Fountaingrove Lodge

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

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

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct an Annual Required - 1 Year inspection, and met with Administrator Megan Leone. Fire clearance is approved for one hundred and seventy-three non-ambulatory, of which 16 may be bedridden. The delayed egress is approved, per fire clearance. Capacity breakdown as follows: AL main building, and the five (5) bungalows are cleared for one hundred and forty (140) non-ambulatory, of which six (6) may be bedridden, the MC building is cleared for thirty-three (33) non-ambulatory, of which ten (10) may be bedridden; Total license capacity is one hundred and seventy-three (173). Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has a plan of operation for dementia care. The facility has a hospice waiver approval for ten (10) residents. Per review of the emergency disaster drills binder, the facility is conducting emergency disaster drills. All exits were clear and unobstructed during the inspection. Facility was observed to be at a comfortable temperature. There was sufficient lighting in the entryway and hallways that the LPA observed during the inspection. LPA reviewed ten (10) resident files, including medication records. LPA reviewed ten (10) staff files. All staff had required criminal record clearance. Staff reviewed, had the required first aid certification and CPR certification. LPA reviewed required staff training, for all direct caregivers and medication technicians. This annual inspection will be completed at a later date by the Licensing Program Analyst (LPA).the state’s words, verbatim · CDSS document, Jul 20, 2026

Allegation investigated: Failure to meet statutory requirements for budget process. Failure to respond to resident association timely.

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 11/10/25 at approximately 9:40am, and met with Administrator Megan Leone. Reporting party alleges “failure to meet statutory requirements for budget process,” and “failure to respond to resident association timely." The Department conducted facility record reviews, reviewed zoom recordings, conducted interviews with staff, and other related parties regarding the allegations. The investigation revealed that The Department reviewed documentation relevant to the allegation, “failure to meet statutory requirements for budget process,” and found that on January 30, 2025, the Semi-Annual Meeting – Budget was scheduled for 2pm and the budget that was to be reviewed at the meeting was provided to residents at 11:22am the same day as the meeting. Continued on LIC9099C.. Substantiated During this meeting it was announced to residents that the 6% monthly care fee increase (MCFI) would be implemented on April 30, 2025. This information supported that a violation had occurred. The allegation is found to be substantiated; The provider failed to make available to residents the budget for the upcoming year 14 days prior to the meeting, the budget was provided to residents less than 3 hours prior to the meeting. This deficiency will be cited, Pursuant to Health and Safety Code (HSC) section 1771.8(d), At least 14 days prior to the meeting to discuss an increase in the monthly care fee, the provider shall make available to each resident or resident household comparative data showing the budget for the upcoming year, the current year’s budget, and actual and projected expenses for the current year, and a copy shall be posted in a conspicuous location at each facility, see LIC9099D. A technical violation for HSC section 1771.8(e) is also being noted as the provider made changes to the materials being presented the day of the meeting, violating the requirement to make available to residents of the continuing care retirement community upon request the agenda and accompanying materials at least seven days prior to the meeting. The materials provided to the Resident Council/Finance Committee (RC/FC) were changed less than seven days prior to the meeting. The Department reviewed documentation, Zoom recordings, and conducted interviews relevant to the allegation, “failure to response to resident association timely.” Emails from the RC/FC to the Executive Director (ED) and another Oakmont Management member (S1) with questions requesting responses were sent on numerous dates (January 14, 16, 2025, and February 24, 2025) with no follow-up responses provided. Additionally, during the Semi-Annual Meeting – Budget on January 30, 2025, residents asked multiple questions and were told they would have a response in writing within 7 days, documents provided do not show that this promise was delivered upon, nor were any written responses outside of an “Occupancy & Care Breakdown” provided as follow ups to residents’ questions. Additionally, the ED did admit that sometimes responses are given verbally to questions and there is no follow-up in writing. Information obtained supports that a violation occurred. Continued on LIC9099C.. Due to this information, the allegation is found to be substantiated. The management failed to provide a written response to the RC/FC’s written requests and concerns. This deficiency will be cited, Pursuant to HSC section 1771.7(d)(1)(d) A continuing care retirement community shall maintain an environment that enhances the residents’ self-determination and independence. The provider shall do both of the following: (1) The management shall respond, in writing, to a written request or concern of the resident association within 20 working days of receiving the written request or concern, see LIC9099D. A technical violation of HSC section 1569.157(c) is also being noted. Fountaingrove Lodge is both a Continuing Care Retirement Community and a Residential Care Facility for the Elderly and thus must also follow the requirement in HSC 1569.157(c) that states, If a resident council submits written concerns or recommendations, the facility shall respond in writing regarding any action or inaction taken in response to those concerns or recommendations within 14 calendar days. There was sufficient information obtained to support violations had occurred regarding the allegations, "failure to meet statutory requirements for budget process" and "failure to respond to resident association timely." 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) and Health & Safety Code (HSC) 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 Administrator Megan Leone. Appeal Rights Provided. The facility went through a change of ownership, and the former licensee is no longer here. The current licensee did not agree to upgrading the watt stopper system in any agreed upon time frame when purchasing the building/facility, and when applying for a change of ownership application as agreed upon with former licensee. Per interviews with staff, S1, and provided documentation by S1, the current information is the watt stopper system is on the list stating that Oakmont Management Group, and Fountaingrove Lodge are coordinating to have this project completed, in 2026. Investigation found that the watt stoppers do work, they no longer have a dimming feature, per interviews, and review of documentation. There was no information obtained to suport that a violation occurred regarding "facility has broken Watt Stoppers that have not functioned for multiple years." The Department reviewed documentation, Zoom recordings, and conducted interviews relevant to the allegation, “failure to provide adequate justification for monthly fee increase.” On January 23, 2025, an email was sent to residents announcing the 2025 Annual Budget and the upcoming Annual Budget meeting on January 30, 2025. The PowerPoint Presentation from the meeting on January 30, 2025, was reviewed, and while the documents reviewed do have a projected revenue growth of 5.9%, and the monthly care fee increase (MCFI) is 6%, HSC section 1788(a)(22) states that the factors for the increase must be based on projected costs, prior year per capita costs, and economic indicators, which were made evident in the budget presentation. The budget presentation included the 2024 budget vs the actual budget, projected costs for 2025, which included operating expenses such as: culinary expenses, care expenses, housekeeping expenses, etc., as well as economic indicators, which included rate of inflation and CPI, it appears that the MCFI factors that were provided in the presentation are in compliance with the statute. While there was confusion surrounding the memory care unit commonly referred to as, “The Terraces,” being included in the budget, The Terraces are part of Fountaingrove Lodge and are one entity being recorded on one financial statement. Continued on LIC9099C.. The Department reviewed documentation, Zoom recordings, and conducted interviews relevant to the allegation, “failure to file and post required reports timely”. It was alleged that the annual reports were not posted and filed timely. During the January 30, 2025, meeting, the ED did confirm that a late fee was paid for filing the 2023 Fiscal Year (FY) Annual Report late. Additionally, documents reviewed revealed that the provider requested and was granted an extension for the 2024 FY Annual Report. Fountaingrove Lodge’s Annual Report is due April 30th of each year and has been submitted late the last two years, however, the appropriate late fee was paid in 2023, and an extension was requested and granted in 2024. When reviewing the community’s website, the Annual Report was easily located, and interviews revealed that it is available within the community and by request. There was no information obtained to support that violations had occurred regarding "facility has broken Watt Stoppers that have not functioned for multiple years'", "failure to provide adequate justification for monthly fee increase", and "failure to file and post required reports timely." Due to this information the Department finds these allegations to be UNSUBSTANTIATED – a finding of unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited. Exit interview conducted with Administrator Megan Leone.the state’s words, verbatim · CDSS document, Nov 10, 2025 · control 21-AS-20250616083546

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1771.8(d) · Plan of correction due date: Nov 24, 2025

HSC1771.8(d)- At least 14 days prior to the meeting to discuss an increase in the monthly care fee, the provider shall make available to each resident or resident household comparative data showing the budget for the upcoming year, the current year’s budget, and actual and projected expenses for the current year, and a copy shall be posted in a conspicuous location at each facility, This requirement was not met as evidenced by: Department's investigation found the provider failed to make available to residents the budget for the upcoming year 14 days prior to the meeting, the budget was provided to residents less than 3 hours prior to the meeting. This a risk to residents' personal rights.the state’s words, verbatim · CDSS document, Nov 10, 2025

Plan of correction: Licensee/Administrator to ensure that they make available to residents' all "required" budget information, including budget information for the upcoming year, "14 days prior to the meeting" with residents regarding the facility budget. Please submit a written plan in ensuring future compliance with this HSC requirement. POC due 11/24/2025.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1771.7(d)(1)(d) · Plan of correction due date: Nov 24, 2025

HSC1771.7(d)(1)(d) A continuing care retirement community shall maintain an environment that enhances the residents’ self-determination and independence. The provider shall do both of the following: (1) The management shall respond, in writing, to a written request or concern of the resident association within 20 working days of receiving the written request or concern, This requirement was not met as evidenced by: Department Investigation found the management failed to provide a written response to the RC/FC’s written requests and concerns as required by HSC. This is a risk to residents' personal rights.the state’s words, verbatim · CDSS document, Nov 10, 2025

Plan of correction: Licensee to ensure that they respond in writing, to a written request or concern of the resident association within 20 working days of receiving the written request or concern as required. Please submit a written plan in ensuring future compliance with this HSC requirement. POC due 11/24/2025.

Allegation investigated: Staff did not issue proper refund to resident.

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 8/19/25 at approximately 9:45am, and met with Administrator Megan Leone. Reporting party alleges "staff did not issue proper refund to resident". LPA reviewed resident R1's records, obtained copies of documents, interviewed staff, and reviewed information obtained from other parties. The investigation revealed that per the contract agreement, page six, 7.2.2., the "entrance fee refund" for an apartment/bungalow, resident would receive the repayment amount within fourteen (14) calendar days after the former apartment/bungalow is reoccupied by a new resident who has executed a residence & services agreement, and paid the applicable entrance fee for the apartment/bungalow, or one hundred twenty (1200 months after the agreement was terminated, whichever is earlier. R1's former apartment was reoccupied by a new resident, resident signed a residence & services agreement, and applicable entrance fee was paid on 6/1/2025. Administrator provided documentation that resident R2 occupied the apartment, signed an admission agreement, and paid applicable entrance fee on 6/1/2025. Continued on LIC9099C.. Substantiated Resident R1 received from Fountaingrove Lodge licensee a refund check on 6/24/25, which was short by $258.71. Administrator offered to have accounting of Fountaingrove Lodge send another check for the owed amount of $258.71. R1 refused this offer and requested that Fountaingrove Lodge provide a new check with the full owed "entrance fee refund". R1 returned the check with the incorrect amount of their refund to the Administrator. The second check requested from Fountaingrove Lodge licensee was received by the resident R1 on 8/6/2025. Investigation revealed, the first refund check to return owed funds to R1, from former unit's occupancy on 6/1/25, was received outside of the required 14 days from this date, per contract. Per review of records, conducted interviews with staff and other related parties, information obtained, the allegation of "staff did not issue proper refund to resident" is substantiated. The following deficiency will be cited, HSC1788.4.(a)(e) Refunds A lump-sum payment after termination of a repayable contract, as defined in paragraph (3) of subdivision (r) of Section 1771, shall not be considered to be a refund and may not be characterized or advertised as a refund. The full lump sum owed, including any interest accrued, shall be paid to the resident within 14 calendar days after resale of the unit, 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. Appeal Rights Given. Exit interview conducted with the Administrator Megan Leone.the state’s words, verbatim · CDSS document, Aug 19, 2025 · control 21-AS-20250710164923

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1788.4(a)(e) · Plan of correction due date: Aug 19, 2025

HSC1788.4. (a)( e)Refunds A lump-sum payment after termination of a repayable contract, as defined in paragraph (3) of subdivision (r) of Section 1771, shall not be considered to be a refund and may not be characterized or advertised as a refund. The full lump sum owed, including any interest accrued, shall be paid to the resident within 14 calendar days after resale of the unit, This requirement was not met as evidenced by: Investigation revealed, the first refund check to return owed funds to R1, from former unit's occupancy on 6/1/25, was received outside of the required 14 days from this date, per contract. This is a risk to resident's rights.the state’s words, verbatim · CDSS document, Aug 19, 2025

Plan of correction: Licensee to ensure that all resident refunds/lump sums owed are refunded to the resident and/or resident's estate per facility's contract agreement. Submit plan of future compliance with this H&S code for future terminations/cancellations of contract agreements. POC due 9/5/2025.

Allegation investigated: Facility staff are not preventing the spread of a communicable disease.

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 8/19/25 at approximately 9:45am, and met with Administrator Megan Leone. Reporting party alleges that “facility staff are not preventing the spread of a communicable disease”. LPA reviewed eight (8) resident records, progress notes, and medical records/medication orders. LPA interviewed staff, S1, S2, S3, and S4, regarding resident care, the allegation of a current contagious disease outbreak, and facility infection control procedures. The investigation revealed that residents' records reviewed identified that none of the eight (8) residents have scabies and/or bed bug bites. Caregivers/staff have all personal protective equipment (PPE) supplies available for use to them if needed, per infection control plan and job duties. Continued on LIC9099C.. Unsubstantiated There have been staff, S3, S4, S5, and S6, that were tested by their own Doctor's for scabies and/or other contagious disease; Staff have notified Administration staff of medical visits, and that they were not infected with scabies and/or other contagious disease. The facility had an inspection conducted by a professional company, Eco Lab, on 8/15/25, which found no scabies and/or bed bug outbreak in the memory care building. There was differing information obtained from what was reported. There was no information obtained in the investigation to support a violation had occurred. Based on LPA interviews, record/document reviews, and related information obtained during the investigation, the allegation is Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies cited. Exit interview conducted with Administrator Megan Leone.the state’s words, verbatim · CDSS document, Aug 19, 2025 · control 21-AS-20250814081323

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct an Annual Required - 1 Year inspection, at approximately 9:45am on 6/4/25, and met with Administrator Megan Leone. LPA toured the facility, assisted living (AL) main building, and the memory care (MC) building, with administration staff, Megan Leone, Administrator/ED, Joel Gonzalez, Business Office Director (BOD), and Michelle Simpson, Health Services Director. Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has a plan of operation for dementia care. The facility has a hospice waiver approval for ten (10) residents. Fire clearance is approved for one hundred and seventy-three non-ambulatory, of which 16 may be bedridden. Capacity breakdown as follows: AL main building, and the five (5) bungalows are cleared for one hundred and forty (140) non-ambulatory, of which six (6) may be bedridden, the MC building is cleared for thirty-three (33) non-ambulatory, of which ten (10) may be bedridden; Total license capacity is one hundred and seventy-three (173) . The delayed egress is approved, per fire clearance. Per review of the emergency disaster drills binder, the facility is completing quarterly drills as required.All exits were clear and unobstructed. Facility fire extinguishers were serviced and tagged as required. All stairwells, four (4) in AL, and one (1) in MC, all had the required emergency evacuation chair, including all had instructions on use posted up. LPA reviewed ten (10) resident files, including medications, and medication records were reviewed. LPA reviewed ten (10) staff files. All staff had required criminal record clearance. All staff have required training. Facility has sufficient supply of perishable and non-perishable food. Freezer and refrigerator was observed to be orderly, and within required temperature (s). Continued on LIC809C... Facility had sufficient supply of the following: cleaners/disinfectants, paper products, soaps, sanitizer, and personal protective equipment (PPE). Facility had sufficient lighting throughout the facility, in observed common areas, hallways, and bathrooms. Facility was at a comfortable temperature during the inspection. Facility had emergency supplies as required; Facility had supplies to meet the requirements of "72 hours- Shelter in Place". LPA is requesting the following documents be updated and submitted by 7/4/25: LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required -if no changes, submit the last page with date/signature of review) Infection Control Plan (ensure to review and update as needed/required -if no changes, submit the last page with date/signature of review) Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed Copy of Current Liability Insurance Copy of Administrator Certificate Updated LIC500 Personnel Report LIC308 - Designation of Administrator Responsibility The following observed deficiencies will be cited: LPA observed with the administration staff during the memory care tour that a resident's, R1, room smelled strongly of urine, observing the room to be in need of a deep cleaning to ensure "facility is free from incontinent odors" as required by regulation; Managed Incontinence 87625(b)(3)- Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence, see LIC809D. LPA observed with the administration staff during the memory care tour that resident’s, R1, room had blinds hanging on their windows that were broken and some pieces missing; LPA observed the blinds hanging on the window in joint/shared private sitting area right outside of R1's room to be in the same condition as their room blinds. 87303(a) Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors, see LIC809D. 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/ED Megan Leone. Appeal Rights Provided to the Administrator/ED.the state’s words, verbatim · CDSS document, Jun 4, 2025

Allegation investigated: Staff is restricting resident's ability to have visitation

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 5/20/25 at approximately 9:45am, and met with Administrator Megan Leone. Reporting party alleges that “staff is restricting resident's ability to have visitation”. LPA reviewed resident’s (R1) records. LPA reviewed the signed admission agreement, including the facility’s “house rules” in the agreement. LPA reviewed all admission documents, including medical assessment, resident care plan, and medication list/Dr’s Orders. LPA reviewed facility policy and procedures regarding resident visitors/guests, including by former staff; LPA reviewed facility policy and procedures on residents/responsible parties hiring a resident companion. Reviewed policy and procedures of staff accepting gifts and gratuities. The LPA obtained copies of requested records. Continued on LIC9099C.. Unsubstantiated The LPA conducted interviews with staff, and other related parties. Per review of records, observations, and information obtained, the investigation revealed there was no information obtained that the facility was restricting resident’s ability to have visitation. There was information reviewed and obtained of communication from administration staff to a current staff (S2) (at the time), of facility employee handbook policy and procedures. The communication documentation stated in writing the responsibility of the facility staff to ensure compliance with the employee handbook and facility policies/procedures regarding employment, and any interactions with residents of the community. The documentation reviewed referred to policy and procedures of a former staff regarding “community visits” when employment ends, interactions with staff during their visits, and requirements of a “resident companion” that need to be complied with, if they are a resident companion. Per interviews, former staff does come into the community to visit with R1. There was differing information obtained from parties interviewed; There was no information obtained in the investigation to support a violation had occurred. Per the investigation regarding the allegation that “staff is restricting resident's ability to have visitation” is unsubstantiated. Based on LPA interviews, record/document reviews, and related information obtained during the investigation, the allegation is Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies cited.the state’s words, verbatim · CDSS document, May 20, 2025 · control 21-AS-20250306141449

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alviso conducted a case management- incident inspection, on 5/20/25 at approximately 3:30pm, and met with Administrator Megan Leone, and Heath Services Director Michelle Simpson.LPA is conducting a case management to obtain more information on a resident AWOL incident that was reported by the Administrator. LPA reviewed resident (R1's) records. On the day the resident (R1) had eloped there was a move-in, and the alarms on the exit door had been turned off. R1 had eloped/AWOL from the memory care unit without staff's knowledge and/or supervision. R1 had a fall when eloping the facility, and was found on the floor outside. R1 had a skin tear on their elbow and abrasion to their eyebrow. Staff provided first aid, and 911 was called as a precaution. R1 was cleared to remain in the facility after assessment by 911 responders. LPA requested copies of specific resident records. LPA requested copies of the AWOL/Elopement training's provided to the staff, and the revised "door security checklist" implemented in the memory care unit. Copies were provided to the LPA. Following deficiency will be cited: The deficiency will be cited, 87705(d) Care of Persons with Dementia - The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions, see LIC809D. 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 Maria Cortes. Appeal Rights Provided to the Administrator.the state’s words, verbatim · CDSS document, May 20, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: May 21, 2025

87705(d) Care of Persons with Dementia - The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement- This requirement was not met as evidenced by: Per LPA's review, On the day the resident had eloped there was a move-in and the alarms on the exit door had been turned off. R1 had eloped/AWOL from the memory care unit without staff's knowledge and/or supervision. R1 was had a fall when eloping the facility, and was found on the floor outside. R1 had a skin tear on their elbow and abrasion to their eyebrow. R1 was cleared to remain in the facility after assessment by 911 responders. This is a risk to resident's personal rights & health & safety.the state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: CORRECTED- POC CLEARED. ADMINISTRATOR TRAINED STAFF ON ELOPEMENT PROCEDURES & IMPLEMENTED REVISED DOOR SECURITY CHECKLIST, INCLUDING DURING MOVE-INS AND MOVE-OUTS.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alviso conducted a case management- incident inspection, on 3/11/25 at approximately 3:58pm, and met with Administrator Megan Leone. LPA is conducting a case management to obtain more information on a resident incident that was reported by the Administrator. LPA reviewed resident (R1's) records. LPA requested copies of specific resident records. LPA also requested a current staff roster. Copies were provided to the LPA. There are no deficiencies cited today. Exit interview was conducted with Administrator Megan Leone.the state’s words, verbatim · CDSS document, Mar 11, 2025

Allegation investigated: Staff do not prevent resident from entering another residents room Staff do not prevent resident from causing harm to other residents Staff are inappropriately locking resident rooms

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 9/10/24 at approximately 2:00pm, and met with Megan Leone, Administrator. LPA reviewed resident (R1 & R2) records, facility records, and obtained copies of records. LPA conducted interviews with staff and other related parties. The investigation revealed that residents R1 and R2 reside in the memory care unit. Residents both have care plans in place, and per review, R1 & R2 are not one to one care need residents. Residents are able to walk around the memory care unit, as the residents are not to be restrained in any way. The memory care unit has a locked perimeter and residents may walk around freely if able to. Residents are monitored and will be redirected if needed. If a resident wanders into a room that is not theirs they are redirected by staff. Residents are able to have their rooms locked to ensure their privacy and to secure their belongings. Residents may have the key if they can manage having the key to their locked room; Continued on LIC9099C... Unsubstantiated Residents may request entry into their room by staff at any time, if wanting to keep their room locked but can't manage having the key to their room. Staff will always assist a resident in having access to their room if they have it closed and locked. Residents may choose to have their rooms door closed and not locked, it is residents choice. Resident rooms may be locked and resident may have the key or not, this would be part of of a care plan with resident and/or responsible party. All resident rooms can be opened from the inside at all times, residents are never locked inside their rooms. Per interviews, and review of records, R1 has a care plan in place and staff monitor as needed. If observed wandering into a resident room that is not theirs, the staff redirect the resident. R1 does get confused of where their room is, and sometimes does wander to the wrong area and/or side of rooms, confused when turned away and redirected. Residents are monitored and redirected by staff, but residents are not to be restrained, forced, pushed around, and/or grabbed roughly by any staff or any other individual working and/or visiting the facility/other resident; Per interviews with staff R1 has been a resident for less than a year, and there has been decline with R1, and staff have been working to meet residents needs. Per review of records/alert charts and interviews, staff were monitoring R1 and redirecting as needed. Residents are reassessed as needed, care plans updated when needed, the facility will do what they can before assessing the resident needs a higher level of care. Staff stated they address the needs of all residents in care. Staff denied to the LPA that they neglect residents in care and/or let residents harm themselves or other residents in care. Per the investigation regarding the allegations that "staff do not prevent resident from entering another residents room, staff do not prevent resident from causing harm to other residents, staff are inappropriately locking resident rooms" there was no information obtained that supported violations had occurred regarding the allegations. 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 Administrator Megan Leone.the state’s words, verbatim · CDSS document, Sep 10, 2024 · control 21-AS-20240521123549

Allegation investigated: Staff did not check on resident every 2 hours. Staff left resident soiled for an extended period of time Staff does not ensure resident is assisted with showering needs Staff does not ensure resident's room is clean and sanitized Staff did not respond to resident's call in a timely manner Staff does not provide resident with clean linen Staff does not ensure resident is provided water

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 8/27/24 at approximately 9:45am, and met with Megan Leone, Administrator. LPA also met with Michelle Simpson, Health and wellness Director, and Juan Ferrel, Memory Care Director. LPA reviewed resident (R1) records, facility records, conducted interviews with staff and other related parties. The investigation revealed that R1was admitted 2/25/24, there was a care plan in place upon admission;This is an intial care plan and will updated as needed. Per review of medical hospice documentation there were no documented issues and/or concerns regarding care of R1, while hospice came into the facility to provide care. The care plan would be reviewed and any changes completed and/or care services immediately needed approximately after the first three weeks in care, per reviews with S3 and provided documentation. Per review of medical documentation, R1 was incontinent, and their care plan noted incontinent care services being provided. LPA reviewed facility records/chart notes on R1, R1 had several falls, no serious injuries noted; R1has had unwitnessed falls per record reviews. Continued on LIC9099C... Unsubstantiated R1 is not a one to one staffed resident. R1 is diagnosed with having Parkinsonism and impaired vision per medical documentation. Two of the falls happened while resident was being escorted by staff, staff helped guide resident down to the floor. Per record reviews, and interviews, R1 was on the schedule for two showers a week and as often as needed. R1's linens and clothing would be laundered on their scheduled day and as often as needed, per staff interviews. Interviews conducted with staff S1, S2, and S3, revealed that residents are all provided hydration, and there is a hydration cart at all times for residents in care. Staff all stated the resident was on two-hour checks for wellness and to check for incontinent care needs. Per interviews with S1, S2, and S3, R1's room was cleaned and bed linen changed every assigned weekday, and as often as needed due to incontinence and/or any other incident/accident. R1's room and/or any area of the unit, would have a work order for rug cleaning if needed due to incontinent accidents. Per staff interviews, if resident called out for any assistance and/or need, the staff would go to the resident and provide services as needed. Staff deny that the resident was ignored and/or neglected by them or any staff. The investigation, review of documentation/records, including medical documentation, interviews with staff, and other parties, provided differing information regarding the allegations. There was no information obtained during the investigation to support that the violations had occurred. Per the investigation regarding the allegations that "staff left resident soiled for an extended period of time, staff does not ensure resident is assisted with showering needs, staff does not ensure resident's room is clean and sanitized, staff did not respond to resident's call in a timely manner, staff does not provide resident with clean linen, staff does not ensure resident is provided water", there was no information obtained that supported that the violations had occurred. 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 Administrator Megan Leone.the state’s words, verbatim · CDSS document, Aug 27, 2024 · control 21-AS-20240403094147

Allegation investigated: Apartment unit has another water leak, not repaired, the unit has had many water leaks in the last few months

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 8/7/2024 at approximately 11:00am, and met with Joel Gonzalez, Business Office Director, and Health Services Director, Michelle Simpson. Administrator would be arriving to the facilty later this morning to meet with the LPA. LPA reviewed records, obtained copies of documents, interviewed staff, and other related parties.The LPA reviewed the following facility records: records on the leaks in the apartment unit, of R1 & R2, repair receipts of 2024 on leaks in the unit, and report on testing the units water damaged areas for mold, inspected by Air Environmental. LPA reviewed plans on facility obtaining a new dishwasher, and the kitchen floor being resealed; The water has been leaking from the kitchen to the apartment unit below. The apartment unit has had leaks on 3/13/24, 4/18/24, 6/15/24, and on 7/27/24. All leaks were repaired, except the leak of 7/27/24 as this will be repaired once the kitchen repairs are completed. LPA reviewed records of options offerred to R1 & R2 regarding their apartment unit, they can move into a comparable unit if available, and they may stay in a guest suite and/or a hotel during apartment unit repairs. These offers have been declined in the past, but are offerred during the repair time for the 7/27/24 leak. Per review of financial account records, there have been rent credits provided for each time leaks occurred resulting in needed repairs. Per interviews, the kitchen has had past plumbing issues, drain issues, and most recently the leaking of the dishwasher. Some of residents' belongings were stored by the facility for them until repairs were completed. Continued on LIC9099C... Substantiated The investigation revealed that R1 & R2's unit has water damage from a leak that occurred 7/27/24, and can't be repaired until other work is completed in the kitchen area, as stated above. Residents, R1 & R2, have had numerous leaks occur in the past, and this year there have been four leaks, see dates above. Per interviews, staff have observed and known of past water leaks in the facility kitchen, including the latest from the dishwasher. Per review of records, conducted interviews with staff and other related parties, information obtained, the allegation of "Apartment unit has another water leak, it's not repaired, the unit has had many water leaks in the last few months" is substantiated. The following deficiency will be cited, 87303(a) Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors., 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. Appeal Rights Given. Exit interview conducted with the Administrator Megan Leone.the state’s words, verbatim · CDSS document, Aug 7, 2024 · control 21-AS-20240731131411

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 19, 2024

87303(a) Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: The investigation revealed that R1 & R2's unit has water damage from a leak that occurred 7/27/24, and can't be repaired until other work is completed in the kitchen area, as stated above. Residents, unit has had numerous leaks occur in the past, and this year there have been four (4) leaks, see dates above. Per interviews, staff have observed and known of past water leaks in the facility kitchen, including the latest from the dishwasher. This is a risk to residents personal rights and/or health & safety.the state’s words, verbatim · CDSS document, Aug 7, 2024

Plan of correction: Licensee/Administrator to submit plan of repairing the water damage in R1 &R2's unit, and plan on repairs to the kitchen, the dishwasher and resealing of the floor. Submit plans of corrections, and estimated start and completion dates. POC due 8/19/24

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct an Annual Required - 1 Year inspection, at approximately 11:25am on 7/25/24, and met with Administrator Megan Leone. Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has an approved dementia plan. The facility has a hospice waiver approval for ten (10) residents. Fire clearance is approved for one hundred and seventy-three non-ambulatory, of which 16 may be bedridden; Capacity breakdown as follows: main building, and the five (5) bungalows are cleared for one hundred and forty (140) non-ambulatory, of which six (6) may be bedridden, the memory care building is cleared for thirty-three (33) non-ambulatory, of which ten (10) may be bedridden, total license capacity is one hundred and seventy-three (173) . The delayed egress is approved, per fire clearance. LPA reviewed nine (9) resident files. LPA reviewed nine (9) staff files. All staff had required criminal record clearance. All staff had required first aid certification, and cpr certification. All staff have required training. Medications and medication records were reviewed. Per review of the emergency disaster drills binder, the facility is completing quarterly drills as required; Fire drills held on 6/6/24, 6/11/24, and an evacuation drill held on 4/30/24. The LPA toured the facility, main building and memory care building, with Administrator Megan and Joel Gonzalez, Business Office Director. Hot water was checked at 119.3 degrees Fahrenheit in the main building and 111. degrees Fahrenheit, which are both within regulation compliance. All exits were clear and unobstructed. Facility fire extinguishers were serviced and tagged as required. All stairwells had evacuation chairs and posted instructions for staff if needed in an emergency. Continued on LIC809C... Emergency disaster plan binder is kept at the concierge desk, and all staff have access as needed in case of an emergency. The plan and identified staff for emergency response was posted up in the copy/mail room, which is the room behind the concierge area. All keys to units and vehicles are in lock boxes accessible by staff on every shift. Food supply was sufficient. Facility had a sufficient supply of emergency food, water, miscellaneous supplies to meet the required 72 hour in place requirement. Facility had a sufficient supply of disinfectants/cleaners, paper products, hygiene products, and personal protective equipment (PPE). The facility had sufficient lighting in all common areas, bathrooms, and hallways. Bathrooms observed by the LPA had grab bars and non-slip flooring/mats as required. LPA is requesting the following documents be updated and submitted by 8/25/2024: LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required-if no changes, submit the last page with date/signature reviewed) Infection Control Plan (ensure to review and update as needed/required-if no changes, submit the last page with date/signature reviewed) Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed Copy of Current Liability Insurance There are no deficiencies cited during today's visit. Exit interview conducted with Administrator Megan Leone.the state’s words, verbatim · CDSS document, Jul 25, 2024

Type of visit: Case Management - Incident

Licensing Prigram Analyst (LPA) Alviso conducted a case management incident inspection, on 2/27/24 at approximately 9:10am, and met with Megan Leone, Executive Director (ED). The case management is being conducted to review and obtain additional information, on a resident incident that was recently reported to the Department. The LPA reviewed the incident report, death report, and resident records, including medical documentation. Per review of records, information obtained, and interviews with staff, R1 was identified as independent, and was able to access the community on their own. Per review of today's records and interviews, staff addressed the incident as needed, when it occurred. No deficiencies cited during today's inspection.the state’s words, verbatim · CDSS document, Feb 27, 2024