Oakmont of Camarillo

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

Allegation investigated: Facility is in disrepair.

Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint visit to investigate the allegation noted above. Upon arrival, the LPA met with Executive Director (ED), Mark Cortes, and the reason for the visit was explained. Entrance interview. During today’s visit, approximately between 10:00am and 11:30am, the LPA along with the ED conducted a brief plant tour, conducted interviews with two staff members, and obtained copies of pertinent documents relevant to the investigation. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that facility is in disrepair. It was reported that the main elevator near the front lobby had been out of service since 12/20/2025 and that the facility did not order the replacement part needed to repair the elevator in a timely manner. Records reviewed and interviews conducted revealed that the elevator went out of service on Friday, 12/12/2025. A service technician from the vendor, TK Elevator, inspected the elevator on the next business day, Monday, 12/15/2025. On 12/16/2025, the facility contacted the vendor to inquire about the status of the repair. At that time, the facility was informed that the required part—hydraulic packing—would be ordered and that a repair crew would be scheduled to complete the work. Although the necessary part was ordered shortly after the technician evaluated the issue, the delivery of the part and completion of the repair took longer than anticipated. A review of communication records with the vendor confirmed that the part has now been received and that a repair crew is scheduled to complete the repair on 01/30/2026 between 6:00 a.m. and 8:00 a.m. Furthermore, the facility consistently contacted the vendor throughout the process to request updates. During this time, one (1) additional elevator remained fully operational and available for use by residents and staff at all times while the main elevator was out of service. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “facility is in disrepair”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 29-AS-20260120140611

Allegation investigated: Staff sexually abused resident in care.

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver findings for the above allegation. The LPA met with Executive Director (ED), Mark Cortes and explained the reason for the visit. Entrance interview. On 08/07/2025, the Department received a complaint alleging that a staff member sexually abused a resident in care. It was reported that Resident #1 (R1) stated they had been sexually abused twice within the past month. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Jonny Canto to interview R1 and obtain relevant documentation. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... A case management visit addressing the same allegation was conducted on 08/06/2025 by LPA E. Peraldi. During the visit, LPA Peraldi interviewed the ED at 11:30 a.m., requested and obtained copies of pertinent documents at 12:00 p.m., and conducted a physical plant tour at 12:15 p.m. During an initial visit on 08/08/2025, between approximately 1:00 p.m. and 2:15 p.m., LPA Chochian conducted a physical plant tour with the Marketing Director (MD), Emilia Ruiz, met with random residents, and interviewed five (5) residents in the assisted living unit and three (3) residents in the memory care unit. Investigator Canto reviewed police records and conducted interviews with residents on 08/21/2025 at approximately 3:38 p.m. and 4:15 p.m. The investigation revealed that on 08/03/2025, R1’s responsible party informed facility staff that R1 had reported being sexually abused twice within the past month. Further statements indicated this was not the first time R1 had made such an allegation. On 05/08/2023, R1 made a similar allegation of being sexually abused by a staff member. An investigation completed on 09/22/2023 found insufficient evidence to support that allegation. A review of R1’s Physician’s Report dated 06/18/2025 listed R1’s primary diagnosis as Alzheimer’s dementia. The report indicated that R1 lacks the capacity for self-care and requires assistance with all Activities of Daily Living (ADLs), including but not limited to bathing, dressing/grooming, feeding, toileting, medication administration, and managing own cash resources. The report also noted that R1 is unable to effectively communicate needs or follow instructions or directions. Per the hospice care plan effective 07/11/2025, R1 was recertified for routine level of care with a primary diagnosis of Alzheimer’s disease. The care plan also documented a medical history that includes hypothyroidism, dementia with psychosis, urinary tract infections (UTIs), and agitation. Interviews further revealed that following the allegation made by R1 on 08/03/2025, R1 was assigned female caregivers only. Staff stated that law enforcement, R1’s Primary Care Physician (PCP), and the hospice agency servicing R1 were notified of the incident. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Additional records reviewed and interviews conducted indicated that the Ventura County Sheriff’s Office (VCSO) responded to the facility on 08/05/2025. According to the report, attempts to interview R1 were unsuccessful, as R1 demonstrated cognitive impairment and difficulty providing relevant responses despite repeated redirection efforts. During an interview with R1’s responsible party, they confirmed that R1 had made similar allegations in the past that were determined to be unfounded. R1’s responsible party also stated that they stopped questioning R1 after the report to avoid influencing or any fabricated responses from R1. Furthermore, VCSO was unable to identify a suspect or establish that a crime had occurred. Based on the information obtained and reviewed during the course of the investigation, the Department has insufficient evidence to support the allegation of “staff sexually abused resident in care”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 29-AS-20250807144942

Allegation investigated: Staff did not ensure resident took medication as prescribed.

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial complaint visit was conducted on 11/20/2025 by LPA M. Arroyo. On today's visit, the LPA met with Executive Director (ED), Mark Cortes. Entrance interview. During the initial visit, LPA Arroyo conducted interviews with five staff, conducted a medication review of three randomly selected residents, and obtained copies of pertinent documents relevant to the investigation. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff did not ensure resident took medication as prescribed. It was reported that Resident #1 (R1) did not take their medications for several weeks, which resulted in R1 being hospitalized. Additionally, when R1 moved out of the facility, medications were found scattered throughout their apartment. The LPA conducted a medication review on 11/20/2025 and observed three (3) randomly selected residents centrally stored medications. Medication review revealed that medications were being properly documented on the Centrally Stored Medications and Destruction Record (CSMDR). The LPA and staff conducted a pill count, and the quantities matched the documentation. Staff also noted when residents did not take their medications as prescribed due to being away from the facility or refusing to take them. Interviews with staff revealed that they had not experienced any problems with R1 refusing medications or administering their prescribed medications. Staff stated that R1 understood the importance of taking their medications as prescribed. Staff explained that during medication administration, they provide residents with a cup of water and wait for the resident to take the medication and return the empty cup. Staff also stated that they have not had issues with residents hiding medications instead of taking them. Further interviews revealed that staff are familiar with residents who refuse medications or have difficulty taking them, and they stated that R1 was not one of those residents. Staff added that R1 was adamant about receiving their medications on time and that they had no concerns regarding R1’s medications. Staff also reported that R1’s family had never expressed any concerns. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff did not ensure resident took medication as prescribed”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 10, 2025 · control 29-AS-20251114180314

Allegation investigated: Staff did not ensure medication was inaccessible to resident. Staff spoke inappropriately to resident in care.

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial complaint visit was conducted on 11/04/2025 by LPA M. Arroyo. On today's visit, the LPA met with Executive Director (ED) Mark Cortes. Entrance interview. During the initial visit, LPA conducted interviews with four staff and two residents, conducted a resident file review, and obtained copies of pertinent documents relevant to the investigation between 12:15 p.m. and 02:45 p.m. On 11/10/2025, LPA Arroyo conducted telephonic interviews with two family members starting at 11:47 a.m. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff did not ensure medication was inaccessible to resident. It was reported that Resident #1 (R1) had taken THC gummies that were allegedly left in their room due to staff not properly cleaning the room. Record review and interviews conducted revealed that R1 was taken to the hospital on 10/02/2025 after feeling dizzy and weak. According to the incident report, R1 was transported to the hospital after care staff called 911. R1 returned to the facility the same day with a diagnosis of syncope. Interviews with staff indicated that all medications are kept in locked medication carts located inside the medication room. Staff stated that the medication room remains locked at all times when medications are not being administered or when staff are not present. Staff also reported that they assist residents with maintaining clean bedrooms and denied observing medications in any resident’s room. Interviews with R1’s family revealed that the facility communicates well with them regarding R1’s condition and needs. They stated that they had no concerns about R1 receiving the correct medications when ordered by a physician, noting that R1 was not on any medications until recently. Furthermore, during an interview, R1 denied eating any candy or taking any gummies. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff did not ensure medication was inaccessible to resident”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that staff spoke inappropriately to resident in care. It was reported that staff were observed being mean and yelling at Resident #2 (R2), telling R2 to stop crying. Interviews conducted with staff revealed that R2 often asks to speak with a specific family member. Staff stated that although they attempt to redirect R2, they sometimes call R2’s family to help calm R2. Staff added that R2’s family has stated they do not mind being contacted, as they want to ensure R2 is safe. Further staff interviews indicated that they have not observed other staff members disrespecting residents and denied ever having disrespected residents themselves while working and providing care. During interviews with R2’s family, they stated that facility staff are great and patient with R2 and expressed no concerns regarding how staff treat R2. Interviews with other residents’ family members revealed that they have not witnessed staff mistreating residents during their visits. Additionally, family members did not report any concerns about facility staff or the way residents are treated, stating that staff have been wonderful to both residents and visitors. Based on interviews, the Department has insufficient evidence to support the allegation of “staff spoke inappropriately to resident in care”. Therefore, this allegation is deemed Unsubstituted at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 10, 2025 · control 29-AS-20251029091523

Allegation investigated: Staff are not meeting resident's oral hygiene needs Staff are not meeting resident's grooming needs

Licensing Program Analysts (LPAs) Martha Arroyo and Brian Balisi conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial complaint visit was conducted on 07/29/2025 by LPA M. Arroyo. On today's visit, LPAs met with Executive Director (ED) Mark Cortes. Entrance interview. During the initial visit on 07/29/2025, the LPA along with the ED conducted a plant tour, interviewed four staff and one family member, and conducted a resident file review and obtained copies of pertinent documents. Hospice records were also requested and obtained during the course of the investigation. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... Records review and interviews conducted revealed Resident #1 (R1) was admitted to the facility on 08/31/2024. Per R1’s physician’s report dated 06/19/2025, R1’s primary diagnosis include dementia and a recurrent sacral pressure ulcer, with a noted lack of capacity for self-care. Per updated Resident Assessment dated 01/28/2025, it indicates that R1 requires hands-on assistance with all grooming and hygiene tasks. This includes assistance with showering or bathing 1–2 times per week, dressing and undressing twice daily, as well as toileting needs. It was alleged that staff are not meeting resident’s oral hygiene needs and staff are not meeting resident’s grooming needs. It was reported that R1 had significant buildup on their tongue and their skin appeared extremely dirty. Records review and staff interviews revealed that R1 was receiving services from Buena Vista Hospice. According to staff interviews, hospice staff provided R1 with showers twice a week, while facility staff gave sponge baths on the other days. Staff also stated that R1’s teeth were brushed daily and that R1 did not refuse oral hygiene care. They also added that any refusals of care are typically documented and communicated between staff; however, there were no refusals reported during the visit. Additional interviews revealed that R1 had specific preferences regarding which staff members assisted with their oral hygiene and grooming. Furthermore, an interview with R1’s family indicated that they visited R1 frequently—several times a week—and consistently observed that R1 was clean and well cared for and reported no concerns regarding R1’s care while residing at the facility. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegations of “staff are not meeting resident’s oral hygiene needs” and “staff are not meeting resident’s grooming needs”. Therefore, these allegations are deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was issued.the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 29-AS-20250724114217

Allegation investigated: Facility staff are not adequately trained and have not received instructions from a professional to manage resident's colostomy bag

Licensing Program Analysts (LPAs) Martha Arroyo and Brian Balisi conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial complaint visit was conducted on 08/29/2025 by LPA M. Arroyo. On today's visit, LPAs met with Executive Director (ED) Mark Cortes. Entrance interview. During the initial visit on 08/29/2025, between 09:32 a.m. and 11:30 a.m., LPA Arroyo conducted interviews with five staff and one resident, conducted a resident file review, and obtained copies of pertinent documents. Report Continued on LIC 9099C... Substantiated Report Continued from LIC 9099... It was alleged that facility staff are not adequately trained and have not received instructions from a professional to manage resident’s colostomy bag. It is the complainant’s concern that facility staff are draining resident’s colostomy bag daily; however, staff have not been trained by a licensed professional to properly drain the colostomy bag. During the visit on 08/29/2025, the LPA requested facility personnel records documenting staff training, including—but not limited to—training in colostomy care provided by a medical professional. However, no training records related to colostomy care were made available for review at that time. Further staff interviews revealed that caregivers had not received training from a medical professional prior to assisting the resident with draining their colostomy bag, and the facility did not have any training records on file related to colostomy care. On 09/12/2025, the LPA was provided with training records indicating that facility staff received colostomy care training from a medical professional on 08/29/2025 and 09/03/2025. However, this training occurred after staff had already been assisting resident with colostomy care. Based on the information obtained and reviewed during the course of the investigation, the Department has sufficient evidence to support the allegations of “facility staff are not adequately trained and have not received instructions from a professional to manage resident's colostomy bag”. Therefore, this allegation is deemed Substantiated at this time. The following deficiencies were observed and cited from the California Code of Regulations, Title 22. (See LIC 809-D). Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 29-AS-20250822191726

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87613(a)(2) · Plan of correction due date: Oct 21, 2025

Ensure that facility staff complete training provided by a licensed professional…training shall be completed prior to the staff providing services to the resident. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as staff was assisting resident with colostomy care prior to getting training by a skilled professional, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Colostomy Care training was provided to facility staff by a skilled professional on 08/29/2025 and 09/03/2025. Training records provided to LPA on 09/12/2025. POC has been met.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Martha Arroyo and Brian Balisi conducted a Case Management - Deficiencies visit in conjunction with complaint visit (Complaint Control # 29-AS-20250822191726). The purpose of the visit is to issue citations for deficiencies observed during the initial complaint investigation. During the initial visit on 08/29/2025, it was disclosed that Resident #1 (R1) has a colostomy bag and was reportedly receiving services from a Home Health Agency. The LPA requested a copy of R1’s Home Health care plan; however, facility staff were unable to provide the document at that time. Staff stated they would contact the Home Health Agency to obtain the care plan and forward it to the LPA. As of today's date, the care plan has not been received. During today’s visit, staff interviews revealed that R1 is not receiving Home Health services for ostomy care. Staff reported that an individual not affiliated with a Home Health Agency is currently providing the care. The LPAs were unable to verify whether the individual providing ostomy care is a qualified or licensed skilled professional. The following deficiencies were cited from the California Code of Regulations, Title 22 and California Health & Safety Code. (See LIC 809-D). The Administrator was informed that failure to correct deficiencies may result in future civil penalties. Exit interview conducted, appeal rights discussed, and a copy of report provided.the state’s words, verbatim · CDSS document, Oct 21, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87611(b)(2) · Plan of correction due date: Oct 31, 2025

The licensee shall complete and maintain a current, written record of care for each resident that includes...the names, address and telephone number of vendors, if any, and all appropriately skilled professionals providing services. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as the facility stated that an outside person provides care for R1’s colostomy bag but do not have any contact information or verified that they are a skilled professional, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: The Licensee will obtain the necessary information to verify all appropriately skilled professional providing services and include in resident's care plan and submit it to CCL no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Martha Arroyo and Brian Balisi conducted an unannounced annual inspection today. Upon arrival, LPAs met with Executive Director (ED), Mark Cortes and explained the reason for the visit. Entrance interview. During today’s inspection, the LPAs along with the Executive Director and Maintenance Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The following was observed: Resident Rooms / Bathrooms: The LPAs observed six (6) random resident bedrooms in the assisted living and memory care unit. All resident rooms were furnished appropriately, with appropriate furnishings, and sufficient lighting. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature measured between the required range per regulations at the time of the visit. The facility also maintains a monthly hot water temperature log to ensure compliance. Kitchen: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. The LPAs observed sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day supply of food and water. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. Report Continued on LIC 809C... Report Continued from LIC 809... Common Areas: The LPAs observed common areas to be clean and in good condition. There are games and/or activity supplies in the activity rooms. There was sufficient space to accommodate both indoor and outdoor activities. An adequate amount of emergency food and water was observed; properly stored. The facility maintained a comfortable temperature. Required postings were observed throughout the common space. The LPAs observed stairwells to have emergency evacuation chairs. There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. Fireplaces observed in various rooms; adequately covered. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced on 12/23/2024. Outdoor Space: The LPAs observed the outdoor garden which had shaded seating areas for resident use. All passageways were observed to be clear and free of hazards. No bodies of water accessible to residents noted at the time of the visit. Record Review: The LPAs reviewed ten (10) resident records and ten (10) staff records starting at 12:20 p.m. Ten resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All records were in order. Ten personnel files including the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments with TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files were in order. During today’s visit, LPAs conducted interviews with five (5) staff and five (5) residents. No concerns were noted. Report Continued on LIC 809C... Report Continued from LIC 809C... Medications Review: The LPAs reviewed medications at approximately 12:15 p.m. The medications in assisted living are centrally stored in a medication room on the 1st floor. Medications in memory care unit are centrally stored inside the memory care unit near the dining room. Medications appear to be given as prescribed at the time of the visit. Infection Control / Emergency Disaster Planning: During today’s visit, the LPAs reviewed the facility's infection control policy as well as their emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. The last fire safety inspection was completed on 08/21/2025 and was found to be in compliance with Fire Code Regulations at the time of inspections. Emergency disaster drills conducted quarterly as per regulation; last disaster drill conducted on 09/13/2025. Exit interview conducted. Report was reviewed and copy provided.the state’s words, verbatim · CDSS document, Oct 21, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident visit. At 11:30 a.m., the LPA met with the Executive Director (ED), Mark Cortes and explained the reason for the visit. The reason for today's visit is to follow up on a self-reported incident report and Suspected Dependent Adult/ Elder Abuse (SOC 341) report received on 08/05/2025. The reports pertain to possible sexual abuse of Resident #1 (R1) by unknown staff. During today’s visit, at 11:30 a.m., the LPA conducted an interview with the ED. At 12:00 p.m., the LPA requested and obtained copies of pertinent documents. At 12:15 p.m., the LPA, along with the ED conducted a physical plant tour. No immediate health and safety concerns were observed during today's inspection. A referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB). Further investigation is needed, and an additional report may follow. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 6, 2025

Allegation investigated: Facility staff speaks inappropriately to residents.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent visit to the facility to issue findings for the above allegation. The initial visit was conducted on 07/26/2024 by LPA Z. Chochian and a subsequent visit was conducted on 01/21/2025 by LPA M. Arroyo. During today's visit, the LPA met Business Office Director, Jenay Turgeon. Entrance interview. During the initial visit on 07/26/2024, LPA Chochian requested and obtained copies of pertinent documents. On 01/21/2025, LPA Arroyo conducted interviews with four staff and six residents between 10:50am ad 1:00pm and obtained copies of pertinent documents relevant to the investigation. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that facility staff speaks inappropriately to residents. It was reported that staff is bullying residents by intimidation, foul language and threats, and has created an unsafe environment for residents. Interviews conducted with residents revealed that the staff is friendly and pleasant whenever they assist. Residents mentioned that staff greet them and all other residents when passing through the common areas and are always ready to help if needed. Additionally, residents stated that they have never witnessed or heard staff using inappropriate language when interacting with other residents or staff, and they have not observed any instances of staff being rude or disrespectful. Furthermore, residents reported having no concerns about living at the facility. Based on interviews conducted with residents, the Department has insufficient evidence to support the allegation of “facility staff speaks inappropriately to residents”. Therefore, this allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Report was reviewed and copy issued.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 29-AS-20240719171036

Allegation investigated: Staff are not meeting the residents needs while in care.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent visit to the facility to issue findings for the above allegation. The initial visit was conducted on 07/26/2024 by LPA Z. Chochian and a subsequent visit was conducted on 01/21/2025 by LPA M. Arroyo. During today's visit, the LPA met with Business Office Director, Jenay Turgeon. Entrance interview. During the initial visit on 07/26/2024, LPA Chochian requested and obtained copies of pertinent documents. On 01/21/2025, LPA Arroyo conducted interviews with four staff and six residents between 10:50am ad 1:00pm and obtained copies of pertinent documents relevant to the investigation. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff are not meeting the residents needs while in care. It was reported that short staffing has been an ongoing issue, resulting in residents being left unattended in common areas due to the lack of sufficient staff to monitor all residents. A record review of staff schedules for May 2024, June 2024, and July 2024 revealed that the facility consistently schedules three to four staff members for the memory care unit during both the AM and PM shifts, as well as two staff members during the NOC shift. Similarly, on the assisted living side, there are two to three staff members scheduled for the AM and PM shifts, and two staff members for the NOC shift. Although one staff member is shared between the NOC shift for both memory care and assisted living, there are at least four staff members available to assist on both sides. Interviews conducted with staff further revealed that residents are offered activities throughout the day, and the facility denied being short-staffed. Additionally, six out of six resident interviews indicated that the residents have no concerns about living at the facility and stated that the facility is meeting their needs. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff are not meeting the residents needs while in care”. Therefore, this allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Report was reviewed and copy issued.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 29-AS-20240723092541

Allegation investigated: Staff mismanaged resident medication. Staff are not following reporting requirements.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 10/11/2024 by LPAs M. Arroyo and B. Balisi and a subsequent visit was conducted on 01/21/2025 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Business Office Director, Jenay Turgeon. Entrance interview. During the initial visit on 10/11/2024, LPAs Arroyo and Balisi conducted a medication review at 12:25pm and obtained copies of pertinent documents relevant to the investigation. On 01/21/2025, LPA Arroyo conducted a medication review at approximately 10:35am, conducted interviews with four staff between 10:50am and 1:00pm, and obtained copies of pertinent documents. Report Continued on LIC 9099C... Substantiated Report Continued from LIC 9099... It was alleged that staff mismanaged resident medication. It was reported that medication errors have occurred with routine medications and wrong dosages were being administered. Record review of Resident #1's (R1) medication records and interviews conducted revealed a discrepancy between the prescribed dosage of Temazepam and the actual dosage administered over several days. Initially, R1 had been prescribed a 30mg dosage of Temazepam (1 capsule) to be taken at bedtime. On 09/19/2024, R1’s physician issued a prescription change, reducing the daily dosage to 15mg (1 capsule), with the new dosage intended to take effect on 09/20/2024. However, despite this directive, the medication administration did not reflect the updated prescription. The Centrally Stored Medication and Destruction Record (CSMDR) indicated that the 30mg dosage continued to be administered until 09/21/2024. Furthermore, the change to the 15mg dosage did not occur until 09/22/2024, a full two days after the physician's order. Based on the information obtained during the course of the investigation, the Department has sufficient evidence to support the allegation of “staff mismanaged resident medication”. Therefore, this allegation is deemed SUBSTANTIATED at this time. It was also alleged that staff are not following reporting requirements. It was reported that medication errors were occurring but were not being reported. Record review and interviews conducted revealed that there was no incident report (LIC 624) on file and the department was not contacted in a timely manner in regard to the facility having medication errors and/or administering wrong medication dosage to residents in care. This medication error which was revealed to be wrong dosage administered to the resident through a medication review was not reported or communicated with the Department. Based on the information obtained and reviewed, the Department has sufficient evidence to support the allegation of “staff are not following reporting requirements”. Therefore, this allegation is deemed SUBSTANTIATED at this time. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 29-AS-20241007173434

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Feb 28, 2025

87465(c)(2) Incidental and Medical Care: .... Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidenced by: Based on record review, the licensee did not comply with the section cited above as R1 was given the wrong dosage of medication after a new order was sent by their doctor, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: Licensee agrees to schedule medication training for all med-techs that includes documentation and medication distribution by a 3rd party vendor and submit proof to CCL by COB 02/28/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Feb 28, 2025

87211(a)(1)(D) Each licensee shall furnish to the licensing agency such reports as the Department may require, including: Any incident which threatens the welfare, safety or health of any resident… This requirement has not been met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as Licensee did not submit an incident report to the Department within seven (7) days of occurrence on medication errors, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: Licensee agrees to review section cited and provide a statement of understanding and submit to CCL by COB 02/28/2025.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Martha Arroyo and Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 9:00 a.m. Upon arrival, LPAs were greeted by the front desk receptionist and explained the reason for the visit. The Executive Director, Mark Cortes arrived shortly after. Entrance interview. The LPAs along with the Executive Director, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPAs inspected the kitchen/food service area at 10:15 a.m. Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be clean and in good condition. The facility maintained a comfortable temperature. LPAs observed required postings throughout the common space. Stairwells were observed to have emergency evacuation chairs. LPAs observed fireplaces in the first floor dining area, library/reading room, the Bistro, and the formal sitting room, all were observed to be adequately screened at the time of the visit. There were no obstructions and/or tripping hazards throughout the facility. Emergency exiting plans/sketch are posted throughout the facility. Report Continued on LIC 809C... Report Continued from LIC 809... BEDROOMS: The LPAs observed two (2) random resident bedrooms in memory care and seven (7) random resident bedrooms in assisted living. All resident bedrooms were furnished appropriately and had sufficient lighting. RESTROOMS: The LPAs observed nine (9) random resident restrooms during the inspection. All resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:24 a.m., the hot water temperature was measured in seven (7) random assisted living bathrooms and two (2) random memory care bathrooms, and the temperature measured between 110.4 – 114.6 degrees Fahrenheit. RECORDS: LPA’s reviewed Resident Records at 11:45 a.m. and Personnel Records at 1:00 p.m. Eight (8) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Eight (8) personnel files and the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. LPAs conducted interviews with five (5) staff and three (3) residents during the inspection. MEDICATIONS: Medications review in Memory Care began at approximately 12:25 p.m. and medications review in Assisted Living began at approximately 1:50 p.m. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medication appeared to be given as prescribed at the time of the visit. Report Continued on LIC 809C... Report Continued from LIC 809C... INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPAs reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced 12/17/2023. Emergency disaster drills conducted quarterly as per regulation; the last fire drill was conducted on 10/10/2024. No citations issued at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 11, 2024

Allegation investigated: Resident sustained multiple falls and injuries while in care / Staff did not follow resident’s care plan Staff did not provide adequate supervision to residents in care Staff did not safeguard resident’s belongings Staff did not conduct a proper assessment of resident in care Staff did not provide proper medication assistance to resident in care Staff did not provide proper food service to residents in care Staff did not maintain facility in safe and sanitary condition Staff did not follow doctor’s orders for resident in care Staff did not follow proper reporting requirements

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility and was greeted by front desk staff. LPA met with Executive Director (ED) Mark Cortes at 08:53AM. Entrance interview conducted. During the initial complaint visit on 07/20/2023, LPA interviewed ED at 02:05PM, toured the facility with Business Office Director Kailey Vanderwall at 02:11PM, and LPA reviewed and obtained copies of pertinent documents. During a subsequent complaint visit on 05/22/2024, LPA spoke with Regional Memory Care Specialist Lena Gutierrez, interviewed staff from 11:17AM to 01:15PM. LPA also reviewed pertinent documents and toured the facility's Memory Care unit with Regional Memory Care Specialist at 02:10PM. Throughout the course of the investigation, LPA interviewed additional staff both telephonically and in person and LPA reviewed all pertinent documents. The following was then determined: Report Continued on LIC 9099-C (p. 2) Unsubstantiated Continued from LIC 9099 (p. 1) Allegation “Resident sustained multiple falls and injuries while in care:” It was alleged that due to lack of care and supervision, Resident #1 (R1) fell 3 (three) times while residing at the facility and sustained multiple “mysterious gashes and open wounds.” Record review revealed that R1 was admitted to the facility on 07/18/2022. R1’s physician’s report upon admit indicated R1 was ambulatory and had a diagnosis of vascular dementia; care plan assessment indicated that R1 “wanders only within the common areas of the secured community.” Incident report reviewed revealed that R1 sustained a fall on 07/31/2022, resulting in a hip fracture. According to incident report, staff and family member interview, R1 was sitting in a chair in the Memory Care outdoor area. R1 scooted their chair out and into a recessed garden bed, resulting in R1 losing their balance and falling as they attempted to stand up. A second fall occurred on 09/17/2022 resulting in an injury to the right side of R1’s head and eye area. A third fall occurred on 05/21/2023 when facility staff reported to R1’s family that R1 had fallen over their walker. Throughout the time R1 resided at the facility, R1 did not require 1:1 supervision, nor did R1 require an escort when ambulating about the secure memory care unit. Incident reports and staff interview revealed that staff were nearby when all 3 (three) falls occurred, and that staff followed the proper protocol for obtaining additional medical care and reporting the incidents. Therefore, based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred; the allegation that “resident sustained multiple falls and injury while in care” is deemed UNSUBSTANTIATED at this time. Allegation “Staff did not provide adequate supervision to residents in care:” It was alleged that “nobody watched [R1]” and that staff did not prevent residents from harming each other while in care. Record review revealed that at no time while R1 was residing at the facility did R1 require 1:1 supervision. Staff interviews revealed that most residents prefer to do activities or otherwise congregate in the common areas during the day. Staff indicated that all residents are checked on at least every 2 hours, even those that choose to remain in their rooms instead of engaging in activities. During the day, there are activity staff present in common areas to support the care staff and that all staff present provide supervision to residents in care. Interview revealed that there is one particular resident that has attempted to enter resident rooms and has engaged negatively with other residents on occasion. However, staff are aware of this resident and their needs and do keep a closer eye on this particular resident. Staff indicated there was an incident involving R1 and a different resident that occurred on 06/16/2023 where R1 attempted to physically Continued on LIC 9099-C (p. 3) Continued from LIC 9099-C (p. 2) fight with the other resident. Staff indicated that in this case R1 was agitated, which resulted in the incident occurring. Staff promptly separated the two residents and assessed both them for any possible injuries. Based on interview, observation, and record review revealed that at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff did not provide adequate supervision to residents in care” is deemed UNSUBSTANTIATED at this time. Allegation “Staff did not provide proper medication assistance to resident in care:” The complaint alleges that facility staff should have been checking R1’s blood pressure and that on occasion, R1’s family member observed medications under R1’s bed. The complaint further alleges that R1’s family member had noticed “missed doses” and because Oakmont has had allegations of medication mismanagement previously, R1’s medications must have been mismanaged as well. LPA reviewed medication records for R1, which showed that R1 had taken all prescribed medications daily in the month of June, prior to R1’s hospitalization on 06/15/2023. R1 briefly returned to the facility on 06/16/2023 and was re-hospitalized on that same day but did not return to the facility. R1’s personal items, including medications, were removed by R1’s family prior to the date the complaint was received. Therefore, R1’s medications were unable to be observed for the inconsistencies alleged. Staff interviewed indicated R1 was fairly compliant with taking their medications and no concerns were noted with R1’s medication administration. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff do not provide proper medication assistance to resident in care” is deemed UNSUBSTANTIATED at this time. Allegation “Staff did not follow resident’s care plan:” The complaint alleges that R1 was charged for items including “fall risk management,” and “escorting” but these services were not provided to R1. Additionally, the complaint alleges that R1 was not assisted with cleaning their feet and that R1 “stayed in pajamas for days.” LPA reviewed Resident Assessment dated 07/12/2022 (pre-assessment), which indicates that R1 required “assistance with set up of grooming materials. Can groom independently,” stand-by assistance for all showering/bathing needs, medication management, and was independent for transfers and escorts. Hospital care notes indicate that although R1 required additional assistance post-fall while at the hospital, the goal during rehabilitation was to discharge R1 back to Assisted Living with stand-by assistance. Assessment dated 11/30/2022 indicates R1 requires set Report Continued on LIC 9099-C (p. 4) Continued from LIC 9099-C (p. 3) up of grooming materials, but can groom independently, hands on assistance with bathing/showering, medication management, occasional reminders and/or escort, and fall management program. Interviews revealed that after R1’s fall and hospitalization, R1 did require additional assistance. R1 did obtain occupational therapy and physical therapy services to assist in gaining back their independence, but that R1 did not fully go back to their level of care R1 had upon admittance to the facility. Staff interviewed indicated that they attempted to assist R1 but that R1 would become agitated, particularly when certain family members were present and that R1 would refuse care when they were agitated. When certain family members weren’t present, R1’s demeanor was calmer and more receptive to receiving care assistance. As R1’s assessment indicates that R1 did not require assistance with dressing, only selection of clothing, staff did not assist R1 in changing clothes. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation that “staff did not follow resident’s care plan” is deemed UNSUBSTANTIATED at this time. Allegation “Staff did not conduct a proper assessment of resident in care:” The complaint alleges that the facility did not conduct a reassessment for R1 after their catheter was removed. LPA reviewed all documents related to R1’s care, which included care notes and 3 (three) resident assessments. When R1 moved into the facility, R1 was noted to be “occasionally incontinent of bladder or bowel and can self-manage, but requires assistance ordering and maintaining supplies.” Resident Assessment dated 08/25/2022, following R1’s fall and hospitalization indicates that R1 is “incontinent of bowel at times” and “has foley catheter.” In the section entitled “Indwelling Urinary Catheter” R1 is noted to have an indwelling catheter and needs staff monitoring and assistance from a licensed nurse. R1 was prescribed home health care to meet their needs while at the facility following the hospitalization and recovery. LPA noted that the indwelling catheter added 16 care points to R1’s care plan. Cost of Care Communication dated 08/29/2022 indicates that R1’s billable acuity score had increased from 105 on the previous assessment to 253 points currently. It is unclear when the indwelling catheter was removed, as the next resident assessment is dated 11/30/2022 and does not include points for an indwelling catheter. Interviews with Executive Director revealed that no new assessment was completed upon removal of the catheter, as the facility did not consider this a change of condition for R1 nor would the removal of the 16 points have constituted a change in R1’s level of care. With or without those points, R1’s care level remained at a level 3. When R1’s condition improved further, a new assessment was completed on 11/30/2022, Report Continued on LIC 9099-C (p. 5) Continued from LIC 9099-C (p. 4) reflecting the new level of care. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff did not conduct a proper assessment of resident in care” is deemed UNSUBSTANTIATED at this time. Allegation “Staff did not provide proper food service to residents in care:” The complaint alleges that R1 was malnourished and was not encouraged to eat proper food. During facility visits, LPA observed food service to the residents, including breakfast and lunch service. LPA observed food served to residents in the Memory Care unit to be varied and contain adequate portions. Staff interviewed indicated that food is pre-prepared for residents in the Memory Care unit and delivered on a large covered cart to maintain food properly during delivery from the commercial kitchen located in the Assisted Living unit. Plates are prepared with the food on the menu, unless a particular resident has a special diet. R1 did have a physician-ordered heart healthy diet and the facility's regular menu is approved by a dietician and is heart healthy, low sodium for all residents in care. One of R1’s family members requested a Mediterranean diet for R1. Interviews revealed that R1 frequently refused to eat what was served and would often request different items from the facility’s order anytime menu. R1 preferred foods such as cheeseburgers or grilled cheese sandwiches. Staff interviewed reiterated that it is R1’s right to be served food of their choosing and it was important that R1 eat a meal, rather than go hungry. So when R1 refused to eat the food served and requested an alternate meal, staff would accommodate that request. Based on interview and observation, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff did not provide proper food service to residents in care” is deemed UNSUBSTANTIATED at this time. Allegation “Staff did not maintain facility in safe and sanitary condition:” The complaint alleges that R1’s restroom was not cleaned regularly, that there was blood and toothpaste observed in R1’s restroom. The complaint also alleges that R1 had access to hazards such as nail clippers and an electric shaver. Record review revealed R1 was hospitalized on 06/15/2023 and R1 only briefly returned to the facility the following day before leaving permanently. The complaint was not received until 07/12/2023, so the initial visit was conducted about a month after R1 moving out of the facility, therefore, LPA could not observe the condition of R1’s room while R1 resided there or immediately afterward. During the initial complaint visit, LPA Dulek toured and took photographs of R1’s former room. LPA did not observe any blood or toothpaste in R1’s restroom. LPA toured other rooms in the memory care unit and all rooms appeared to be relatively clean and sanitary. During a subsequent visit, LPA observed housekeeping staff Report Continued on LIC 9099-C (p. 6) Continued from LIC 9099-C (p. 5) cleaning rooms. Staff interviewed indicate that housekeeping is scheduled regularly to clean resident rooms/restrooms and that care staff assist with cleaning the common areas of the facility, as time permits during their scheduled shifts. Care staff empty resident trash cans daily on each shift. Staff indicated there are times when housekeeping isn’t completed per the schedule, depending on staffing, but that rooms remain relatively clean. Interviews also revealed that all sharp objects remain secured in the Memory Care unit. Staff interviewed indicated that the previous Memory Care Director had stored some residents’ nail clippers and shavers labeled and locked in the medication room if a resident did not have a lock on their restroom cabinet. Review of R1’s physician report and needs and service assessment indicated that R1 is not at risk if allowed direct access to personal grooming and hygiene items and that R1 “can groom independently.” As R1 is not at risk with these items, it is R1’s personal right to be allowed to groom themselves independently. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff did not maintain facility in safe and sanitary condition” is deemed UNSUBSTANTIATED at this time. Allegation “Staff did not safeguard resident’s belongings:” The complaint alleges that items belonging to R1, including a trash can, shavers and chargers went missing and various other residents (not including R1) were wearing other residents’ clothing. LPA reviewed R1’s facility file, which included a document entitled “Optional Inventory of Personal Property”. This document allows the resident to provide an inventory of items brought into the facility for safeguarding by facility staff. However, R1’s responsible party marked the box indicating “I do not wish to inventory personal property” and signed the form upon admit to the facility. Interviews revealed that R1’s family did not provide any other listing of R1’s items and that different family members visited R1 at the facility and had access to R1’s personal belongings in R1’s room regularly. Staff interviewed indicated that all residents in the memory care unit have a locked cabinet in their private restroom where personal grooming items, such as shavers are stored locked and inaccessible to residents in care. Although R1 did not have a roommate at the time of the complaint allegation, R1 did occupy a shared room and did have a roommate part of the time they resided at the facility. Staff indicated that both residents’ grooming items would have been stored in the same locked cabinet and since there was no written inventory of R1’s items, staff would have been unable to ascertain which specific items belonged to R1 and which belonged to the roommate. Both staff and management interviewed indicated that when R1 moved out, the family did take a shaver and charger with them. With Report Continued on LIC 9099-C (p. 7) Continued from LIC 9099-C (p. 6) regard to residents’ clothing items, interviews revealed that each resident maintains and stores their own personal clothing in their personal room. Facility staff wash each resident’s laundry separately and return the laundry directly to the resident’s room. Staff stated that often when a resident passes away, the family will donate the resident’s clothing to other residents in need or to the facility to utilize for residents who may not have enough clothing. Interviews revealed that it is only with family approval that they will give clothing to a particular resident in need. Staff interviewed indicated there have been no concerns with incorrect clothing with any other resident or their families. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff did not safeguard resident’s belongings” is deemed UNSUBSTANTIATED at this time. Allegation “Staff did not follow doctor’s orders for resident in care:” The complaint alleges that the facility did not ensure R1’s orders for knee-high compression socks were worn, nor did the facility provide a heart-healthy diet. LPA reviewed R1’s needs and service appraisal and noted that R1 did not have compression socks upon admittance to the facility. Assessment dated 08/25/2022 also did not indicate R1’s need for compression hose, however the 11/30/2022 assessment did include R1 “requires assistance with applying and removing compression hose.” Interviews with staff revealed that staff did assist R1 in putting on the compression hose, as R1 would allow. Often, R1 would become agitated and try to hit staff when they attempted to assist R1 with their compression hose. When staff did get the compression hose on, interviews revealed that R1 would either take off their compression hose or pull it down and not wear it properly. Staff interviewed indicated they attempted to assist R1 daily with compression hose, but R1 did not allow the compression hose to be on their legs most days. Record review revealed that R1’s doctor did indicate a heart-healthy diet on R1’s physician’s report dated 08/19/2022. Interview with staff revealed that the regular menus and food selection for Oakmont is all a low-sodium and heart healthy menu. No special diet was necessary for R1, as the provided menu is in line with R1’s doctor’s orders. However, staff interviewed indicated that R1 refused to eat the meals provided to R1 on a regular basis. All food from the regular menu was prepared in the kitchen and delivered to the Memory Care unit, but when R1 refused to eat the food provided, R1 was allowed to order an alternative choice. Staff interviewed indicated they informed both the resident’s responsible party as well as R1’s physician that R1 was ordering items such as cheeseburgers and grilled cheese, rather than eating from the provided menu. Staff interviews revealed that R1 was encouraged to eat per their diet, but R1 refused. Based on interview and record review, there is Report Continued on LIC 9099-C (p. 8) Continued from LIC 9099-C (p. 7) insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff did not follow doctor’s orders for resident in care” is deemed UNSUBSTANTIATED at this time. Allegation “Staff did not follow proper reporting requirements:” The complaint alleges that the facility did not report an unusual incident to the police, although ED indicated it had been reported. LPA reviewed information provided, including a police report number. Upon further inquiry, LPA discovered that police had been out and interviewed both facility staff and residents on the date in question, however no report was written by the police department, as both residents involved have a diagnosis of dementia. Staff and management interviewed indicated that the police were present at the facility and conducted interviews. The incident was reported to Community Care Licensing (CCL) both over the telephone and in writing and an Alleged Abuse Report was filed with Adult Protective Services (APS) and Long Term Care Ombudsman (LTCO). Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff did not follow proper reporting requirements” is deemed UNSUBSTANTIATED at this time. No citations issued related to the above listed allegations. Exit interview conducted. A copy of today’s report was provided. Continued from LIC 9099-A (p. 9) Allegation: “Staff refused to accept resident back to the facility:” LPA reviewed resident records for R1 and conducted interviews. Record review revealed that R1 had increasing agitation, aggression and exit seeking in June 2023. This behavior resulted in staff calling 9-1-1 on 06/15/2023 and paramedics taking R1 to the hospital. Interviews revealed that R1 returned to the facility on 06/16/2023, but later that evening, there was an altercation between R1 and another resident which resulted in R1 being sent to the hospital again. By 06/17/2023, the hospital planned to discharge R1 back to the facility, however facility management did not allow R1 to return to the facility. Interview revealed that it was a corporate decision, made above the local level, to refuse R1’s return to the facility. Additional staff interviews revealed that R1 had been showing increasing agitation and aggressive behavior and that R1 required a higher level of care. LPA reviewed documents sent to Community Care Licensing (CCL) and noted that the facility had not issued a valid eviction notice for R1 at any time. Based on record review and interview, there is sufficient evidence to support the allegation, therefore the allegation that “staff refused to accept resident back to the facility” is deemed SUBSTANTIATED at this time. Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D): Exit interview conducted. A copy of the report and appeal rights were reviewed and provided.the state’s words, verbatim · CDSS document, Jul 22, 2024 · control 29-AS-20230712142031

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: Jul 29, 2024

87468.2 (a) (20) To be protected from involuntary transfers, discharges, and evictions... for residents. For purposes of this paragraph, "involuntary" means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident. This requirement is not met as evidenced by: Based on interview and record review, the facility did not comply with the above cited section, as R1 was sent to the hospital on 06/16/2022 and the facility refused to accept R1 back to the facility following hospital discharge, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 22, 2024

Plan of correction: As R1 no longer resides in the facility, ED agreed to send to CCL a statement of understanding related to resident transfer, involuntary discharge, and evictions by POC due date.

Allegation investigated: Resident sustained injury while in care. Staff do not respond to call button in a timely manner. Staff did not seek medical attention in a timely manner. Facility is in disrepair. Staff are not trained for the job assigned to them.

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility at 04:00PM and met with Executive Director (ED) Mark Cortes and Regional Operations Specialist Matt Ryan. Entrance interview conducted. During the initial complaint visit on 09/22/2022, LPA interviewed ED Foerschner at 11:40AM, toured the facility with Executive Director 12:25PM, and LPA reviewed and obtained copies of pertinent documents. During a subsequent complaint visit on 05/22/2024, LPA spoke with Regional Memory Care Specialist Lena Gutierrez, interviewed staff from 11:17AM to 01:15PM. LPA also reviewed pertinent documents and toured the facility's Memory Care unit with Regional Memory Care Specialist at 02:10PM. Throughout the course of the investigation, LPA interviewed additional staff both telephonically and in person and LPA reviewed all pertinent documents. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegation “Resident sustained injury while in care:” It was alleged that due to lack of care and supervision, Resident #1 (R1) fell and sustained an injury while in care. Record review revealed that R1 was admitted to the facility on 07/18/2022. R1’s physician’s report upon admit indicated R1 was ambulatory and had a diagnosis of vascular dementia; care plan assessment indicated that R1 “wanders only within the common areas of the secured community.” Incident report reviewed revealed that R1 sustained a fall on 07/31/2022, resulting in a hip fracture. According to incident report, staff and family member interview, R1 was sitting in a chair in the Memory Care outdoor area. R1 scooted their chair out and into a recessed garden bed, resulting in R1 losing their balance and falling as they attempted to stand up. At the time of the fall, R1 did not require 1:1 supervision, nor did R1 require an escort when ambulating about the secure memory care unit. Incident report and staff interview revealed that staff were nearby when the fall occurred, and that staff followed the proper protocol for obtaining additional medical care and reporting the incident. Therefore, based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred; the allegation that “resident sustained injury while in care” is deemed UNSUBSTANTIATED at this time. Allegation “Staff do not respond to call button timely:” It was alleged that on occasion, R1’s family member stayed at the facility with R1 overnight and that R1’s call button was not responded to timely. LPA reviewed Care Point Server records for R1. Record review revealed response times recorded within the identified appropriate time frame reported by facility staff. Interview revealed that there are few residents in the Memory Care unit utilizing the pendant call system. When a resident presses the pendant, the alerts go to the front desk console as well as the staff pagers. Staff then will respond to the resident’s room for assistance. Interview revealed that there are times when staff are busy with other residents, but that the staff work together and communicate with one another to ensure all calls and residents’ needs are met timely. During facility visits throughout the complaint inspection, LPA observed staff tending to residents’ needs and no additional residents identified any concerns related to timeliness. Based on interview, observation, and record review revealed that at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff do not respond to call button timely” is deemed UNSUBSTANTIATED at this time. Allegation “Staff do not seek medical attention timely:” The complaint alleges that a witness observed another resident (Resident #2 – R2) who resides in Memory Care sitting outside on the patio and according to the complaint, R2 appeared overheated and in need of Report Continued on LIC 9099-C medical care. LPA spoke with facility Management as well as facility staff that were present at the time of the alleged incident. Staff indicated that R2 enjoys sitting outside in the fresh air and in the sun. On the date of the alleged incident, according to staff interviewed, R2 had not been outside for longer than about 15 to 20 minutes when staff escorted R2 back inside. R2 was tired when staff brought them back into the facility, so staff assisted R2 to bed. There was no medical treatment necessary for R2 relating to their time spent outside and therefore no incident report was needed. LPA observed R2 in the facility during the initial complaint visit; R2 appeared happy and healthy. Based on interview and observation, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff do not seek medical attention timely” is deemed UNSUBSTANTIATED at this time. Allegation “Facility in disrepair:” The complaint alleges that the sensors in R1’s room are non-functional. LPA reviewed motion sensor logs for R1’s room for the relevant time period, which did indicate multiple reports of motion in R1’s room. During the initial compliant visit, LPA tested the motion sensors in R1’s room and they were functional at the time of the visit. Staff interviewed indicated that R1’s motion sensors do function. LPA toured the facility during the initial complaint visit and both subsequent complaint visits, as well as multiple other unrelated visits throughout the course of the investigation and no concerns were observed during any visits. Based on interview, record review, and observation, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation that “facility is in disrepair” is deemed UNSUBSTANTIATED at this time. Allegation “Staff are not trained for the job assigned to them:” The complaint alleges that new staff are not trained properly and therefore are unable to care for the residents. LPA reviewed training logs for various facility staff, including medication technicians and care staff. Interviews revealed that the facility utilizes computer training, including videos and quizzes as well as shadowing and in-person training prior to staff working in the facility with residents. Residents interviewed indicated their needs are met, and that staff are providing adequate care. Training records reviewed revealed that staff are trained in accordance with regulation. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff are not trained for the job assigned to them is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of today’s report was provided.the state’s words, verbatim · CDSS document, Jun 21, 2024 · control 29-AS-20220921163357

Allegation investigated: Medications are not being administered as prescribed Medications are not being refilled timely

Licensing Program Analyst (LPA) Kelly Dulek conducted subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA arrived at the facility at 09:12AM and met with Executive Director (ED) Bradlee Foerschner. Entrance interview conducted. During the initial complaint visit, conducted on 04/29/2022, LPA toured the facility with Administrator at 1:50PM, conducted staff interviews at 2:00PM and 3:18PM, and LPA gathered copies of pertinent documents. Throughout the course of the investigation, LPA spoke both in person and telephonically with facility staff related to the complaint allegations, interviewed residents and reviewed medications. The following was then determined: Report Continued on LIC 9099-C Substantiated Allegation: “Medications are not being self-administered as prescribed:” The complaint alleges that medications for multiple residents are not administered as prescribed, including Resident #1 (R1) and Resident #2 (R2). LPA reviewed Medication Administration Records (MAR)s for R1 and R2. R1’s medication Docusate Sodium 100mg had a change in order effective 04/22/2022, when the medication changed from being administered once daily to twice a day. However, the medication is not marked as administered at all on 04/23/2022 and instead indicates “withheld per doctor order,” even though the new prescription was valid effective 04/22/2022. Then on 04/24/2022, the medication is only marked once daily under the prescription that was no longer valid. On 04/25/2022, this medication was marked as administered once on the prescription that was no longer valid and once under the new prescription. MAR review for R1 indicates Scopolamine 1mg patch was ordered “apply 1 patch transdermally behind an ear every 3 days (72 hours) for vertigo.” MAR is marked with this medication administered every day from 04/01/2022 to 04/30/2022, with the exception of 04/14/2022 and 04/15/2022 when R1 was out of the facility and on 04/23/2022 when the medication is marked as “medication unavailable.” It is unclear whether the medication was actually administered daily as initialed by staff or if the medication was given as prescribed and incorrectly marked on the MAR. Medications for Resident #3 (R3) reviewed contained additional inconsistencies. R3’s medication Docusate Sodium 100 mg softgel was prescribed “take one capsule twice daily for 3 days with a start date of 04/07/2022, but is marked as administered beginning on 04/12/2022 at 05:00PM, and marked twice daily through 04/28/2022 (with some exceptions), even though the stop date is listed as 04/26/2022 at 04:00PM. Based on record review, the allegation that “medications are not being administered as prescribed” is deemed SUBSTANTIATED at this time. Allegation: “Medications are not being refilled timely:” The complaint alleges that multiple residents medications are not being refilled on time, resulting in medications being unavailable to administer. LPA reviewed MAR printouts for multiple residents, including all those listed on the complaint allegation. MAR review revealed that R1’s medication polyethylene glycol indicates “medication unavailable” on 04/08/2022 and 04/09/2022. Multiple medications for R3 are marked as “medication unavailable” including R3’s Desoximetasone 0.25% cream, Guanfacine HCL ER 2mg tablet, Metformin HCL 500mg tablet, and Preservision. There were an additional 4 (four) medications for Resident Continued on LIC 9099-C #4 (R4) that were marked as unavailable during the same time period of 04/08/2022 to 04/10/2022, including R4’s Atorvastatin 40mg tablet, Diltiazem 30mg tablet, Meclizine 12.5mg caplet, and Xarelto 15mg tablet. Interview with medication staff revealed that the policy is to refill all medications when there are about 8 doses remaining to allow for sufficient time to receive the medications. However, on multiple occasions, including on the date of LPA KaSandra Lopez’s visit on 04/22/2022, there was only 1 dose remaining for many medications and refills had not yet been requested. Staff interviewed indicated this is a re-occurring concern that has been brought to management’s attention but has yet to be remedied. Therefore, based on interview and record review, the allegation that “medications are not being refilled timely” is deemed SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D): Exit interview conducted. Today’s reports and appeal rights were reviewed and provided via email. Allegation: “Facility staff gave a resident medication prescribed to another resident:” The complaint alleges that on many occasions, when a resident runs out of a medication, facility staff have used another resident’s medication in it’s place. LPA conducted interviews with staff, who all indicated they have never administered medications to one resident that are prescribed to another resident. Additionally, most staff interviewed had never heard of any other staff giving medications prescribed to one resident to another resident. Only one staff interviewed had heard of this happening, but this staff could not provide details as to a date this occurred, or which residents and medication were involved. Residents interviewed indicated medications are given on time and none are aware of any instances where they were given another resident’s medications. MAR records reviewed also did not have any indication of medications being shared amongst residents. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “facility staff gave a resident medication prescribed to another resident” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff are not trained properly:” The complaint alleges that staff working in the facility’s medication room have not received the appropriate training, both prior to beginning work as well as ongoing training requirements. LPA reviewed training records for 4 (four) medication technicians working in the facility at the time of the allegation. All 4 (four) of 4 (four) records reviewed did contain initial trainings for all staff, as well as ongoing trainings, both related to resident care as well as medication trainings. Staff interviewed indicated their training consists of both shadowing an experienced staff member, as well as computer trainings. Additionally, the facility conducts ongoing monthly in-service training for all staff. Specific medication technician ongoing trainings are also conducted on an as needed basis in addition to the monthly in-services. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation, therefore the allegation “staff are not trained properly” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff are sleeping during the overnight shift:” It was alleged that facility staff, particularly the NOC medication technician are sleeping during the overnight shift, rendering them unable to administer medications during their shift. LPA interviewed staff and residents. Interviews revealed that at the time of the complaint allegation, there were no residents taking regularly Report Continued on LIC 9099-C prescribed medications during the overnight shift. At that time, there were residents who requested PRN (as needed) medications regularly during the NOC shift. Residents interviewed indicated that while sometimes they do have to wait for a PRN (as needed) medication to be brought to them, they do not regularly have any problems or concerns getting their PRN medications. Staff interviewed have heard that staff do sleep on the NOC shift, but none interviewed had witnessed this occurring, nor had specific details on dates or staff involved. Management interviewed indicated they have showed up unannounced to audit the overnight shift and have not observed any staff sleeping during these audits. Based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff sleeping during the overnight shift” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff are not competent to provide the services necessary to meet resident needs:” Interview with both residents and facility staff revealed that facility staff are meeting the residents’ needs. Staff indicated they follow the care plans in place for each resident, and they regularly review the care plans to ensure there are no changes. When changes do occur with a resident’s services, the Health Services Director or the Memory Care Director discuss with the staff the additional services the resident now requires. Also, facility staff document on each resident’s care notes if there are any observed changes. These notes are reviewed during change of shift as well as by the Health Services Director in Assisted Living or the Memory Care Director. Facility staff are trained prior to providing care to the residents on individual residents’ care needs on the computer, with quizzes, and by shadowing experienced staff. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff are not competent to provide the services necessary to meet resident needs” is deemed UNSUBSTANTIATED at this time. No citations issued related to the above complaint allegations. Exit interview conducted. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, May 28, 2024 · control 29-AS-20220422121330

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 28, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as residents' medications were not refilled timely and not avaiable, as well as other medications not documented as administered as prescribed, which posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, May 28, 2024

Plan of correction: ED conducted a thorough medication audit through an outside agency, which resulted in corrections. All medication technicians were also trained by an outside consulting agency. POC cleared.

Allegation investigated: Facility staff are not assisting with self-administration of medications as prescribed Medications are not being refilled timely Facility staff did not respond timely to resident’s request for assistance

Licensing Program Analyst (LPA) Kelly Dulek conducted subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA arrived at the facility 09:12AM and met with Executive Director (ED) Bradlee Foerschner. Entrance interview conducted. During the initial complaint visit, conducted on 06/23/2022, LPA toured the facility with then-Administrator Martha Berard at 04:26PM and LPA gathered copies of pertinent documents. Throughout the course of the investigation, LPA spoke both in person and telephonically with facility staff and residents related to the complaint allegations, as well as other relevant parties. The following was then determined: Report Continued on LIC 9099-C Substantiated Allegation: “Facility staff are not assisting with self-administration of medications as prescribed:” The complaint alleges that the facility staff are not assisting Resident #1 (R1) with their prescribed medications. LPA reviewed medications, Medication Administration Records (MAR), Centrally Stored Medication and Destruction Record (CSMDR), and Controlled Drug Record for R1. Record review revealed that pill #29, 27, 26, and 20 of R1’s Oxycodone-Acetaminophen were not properly documented on the Controlled Drug Record as there is no date and/or time listed that the pills were administered. Additionally, controlled drug record indicates “take 1 tab by mouth every day at 8:30AM, however, on 06/02/2022 the medication was given at 08:30AM, pill #29 was likely also administered on 06/02, however the date, time, and signature are missing. Also on 06/02/2022, staff signed that R1 took pill #28 at 12:30AM, however this could not be possible if pill #30 was administered at 08:30AM as prescribed. Additional entries include times varying from 06:00 (presumably AM), 12:30 (unclear if AM or PM), to 07:00PM. However, this document only indicates it is intended for the 08:30AM medication. Physician’s orders for R1 as well as MAR indicate R1’s Oxycodone-APAP 10/325mg is prescribed “take 1 tablet by mouth every 3 hours as needed for moderate-severe pain.” MAR indicates this medication was administered on the following dates: 2X on 06/01/2022, 3X on 06/02/2022, 06/03/2022, 06/04/2022, 06/05/2022. Then under a separate line with no prescription number marked, the medication was administered on the following dates: 2X on 06/17/2022, 06/19/2022 and 06/21/2022. Under another prescription number and a 3rd line, the medication was administered 2X on 06/20/2022. It is unclear why the medication is documented on multiple line items and the electronic record does not accurately reflect the manually written Controlled Drug Administration Record. Additionally, interviews revealed that on at least one occasion, the medication technician delivered R1’s medications to their room and left the medications in the room for R1’s private caregiver to administer to R1. R1’s private caregiver reported that one time 2 pills of the same medication were brought and left for R1 in the room, when only 1 pill was prescribed at that time. Had R1 self-administered this medication as prepared by the medication technician, R1 would have been administered twice the prescribed dose. Based on interview and record review, the allegation “facility staff are not assisting with self-administration of medications as prescribed” is deemed SUBSTANTIATED at this time. As R1 was also listed in Complaint Control # 29-AS-20220422121330, this allegation was addressed, and citation was issued under this referenced complaint, no citation will be issued during today’s visit. Allegation: “Medications are not being refilled timely:” The complaint alleges that medications for R1 were not refilled timely, resulting in R1’s furosemide 20mg Report Continued on LIC 9099-C 20mg tablet not able to be administered for 2 days. R1’s MAR indicates that RX#1931532 had a stop date of 06/10/2022. Beginning with the 05:00PM dose of that medication and continuing through the 08:00AM dose on 06/12/2022, the MAR indicates exceptions stating “withheld per DR/RN orders.” R1’s MAR also indicates RX#1940373 was written on 06/10/2022. Under this prescription number, the medication does not show as administered until the 08:00AM dose on 06/15/2022 even though the prescription has an orig date of 06/10/2022. According to R1’s MAR review, R1’s furosemide 20mg tablet was not administered from 05:00PM on 06/10/2022 until 08:00AM on 06/15/2022. Staff interviewed indicated that medication technicians should be calling for refills on medications when there are approximately 8 pills remaining, but this was not always completed per policy. Staff indicated that at times R1’s medications were not refilled timely and R1 was therefore unable to receive their prescribed medications. Based on record review and interview, the allegation “medications are not being refilled timely” is deemed SUBSTANTIATED at this time. As R1 was also listed in Complaint Control # 29-AS-20220422121330, this allegation was addressed, and citation was issued under this referenced complaint, no citation will be issued during today’s visit. Allegation: “Facility staff did not respond timely to resident's request for assistance:” The complaint alleges that R1 was given a pendant that did not function properly, resulting in R1 experiencing long wait times when R1 requested assistance. LPA reviewed CarePoint Server Console Page Report for R1 for period of 06/08/2022 to 06/20/2022. LPA noted there were 144 total calls for assistance during this time period. Of those calls, response time ranged from 45 seconds to 1 hour, 59 minutes, 16 seconds. Interviews revealed that an acceptable call response is from 10-15 minutes maximum. LPA counted a total of 28 times during the designated time period that R1’s call response time was greater than 15 minutes. Interviews revealed that R1 did request assistance frequently, either to request PRN (as needed) medications or for transfer assistance and that sometimes residents have to wait for assistance, particularly during busy time periods. Residents interviewed also indicated at times they have to wait too long when they need assistance. Based on record review and interview, the allegation that “facility staff did not respond timely to resident’s request for assistance” is deemed SUBSTANTIATED at this time. As this allegation was also listed in Complaint Control # 29-AS-20220323121610 related to R1 and both complaints were investigated concurrently, citation was issued under this referenced complaint and no citation will be issued related to this allegation during today’s visit. Exit interview conducted. A copy of the report and appeal rights were provided via email. Allegation: “Facility staff are not properly assisting resident with transfers:” The complaint alleges that facility staff did not properly assist R1 with transfers to the commode, resulting in R1 falling. Interviews revealed that R1 does call most nights/early morning time and request to be transferred to the commode. Staff interviewed indicated that R1 has begun buckling their legs during transfers, which makes transferring R1 more difficult. Staff stated that this is what has been happening recently, which has resulted in staff having to lower R1 to the floor. Interview also revealed that some staff and private caregiver are able to safely assist R1 with transfers with only 1 person present, but due to the buckling of their legs, staff are ensuring that R1 is transferred with 2 staff present only. Resident assessment dated 08/27/2021 indicates R1 “requires one person physical assistance with transfers” and “resident has not fallen within the past year.” LPA reviewed incident reports for the indicated time period and there were no incident reports indicating R1 had fallen. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation had occurred, therefore, the allegation “facility staff are not properly assisting resident with transfers” is deemed UNSUBSTANTIATED at this time. No citations issued related to the above allegation. Exit interview conducted. A copy of today’s report was provided.the state’s words, verbatim · CDSS document, May 28, 2024 · control 29-AS-20220616165315

Allegation investigated: Facility staff are not meeting resident's basic care needs Illegal eviction

Licensing Program Analyst (LPA) Kelly Dulek conducted subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA arrived at the facility at 09:24AM and met with Executive Director (ED) Bradlee Foerschner. Entrance interview conducted. During the initial complaint visit, conducted on 08/11/2022, LPA toured the facility with Regional Operations Specialist at 02:10PM, interviewed staff at 01:32PM, 02:25PM, 03:13PM, and 04:38PM and LPA gathered copies of pertinent documents. Throughout the course of the investigation, LPA spoke both in person and telephonically with facility staff related to the complaint allegation, as well as other relevant parties, and reviewed all documents obtained. The following was then determined: Report Continued on LIC 9099-C Substantiated Continued from LIC 9099 (page 1) Allegation: “Facility staff are not meeting resident’s basic care needs:” The complaint alleges that the facility staff are not meeting Resident #1 (R1)’s basic care needs, as R1 has been able to elope on the following dates: 06/05/2022, 06/07/2022, 06/29/2022, and 07/11/2022. R1’s physician’s report indicates that R1 has a diagnosis of dementia, can ambulate without the use of assistive devices, has wandering behavior and is unable to leave the facility unassisted. Following the first 2 (two) elopement incidents, R1 was given a Wanderguard bracelet and additional status checks were conducted on R1. However, interview revealed that the Wanderguard bracelet will only set off an auditory alarm if the resident exits from the Assisted Living common areas, not the secure Memory Care unit and R1 resided in the Memory Care unit. Additionally, following the second elopement, the facility had required that R1 have a private companion due to safety concerns and exit seeking behaviors. However, after noting that the private companion agitated R1 more, the facility allowed R1 to remain in the facility without a private companion. LPA conducted a case management visit and issued a citation related to R1’s elopements. On 06/09/2022, facility staff conducted a new needs and service assessment, which did not indicate the need for 1:1 supervision for R1, however did note R1’s exit seeking behavior. R1 then eloped a third time on 06/29/2022, which resulted in a Case Management visit and additional citation on 07/08/2022. A self-reported incident report was sent to CCL related to a 07/11/2022 incident which indicates that R1 “attempted elopement” on this date. However, care notes for R1 reviewed at the facility indicate R1 “eloped with another resident.” Interviews with staff present during the incident indicated that R1 was “found with another resident on the sidewalk outside Oakmont wandering toward the public sidewalk.” During the initial complaint visit, LPA Dulek and Regional Operations Specialist, along with Memory Care Director toured the facility. During the tour, Memory Care Director showed LPA an inconsistency with the door strike on the door R1 eloped through during all elopement incidents and all of R1’s additional elopement attempts. If the door was pushed on the door strike rather than pressing the exit bar, then the door would open without engaging the delayed egress nor would it sound an auditory alarm. Previous ED and Memory Care Director had discovered this immediately following R1’s elopement on 07/11/2022. However, during the initial complaint visit on 08/11/2022, the door strike had not been repaired. Further, in a conversation with R1’s family following the 07/11/2022 incident, management had indicated the facility cannot keep R1 safe. Based on interview, observation, and record review, there is sufficient evidence to support the allegation, therefore the allegation Continued on LIC 9099-C Continued from LIC 9099-C (page 2) that “facility staff are not meeting resident’s basic care needs” is deemed SUBSTANTIATED at this time. Allegation: “Illegal eviction:” It was alleged that Resident #1 (R1) was asked to be picked up from the facility following an elopement on 07/11/2022, then the facility management would not allow R1 to return to the facility without a private companion. Interview with R1’s family revealed that management had called and spoken with R1’s family members and informed them that the facility was unable to meet R1’s care needs following the 07/11/2022 elopement. The family was informed that R1 could return with a 24-hour private companion at a cost of $40/hour. Without a private companion R1 was unable to return to the facility. Staff interviewed confirmed the resident was offered the ability to return to the facility with a private companion. However, staff interviewed also confirmed that the previous attempt to have a 1:1 private companion with R1 had caused R1 additional stress and increased agitation; therefore the 1:1 care was almost immediately discontinued. Staff acknowledged that although they had offered this option to R1’s family, this was not a viable option due to the previous experience. R1’s assessments reviewed, and staff interviewed indicate that staff were aware that R1 was an elopement risk upon admit to the facility. Additionally, staff interviewed indicated that the previous ED and Memory Care Director had discovered the inconsistency with the door strike, which was what was allowing R1 to exit the facility unnoticed, yet this door was not repaired upon discovery. Staff acknowledged that had this door functioned properly, the delayed egress would have sounded an auditory alarm when R1 attempted to elope and staff could have responded appropriately, preventing elopement incidents. Interviews and record review revealed this was the only door R1 eloped or attempted to elope through. Interview with R1’s family revealed that R1 was moved out 2 (two) days after the elopement incident, as they were verbally told the facility could not keep R1 safe and they would continue to incur charges until R1’s belongings were removed. Record review revealed that no written notice was given to CCL nor to the family. Therefore, based on interview and record review, the allegation “illegal eviction” is deemed SUBSTANTIATED at this time. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided via email, per ED Foerschner’s request. Continued from LIC 9099-A (page 5) Allegation: “Insufficient staffing:” The complaint alleges there is not enough staff at the facility in the Memory Care unit. LPA reviewed staff schedules and conducted staff interviews. At the time of the complaint allegation, there were 3 (three) care staff scheduled during the am shift, 3 (three) care staff during the pm shift and 2 (two) care staff during the NOC shift. Interviews revealed that when staff call out, either staff will stay and work a double shift or the facility will use agency staffing. Additional staffing during the day hours include the Memory Care Director, medication technician, and activity staff. As the complaint relates to morning/daytime staffing, LPA observed staff during this specific time period. During the LPA’s visits, LPA observed multiple staff throughout the Memory Care unit, as indicated in the staff schedule. At the time of the initial complaint visit, there were 17 residents in Memory Care. Staff interviewed indicated that there is sufficient staffing to meet the care needs of the residents. Based on interview and record review, although the allegation may be valid, at this time, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “insufficient staffing” is deemed UNSUBSTANTIATED at this time. Allegation: “due to lack of supervision, resident eloped from the facility:” The complaint alleges that the facility staff are not properly supervising R1, resulting in several elopements from the facility. Record review and interviews did confirm that R1 has had several elopements and attempted elopements from the facility through one specific door. Interviews revealed that on days R1’s family has visited R1 that their elopement attempts have increased and, on those days, staff keep a closer watch on R1 to prevent elopements. As identified above, the facility does have sufficient staff coverage in the Memory Care unit and activities are offered to all residents. Following R1’s fourth elopement from the facility, which included a second resident leaving the secure Memory Care unit with R1, ED and Memory Care Director conducted additional testing and observation of the door in which R1 has exited during every elopement. Interview revealed that there was an inconsistency in the door strike, which allowed R1 to exit without an auditory alarm sounding, thus indicating a maintenance/physical plant concern rather than lack of supervision. Record review revealed that although R1 did have wandering behavior, R1 did not require 1:1 supervision. Staff interviewed indicate that R1 was redirected when R1 was found wandering away from the common areas and towards R1’s preferred exit door. However, R1’s room was located in the hallway close to Report Continued on LIC 9099-C Continued from LIC 9099-C (page 6) the exit door and as R1 does not require 1:1 supervision, staff are not always present in that hallway. During all facility visits related to R1’s elopement, sufficient staffing was observed, and staff responded quickly to all auditory exit alarms. Based on interview, record review, and observation, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “due to lack of supervision, resident eloped from the facility is deemed UNSUBSTANTIATED at this time. Allegation: “Facility staff are not engaging resident in activities:” The complaint alleges that Resident #1 (R1) was not engaged in activities during the morning shift, causing R1 additional unwanted behaviors. During the investigation, LPA Dulek obtained and reviewed a copy of the facility’s Memory Care activity schedule, observed residents and staff engaged in activities, and interviewed activity staff, as well as care staff. Interviews revealed that R1 hesitated to engage in activities. Staff invited R1 to participate in all scheduled activities and escorted R1 to the activity areas, but R1 would just sit at the table and not engage. After some time, R1 would then leave the activity area and wander the secure Memory Care area. Care notes indicated staff kept bringing R1 back to activities. Review of activity schedule revealed the facility offers a minimum of 8 (eight) activities at various times throughout the day with the first activity beginning 09:30AM and the last offered beginning at 06:30PM. During various facility visits throughout the investigation, LPA observed many residents involved in the facility activities and facility staff assisting the residents in their activities. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation that “facility staff are not engaging resident in activities” is deemed UNSUBSTANTIATED at this time. No citations issued related to the above complaint allegations. Exit interview conducted. A copy of the report was provided via email, per ED’s request.the state’s words, verbatim · CDSS document, May 6, 2024 · control 29-AS-20220808170551

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(c)(1) · Plan of correction due date: May 6, 2024

87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for...ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidenced by: Based on interview, observation and record review, the facility did not comply with the above cited section as R1 was able to leave the facility unassisted multiple times and management stated they could not meet R1's care needs, which posed an immediate risk to residents' safety.the state’s words, verbatim · CDSS document, May 6, 2024

Plan of correction: Ongoing training plans related to care and supervision following the elopement incidents were provided to LPA. POC cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: May 10, 2024

87468.2 (a) (20) To be protected from involuntary transfers, discharges, and evictions...protections for residents. For purposes of this paragraph, "involuntary" means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident. This requirement is not met as evidenced by: Based on interview and record review, the facility did not comply with the above cited section, as R1 was asked to leave the facility following their 4th elopement and was not permitted to return to the facility without a 1:1 which had proven unsucessful, which posed a potential personal rights risk to R1.the state’s words, verbatim · CDSS document, May 6, 2024

Plan of correction: As R1 no longer resides in the facility, ED agreed to send to CCL a statement of understanding related to resident transfer, involuntary discharge, and evictions by POC due date.

Allegation investigated: Staff do not provide residents with adequate beverages Staff do not treat residents with dignity

Licensing Program Analyst (LPA) Kelly Dulek conducted subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA arrived at the facility at 09:24AM and met with Executive Director (ED) Bradlee Foerschner. Entrance interview conducted. During today’s visit, LPA interviewed various residents and staff from 01:50PM to 02:48PM. During the initial complaint visit conducted on 03/06/2024, LPA interviewed ED at 01:47PM, toured the facility at 02:25PM, and interviewed Resident #1 (R1) at 03:03PM. LPA also attempted to interview R1’s family member via telephone during the course of the investigation and other relevant parties. The following was then determined: Allegation: “Staff do not provide residents with adequate beverages:” The complaint alleges that beverages were withheld from R1, while residing in the facility’s Assisted Living Report Continued on LIC 9099-C Unsubstantiated unit. During both the initial complaint visit and the subsequent complaint visit, upon arrival at the facility, LPA observed beverage options in the facility’s Bistro, including ice water, lemon water, coffee, decaf coffee, and hot water for various tea choices. The facility also contains a lounge/bar area, which is open daily during designated hours and contains both alcoholic and non-alcoholic drink options. In the dining room, which is available throughout the day and evening, there are multiple choices for beverages, including but not limited to sodas, juices, coffee, hot and iced tea, as well as milk. Water is also available in the activity room and on each medication cart, as well as available bottled water. Residents throughout Assisted Living have access to water in their rooms, in both their bathroom sink, as well as kitchenette (if the unit is so supplied.) R1’s room was observed to contain bottles of Arrowhead water in a cabinet above their sink. R1 also had a mug available for use in their room. R1’s refrigerator, which is stocked by either the resident or their family, was observed to be empty at the time of the initial visit. Interview with R1 revealed they do have access to beverages at meals as well as between meals. Interview with staff revealed that although R1 is not observed utilizing the Bistro often, they are aware beverages are available throughout the facility. Other residents interviewed indicated the facility provides beverages to meet their needs. Based on interview and observation, there is insufficient evidence to support the allegation, therefore the allegation that “staff do not provide residents with adequate beverages” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff do not treat residents with dignity:” The complaint alleges that R1 indicated that “people are mean” at the facility. During the initial complaint investigation, LPA interviewed R1 for additional details. R1 indicated staff are nice to her and the other residents and does not recall anyone being mean to her. Other residents interviewed indicated the staff are all kind, courteous and helpful. No residents have observed any instances where residents were not treated with dignity. Staff interviews also revealed that residents are treated well, there have been no reports to their knowledge of any residents being mistreated and they have not witnessed any incidents related to residents’ dignity. Staff did indicate that occasionally there are incidents where residents have been unkind to one another, but they encourage the residents to speak amongst themselves with respect and work through any concerns they may have. Staff do intervene when necessary. Based on interview and observation, there is insufficient evidence to support the allegation, therefore the allegation that “staff do not treat residents with dignity” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of today’s report was provided via email.the state’s words, verbatim · CDSS document, May 6, 2024 · control 29-AS-20240228120312

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident that occurred on 03/03/2024. LPA met with Executive Director (ED) Bradlee Foerschner. LPA explained the reason for today's visit. On 03/04/2024, ED sent an email to the LPA, which included an Incident Report and suspected abuse report related to an altercation involving Resident #1 (R1) and Resident #2 (R2) who reside in Traditions. The altercation resulted in injury to R2, so R2 was sent to the hospital for medical treatment and subsequently moved out of the facility. During today's visit, LPA interviewed ED related to the incident and LPA toured the facility at 02:25PM. No immediate health and safety hazards were identified during today’s visit. LPA will return at a later date to continue the investigation into the incident. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Mar 6, 2024

Allegation investigated: Licensee did not provide safe, comfortable accommodations for resident in care Facility staff did not assist resident with basic care needs Facility staff neglected resident Facility staff did not respond timely to resident's request for assistance

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility at 09:34AM and met with Executive Director Bradlee Foerschner. Entrance interview conducted. During today's visit, LPA conducted staff and resident interviews from 11:14AM to 1:50PM. Previously, during an initial complaint visit which took place on 03/30/2022, LPA toured the facility with Business Office Director at 10:38AM, conducted resident and witness interviews from 11:26AM to 11:50AM, interviewed Administrator Martha Berard at 12:25PM, and LPA gathered copies of pertinent documents. Throughout the course of the investigation, LPA reviewed all relevant documents. The following was then determined: Report Continued on LIC 9099-C Substantiated The complaint alleges that there was an incident that occurred during the overnight shift from 03/21/2022 to03/22/2022 involving Resident #1 (R1). It was alleged that R1 had called for assistance using their pendant and staff was not responding to the requests. R1 then called 9-1-1 to request assistance. Staff #1 (S1) did respond at some point, entered R1's room and assisted R1 to their bedside commode. When emergency personnel arrived at the facility S1 was in R1's room and S1 indicated they were caring for R1, so emergency personnel left the facility. S1 then left R1 on the commode and exited R1's room. R1 continued to press their pendant, but no one responded. R1 could not find their telephone to call for assistance. R1 then self-transferred back to their bed. Documents reviewed included resident's care plan and physician's report, incident report submitted by the facility Administrator, as well as statements provided by morning staff who had found R1. Interviews and documents reviewed revealed that R1's phone was found on the bedside table with the batteries removed, although typically R1 sleeps with their phone in their bed. Additionally, interviews revealed that due to R1's condition it is highly unlikely that R1 would physically be able to remove the batteries from their phone. R1 is unsure who removed the batteries from their phone, but indicated R1 did not do it themselves. S1 did indicate they had access to R1's phone when in their room to assist. Staff interviews revealed that in the morning, R1 was found in their bed with their head at the foot of the bed and feet by their pillows with their bedding tangled. Staff stated R1 was in a "urine-soaked bed" with the chuck pad soaked through, and the sheets and mattress wet with urine. Management did interview S1 in relation to the incident, but S1's statements "did not add up." As a result of the incident, S1's employment was terminated. Staff indicated 45 calls using their pendant were not responded to. R1's resident assessment does reflect that R1 requires one person physical assistance with transfers. Interviews revealed that although R1 wore an incontinence brief, it was typical that R1 would call for assistance during the overnight shift to request transfer assistance to and from the commode. Therefore, based on interview and record review, the allegations that "Licensee did not provide safe, comfortable accommodations for resident in care," "Facility staff did not assist resident with basic care needs," "Facility staff neglected resident," and "Facility staff did not respond timely to resident's request for assistance" are deemed SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted. Today’s reports and appeal rights were reviewed and provided via email.the state’s words, verbatim · CDSS document, Dec 7, 2023 · control 29-AS-20220323121610

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 21, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as on the night of 03/21/2022, R1 was left with their bed and bedding wet with urine and no access to their phone, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 7, 2023

Plan of correction: Executive Director agreed to review staff training records and provide record of personal rights training to CCL. If no training was done at the time of the incident, ED will retrain current staff on residents personal rights and provide proof of training to CCL by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87468.2(a)(8) · Plan of correction due date: Dec 8, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) (8)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as on the night of 03/21/2022, S1 left R1 on their commode and did not respond to R1's calls for assistance, which posed an immediate safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 7, 2023

Plan of correction: S1 was terminated as a result of the incident that occurred. POC cleared.