Grand Oaks Assisted Living

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are not abiding to the admission agreement Staff do not provide adequate transportation services

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to deliver findings. LPA met with Assistant Administrator Alena Lema. LPA interviewed staff and residents. LPA reviewed records. Based on records review and interviews, facility is charging a $35 dollar additional internet/wifi fee to residents. Facility does not have a list of optional services that show fees listed in the admissions agreement. Based on records review and interviews, the admissions agreement states Licensee will provide transportation to medical and dental appointments. Based on interviews, since on or about August 2025, facility is not assisting residents with transportation to doctor/dental appointments. Substantiatedthe state’s words, verbatim · CDSS document, Jan 26, 2026 · control 24-AS-20251105104638

Allegation investigated: Facility staff are not properly supervising resident who is a fall risk.

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to deliver findings. LPA met with Assistant Administrator Alena Lema. LPA interviewed staff. LPA reviewed records. LPA observed photos. Based on interviews and photos and records review, facility staff were not properly supervising R1. Photos reveal R1 with half bedrails and another postural support/restraint near the bottom end of the bed with large pillows and a tv tray in between the bedrails and the additional postural support/restraint in attempt to prevent R1 from getting out of bed due to R1 being a high fall risk. Based on records review, there was no doctor perscription for R1 for restraints or postural supports. Facility has a plan for low/moderate fall risk residents, but does not have a plan for high risk fall residents. Substantiatedthe state’s words, verbatim · CDSS document, Jan 26, 2026 · control 24-AS-20251119202642

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff neglected resident of goods and services. Staff neglected resident of physical care. Resident's health and safety endangered.

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct a complaint investigation. LPA explained the purpose of the visit and was granted entry by Medication Technician Jessica Onsurez. Administrator Alena Lema and Administrator David Shellhamer responded to the facility to assist with the visit. LPA obtained a copy of the staff roster. Based on records review there was not a staff listed on the staff roster that are listed in this complaint. Based on interviews, the facility has not received any residents from the skilled nursing facility that is listed in this complaint. Based on LPA's interviews and record review, this agency has investigated the complaint alleging, Staff neglected resident of goods and services, Staff neglected resident of physical care and Resident's health and safety endangered. We have found that the complaint was UNFOUNDED, which means it could not have happened, and/or is without a reasonable basis, therefore we have dismthe state’s words, verbatim · CDSS document, Jan 10, 2026 · control 24-AS-20251106212728

Allegation investigated: Licensee is not ensuring that staff are seeking medical attention for resident as necessary.

On 07/08/25, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct the required 10 day site visit. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility. LPA met with Administrator and Residential Care Coordinator (RCC) to discuss the allegation. During the investigation, LPA toured the facility, reviewed Resident R1's records and interviewed staff. Based on the information received, R1 was admitted on Infinite Heart Hospice on 06/04/25 with a plan of care to include Hospice Nursing visits and Home Health visits . LPA observed Hospice records including the plan of care , nursing visits and assessments. Medical attention is being provided. Although the allegation may have happened, there is not a preponderance of evidence to prove that the alleged violation occurred, therefore the allegation is Unsubstantiated. Exit interview conducted and copy of report was left with Administrator. No deficiency citthe state’s words, verbatim · CDSS document, Jul 8, 2025 · control 24-AS-20250630132724

Allegation investigated: Staff retained resident whose needs are beyond the scope of care of the facility Staff did not treat residents with respect Staff allowed family members to reside at the facility

On 05/30/25, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to deliver findings on the above allegations. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility. LPA met with Administrator, David Shellhamer to discuss the findings. During the investigation, LPA interviewed Reporting Party and staff. LPA reviewed R1's records and observed R1 was a new admission on 03/11/25. R1 was discharged from the hospital on 03/11/25, placed on hospice and passed away on 03/13/25. Hospice care plan was observed on file. Interviews with staff and residents were conflicting in regard to residents not being treated with respect. Resident R2 was admitted to the Skilled Nursing Facility (next door) on 02/27/25 and discharged from Assisted Living on 03/30/25. R2's son stayed in the AL facility for 3 days during the period 03/09/25-03/12/25. The Department has investigated the allegations. Although the allegations may have hthe state’s words, verbatim · CDSS document, May 30, 2025 · control 24-AS-20250312094236

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff does not ensure resident medication is administered as needed.

On 10/29/24, Licensing Program Analysts (LPAs) L. Salazar and K. Kaur arrived at the facility unannounced to deliver findings on the above allegations. LPAs stated the purpose of their visit and were allowed entry into the facility. LPAs met with Residential Care Coordinator and Adminstrator to discuss the findings. Administrator is out of the facility and was available via telephone. During the investigation, LPA Salazar reviewed Centrally Strored Medication Destruction Records (CSDMR), Medication Administration Record (MAR), and observed 9 out of 23 days in April 2024, Resident R1 did not recieve their medication. LPA interviewed facility Staff S1, who signed off on the MAR. S1 stated they could not read the blood sugar levels and documented as "HI" and did not administer medication on 9 our of the 23 days recorded. Based on LPA’s observation of records and interview with Staff S1, the preponderance of evidence standard has been met; therefore, the above allegation is found to be Subthe state’s words, verbatim · CDSS document, Oct 29, 2024 · control 24-AS-20240725113052

Allegation investigated: Facility staff did not dispense medications as prescribed Licensee did not ensure that resident's medication was administered by an appropriately skilled professional

On 10/29/24, Licensing Program Analysts (LPAs) L. Salazar and K. Kaur arrived at the facility unannounced to deliver findings on the above allegations. LPAs stated the purpose of their visit and were allowed entry into the facility. LPAs met with Residential Care Coordinator and was available via telephone. During the investigation, LPA Salazar toured facility, and conducted interviews with staff. Based on the information received,facility staff was giving medication per Dr.'s order and staff were allowed to administer the predosed medication from Hospice. Based on the information recieved, the allegations Facility staff did not dispense medications as prescribed and Licensee did not ensure that resident's medication was administered by an appropriately skilled professional are Unfounded. Meaning, that the allegations are false, could not have happened and/or are without reasonable basis, therefore, we have dismissed the complaint. Exit interview conducted. Nothe state’s words, verbatim · CDSS document, Oct 29, 2024 · control 24-AS-20240913135352

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Licensee did not provide a copy of the resident's records to the resident's legal representative.

On 9/12/2024, Licensing Program Analyst (LPA) M. Medina conducted an unannounced initial 10-day complaint visit. LPA introduced self and stated purpose of visit. David Shellhamer, Administrator was not available to conduct today's visit. LPA met with Wendi Valdez, Resident Care Coordinator. This agency has investigated the complaint alleging Licensee did not provide a copy of the resident's records to the resident's legal representative. Based on the information received, Resident R1 passed away prior to the licensure of Grand Oaks Assisted Living on 06/06/24. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Nothe state’s words, verbatim · CDSS document, Sep 13, 2024 · control 24-AS-20240904155634

Allegation investigated: Staff administered the incorrect medication to residents in care. Staff opened residents mail.

On 08/28/24, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct the required 10 day site visit. LPA was greeted by Administrator and Residential Care Services Coordinator, stated the purpose of the visit, and was allowed entry into the facility. LPA conducted interviews and records review. Based on the information received, and although the allegations may have happened, there is not a preponderance of evidence to prove that the alleged violations occurred, therefore the allegations are Unsubstantiated. Nothe state’s words, verbatim · CDSS document, Aug 28, 2024 · control 24-AS-20240819102011

Allegation investigated: Staff did not provided care for resident Staff did not shower and bathe resident Staff did not change resident's bedding

On 07/23/24, Licensing Program Analyst (LPA) arrived to the facility unannounced to conduct the required 10 day site inspection. LPA was greeted by Residential Care Coordinator (RCC), stated the purpose of the visit, and was allowed entry into the facility. LPA requested the facility roster and did not observe resident's name that was reported in the allegations. LPA asked RCC to contact the Administrator next door at Grand Oaks Skilled Nursing Facility (SNF) to obtain a facility roster. Administrator of SNF, Michelle Lawrence, arrived at the facility with the SNF roster. LPA observed resident on SNF roster and it was verbally confirmed the resident does not live in the jurisdiction of CCL regulations. A cross report to CDPH has been made. Based on the information received, the allegations are UNFOUNDED, meaning they are false, could not have happened, and/or without a reasonable basis. Therefore, we have dismissed the complaint. Unfoundedthe state’s words, verbatim · CDSS document, Jul 22, 2024 · control 24-AS-20240719161548

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.