approximately 4:27 pm, and met with Administrator Janna O'Sullivan, and Health Services Director Janice Foster. This inspection is being conducted to cite a deficiency that was identified during the complaint inspection of earlier today, see LIC9099, dated 4/17/24. There were some concerns regarding the resident's hygiene care, and updating the plan to ensure needs will/can be met. A meeting was held to discuss concerns, Per LPA interviews with staff, It was identified that staff, S2, made an inappropriate comment during the meeting held to address a resident's (R1) care plan; In summary, the comment regarded the hygiene care plan, previously this type of plan was referred to as the "grandma and grandpa stinky club." This deficiency will be cited, 87468.1(a)(1) Personal Rights of Residents in All Facilities- Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons, see LIC809D. The following deficiency was cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation and/or Health & Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with the Administrator. Appeal rights provided.the state’s words, verbatim · CDSS document, Apr 17, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 3, 2024

87468.1(a)(1) Personal Rights of Residents in All Facilities- Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: LPA interviews identified that staff, S2, made an inappropriate comment during the meeting held to address a resident's (R1) care plan; In summary, the comment regarded the hygiene care plan, previously this type of plan was referred to as the "grandma and grandpa stinky club." This is a potential risk to residents' personal rights and/or risk to health and safety.the state’s words, verbatim · CDSS document, Apr 17, 2024

Plan of correction: Licensee/Administrator to ensure that no residents personal rights are violated, per regulation. Contact Sonoma County Ombudsman Agency and schedule a "Resident Personal Rights" training for care staff, including S2. Once the training is obtained from the Ombudsman Agency for facility staff, submit proof of training, and plan of facility future compliance with this regulation. POC due by 5/3/24.

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPAs) Julie Florio and Dina Alviso arrived unannounced, to conduct a required 1-year annual inspection continuation visit and met with Janna O'Sullivan, Administrator, and Janice Foster, Health and Wellness Director. LPAs reviewed eight resident files and 10 staff files. All resident files had required documentation. All staff files had current CPR/First Aid certificates. Six out six direct care staff files did not have the minimum required training, of which four files did not have documentation of required initial training and five files did not have documentation of required annual training. Although the food supply was sufficient at prior facility visit, LPAs documented and obtained photographs of observed food that was found left uncovered on the kitchen counter and several instances of unsealed/uncovered food in the walk-in refrigerator and freezer as well as in the dried goods storage room in the main kitchen. Documents which shall be updated include, but are not limited to, the following: All required initial and annual training including medication administration training for MedicationTechnicians. Proof of training regarding proper food storage per the Health and Safety Code for all kitchen staff. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted with Administrator. Appeal rights provided.the state’s words, verbatim · CDSS document, Apr 17, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Alviso and Florio conducted a Required- 1 Year visit, on 3/7/24, at approximately 8:30am, and met with Health Services Director, Janice Foster. The Administrator Janna O'Sullivan, will be arriving to the facility to meet with the LPAs, per Health Services Director. Facility has an approved dementia plan of operation. There is an approved hospice waiver for ten (10) residents. Facility has an infection control plan as required. The facility has a required emergency & disaster plan. Fire clearance is approved for one hundred fourteen (114) non-ambulatory, of which six (6) may be bedridden. LPAs started reviewing staff files, including annual training. LPAs toured the facility with the Administrator and Health Services Director. The exits were observed to be clear throughout the facility during the tour. Medications were locked and inaccessible to residents, and all others that are not trained to handle medications. Medications were observed to be stored appropriately in both the memory care unit, and assisted living area. Cleaners/toxins were observed to be locked up and inaccessible to residents in care. LPAs observed the housekeeping carts to be locked during the tour, which makes any cleaners/toxins inaccessible to residents in care. The facility had sufficient lighting in hallways, restrooms, and common areas throughout the facility. The food supply was sufficient. LPAs observed emergency disaster supplies, and 72 hour shelter in place supplies during the tour. LPAs observed random resident room bathrooms, all had grab bars, and non-skid flooring in showers for resident use. This annual will be completed at a later date.the state’s words, verbatim · CDSS document, Mar 7, 2024

Allegation investigated: Facility staff mismanaged residents' medications. Resident's medication information was not kept confidential

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 12/20/23 at approximately 9:30am, met with Administrator Jana O'Sullivan, and H&W Director Janice Foster. LPA reviewed resident records, R1 & R2 records, and facility records. LPA conducted interviews with staff, S1, S2, and other related parties. The investigation revealed that R1 had a prescription medication go out of the community with another resident's, R2, medications who had moved out of the facility. R2's responsible party contacted the facility regarding the medication that was not R2's that was included with R1's upon their discharge from the facility. Responsible party stated they would return R1's medication back to the facility. The facility received R1's prescription medication from the responsible party who dropped it off to them. Per record review, R1 didn't miss any medication. Resident's identification, name and medication information, was not kept confidential as required, Resident's prescribed medication was not kept secured, centrally stored, ensuring "all individuals" that don't handle facility resident medications, don't have access to the medications. Continued on LIC9099C... Substantiated These deficiencies will be cited, see the following: 87465 (h)(2) Incidental Medical & Dental Care-The following requirements shall apply to medications which are centrally stored: 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, see LIC9099D 87468.2(a)(2) Additional Personal Rights of Residents in Privately Operated Facilities- To have their records and personal information remain confidential and to approve their release, except as authorized by law, see LIC9099D Based on resident record reviews, staff interviews, photo, information obtained from interview(s) with other parties, the allegations of "facility staff mismanaged residents' medications, and resident's medication information was not kept confidential" are Substantiated. The preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Appeal Rights Given. Exit interview conducted with the Administrator Janna O'Sullivan.the state’s words, verbatim · CDSS document, Dec 20, 2023 · control 21-AS-20231218152714

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Dec 21, 2023

87465 (h)(2) Incidental Medical & Dental Care- 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 was not met as evidenced by: LPA's record reviews, and interviews, R1 had a prescription medication go out of the community with R2's medications who had moved out of the facility. R2's responsible party contacted the facility and returned R1's medication. The medication was not kept secured and inaccessible to all others that don't and/or shouldn't have access to the medications. This is an immediate risk to the health and safety of residents in care, and a risk to residents personal rights.the state’s words, verbatim · CDSS document, Dec 20, 2023

Plan of correction: CLEARED-LICENSEE HAD AN IN-SERVICE TRAINING CONDUCTED WITH ALL MEDICATION STAFF THAT ASSIST RESIDENTS WITH MEDICATIONS. ADMINSITRATOR PROVIDED PROOF OF TRAINING THAT WAS DONE AFTER THE MEDICATION INCIDENT OCCURRED.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(A)(2) · Plan of correction due date: Dec 21, 2023

87468.2(a)(2) Additional Personal Rights of Residents in Privately Operated Facilities- To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not met as evidenced by: R1 had a prescription medication go out of the community with another resident's, R2, medications who had moved out of the facility. R1's identification, their medication pills, name and medication information, was not kept confidential as required. This is an immediate risk to residents health and safety, and to resident's personal rights.the state’s words, verbatim · CDSS document, Dec 20, 2023

Plan of correction: Licensee to ensure that all resident's medication records, personal information, medical information, etc, are kept private and confidential as required. Licensee to hold an in-service with all medication staff regarding ensuring Personal rights of all resident's in care., ensuring resident's personal/private medical/medication information stays confidential at all times, during all policy and procedures of the facility. POC due 12/21/23. Proof of training due by 12/29/23.

Type of visit: Case Management - Incident

Licensing Program Analyst(LPA) Alviso, conducted a case management inspection, and met with Jana O'Sullivan, Administrator. The case management inspection is being conducted to cite a deficiency observed during the complaint investigation of earlier today, see LIC9099s/9099D of 12/20/2023. During the LPA's investigation it was identified that a resident, R1, incident had not been reported. A resident's (R1) medication had not been centrally stored as required, and had been sent out of the community with another resident's medications during the discharge of R2. This deficiency will be cited, 87211(a)(1)Reporting Requirements-(a) 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, see LIC809D. The following deficiencies were cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 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 the Administrator. Appeal rights provided.the state’s words, verbatim · CDSS document, Dec 20, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Dec 29, 2023

87211(a)(1) Reporting Requirements-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, This requirement was not met as evidenced by: LPA's investigation finding that a resident's (R1) medication had not been centrally stored as required, and had been sent out of the community with another resident's medications during the discharge of R2. This is a potential risk to residents personal rights.the state’s words, verbatim · CDSS document, Dec 20, 2023

Plan of correction: Administrator to submit an incident report as required, and to submit facility policies and procedures regarding reporting requirements. Submit a plan of future compliance-all due by 12/29/23.