University Retirement Community at Davis

Allegation investigated: Resident sustained severe injuries resulting in death due to staff neglect

****This is an amendment to report**** On 9/11/2026, Licensing Program Analyst (LPA) Jill Nakagawa met with Maria Burton to present findings from a complaint investigation related to an allegation of “resident sustained severe injuries resulting in death due to staff neglect”. The Department conducted the investigation which included interviews with residents, staff, families, emergency medical responders, physicians, and Davis Police officers. Additionally, the Department reviewed medical records, facility records, emergency medical responders’ notes, Davis Police report as well as reviewed photographic evidence. (Continued on 9099-C) Unsubstantiated (Continued from 9099) On 1/10/2026 at approximately 9:30 pm, staff heard a sound and went to investigate. Upon entering Resident (R1) and (R2) room, it was discovered that R1 was lying in bed with blood on their face, forehead and top of head. R2 was sitting in a recliner fully dressed with a small amount of blood on their hand. 911 was called and R1 was taken to the hospital. Prior to the incident, both residents had dinner with their spouses who then helped get R1 and R2 ready for bed which was uneventful. Davis Police conducted an investigation and determined R2 inflicted the injury upon R1. R1 repeatedly said "assault," and "roommate" when asked by medical staff who assaulted them. R2 was interviewed but did not recall the event. Interviews and record review found neither resident had a history of falls, aggressive behaviors, or any noted altercations (verbal or physical) with each other or any other individuals. R1 and R2 had been roommates since 8/25/25 with no history of aggression or incidents. Interviews with R1 and R2’s spouse showed that neither resident expressed any concerns regarding each other. Based on interviews and record review, there is insufficient evidence to prove the facility had knowledge that R2 would become aggressive towards R1 causing injury. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Report signed by Maria Rodriguez, RCFE Manager for Maria Burton, Administrator.the state’s words, verbatim · CDSS document, Sep 11, 2026 · control 21-AS-20260513092443

Type of visit: Case Management - Other

On 07/31/2026, Program Analyst (PA) Lovina Aquino and Financial Analyst (FA) Ashmita Roshan arrived at the facility and met with Interim Executive Director (IED), Shelley Kendrick to complete the required triennial visit for University Retirement Community at Davis, a Continuing Care Retirement Community (CCRC). Prior to the visit, the PA and FA reviewed documentation requested from and provided by the IED to ensure that the provider is operating the CCRC in compliance with the statutes and is performing the services specified in its continuing care contracts. During today’s visit, the PA, FA, and IED discussed the documentation received prior to the visit and toured the CCRC to ensure that all required postings and documents were accessible to residents and visitors. This includes the Certificate of Authority, which remains valid and is properly displayed at the front desk. CCCB staff also toured the community, the assisted living, independent living and memory care unit. During the tour, CCCB staff observed that the community was not in compliance with the following Health and Safety Code (H&SC) sections: 1771.7 (f) - CCRC Resident Rights were not posted 1771.8 (g) – Annual Report on file were outdated 1771.7 (d) (2) Resident Satisfaction Survey was not available As a result of the visit, technical violations related to the required postings and resident information requirements were issued. (Report continued on LIC 809 C) Additionally, CCCB staff will follow up with a thank you letter and visit summary to the IED within seven days of the visit. An exit interview was conducted with the IED. Due to connectivity issues, CCCB staff completed the LIC 809 upon return to HQ and emailed the IED for signature.the state’s words, verbatim · CDSS document, Jul 30, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a case management visit regarding the self-reported incident of resident (R1) eloping from the facility on 06/16/2026. LPA met with Administrator Maria Burton to discuss. The self-reported incident occurred on 06/16/2026, when resident (R1) left the facility between 8:40 AM (after med. tech. came and administered medications) and 10:00 AM (when the private caregiver arrived and found R1 was not in the room). Caregivers searched facility and nearby area. R1 was spotted by private caregiver walking a short distance away on Shasta Drive. Private caregiver picked R1 up and returned to facility. R1 was assessed and found to have no injuries. LPA reviewed records which included the facility's incident report and R1's Physician's Report, which indicates R1 is unable to leave the facility unsupervised. (Deficiency cited). Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and/or the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. An immediate civil penalty is being issued in the amount of $500 per Health and Safety Code 1568.0822(C)(3) Absence of Supervision.the state’s words, verbatim · CDSS document, Jul 23, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 23, 2026

Personnel Requirements – General 87411(a) –Personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidenced by: Based on iself-reported incident report facility did not provide supervision to R1 resulting in an elopement. The absence/lack of supervision is an immediate risk to the Health, Safety and Rights of residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: A $500 immediate civil penalty was assessed. Licensee/Administrator to submit in-service retraining to all staff on elopement protocols and designate staff to ensure private caregivers are on duty as scheduled. POC due by 7/27/26.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 01/12/2026 at University Retirement Community at Davis to conduct an Annual Inspection. The facility is a CCRC which is licensed for 500 residents. There are currently 48 residents residing in Assisted Living and Memory Care. LPA met with Maria Rodriguez-Meza, the RCFE Manager and toured the facility, including Memory Care, Assisted Living, common areas, kitchen, outdoor recreation areas, auditorium, beauty salon,The Nook (a small store) and dining areas. The facility recently completed renovations and remodeling to the entrance of the facility, as well as the activities room and the library. Assisted Living currently has 39 residents. Memory Care currently has 11 residents. Ten (10) apartments in the Memory Care and Assisted Living were inspected and found to be clean, well-maintained and had the required furnishings, free of materials deemed hazardous to individuals with Dementia: medications and toiletries. Assisted Living apartments were clean, well-organized and set up for the particular needs and tastes of the individual. The Assisted Living Dining Room/Activities Rooms are on the first floor for easy access for the Assisted Living residents. The upstairs dining room, was clean with tables set and ready for the upcoming dinner seating. The kitchen provides food for all areas of the facility (Independent, Assisted, Memory Care and Skilled). LPA found the kitchen to be clean and sanitary, with an ample supply of perishable and non-perishable foods, and stored appropriately. All kitchen equipment was clean and safely stored. Continued on 809-C..... Continued from 809..... Independent Living currently has 265 residents who live in the main building, apartments and cottages on the premises. The Licensee has an approved Dementia Plan of Operation and an Infection Control Plan. Fire system is checked monthly by staff and an inspection of the Automatic Fire Sprinkler System was checked by an independent fire protection company 09/2025. Fire extinguishers were serviced on 02/27/2025 and units inspected were fully charged. Assisted Living and Memory Care conducted a fire drill on 12/7/2025. Facililty files are all kept electronically. HR and RCFE Office was able to provide the necessary documents. LPA inspected 5 resident files and 5 staff files and found them to be complete, including residents' Care Plans and Staff training records. LPA requested latest Certificate of Liability Insurance. LPA requested an updated LIC500 for Assisted Living and Memory Care. No deficiencies were found at the time of inspection. No citations issued. Exit interview conducted with Maria Rodriguez-Meza..the state’s words, verbatim · CDSS document, Jan 12, 2026

Allegation investigated: Facility does not have running water. Staff not providing residents with water.

On 9/26/25 Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conclude the investigation regarding the above allegations and to deliver findings. LPA met with Maria Burton, Assisted Living Administrator to discuss findings. The complaint alleges that Facility does not have running water and Staff not providing residents with water. The complainant states that since 7/31/25 there is no running water; however the complainant also states that there is a small stream of water coming from the sink. It was reported to the Department by the facility on 8/4/25 that there had been a water main break and the facility was in the process of making repairs. (Continued on 9099-C) Unsubstantiated (Continued from 9099) On 8/5/2025 LPA conducted a facility tour and observed that the allegation listed in the complaint is located on the Independent Living (IL) portion of the facility. LPA conducted interviews of residents on each of the four floors in the main building. Independent Living (IL) Residents from the 3rd and 4th floors reported a loss of water pressure, experienced low water flow and low pressure including difficulty in flushing toilets. Two (2) of three (3) residents on the 3rd and 4th floor stated that they were able to retrieve bottled water from resident services downstairs. IL residents from the second floor of the building did not experience the same loss of water pressure and stated they were able to access water and could flush toilets. The LPA observed that the Assisted Living and Memory Care units on the first floor, which are under the license from CCL did have water pressure and were able to access water, and flush toilets. In addition, it was reported to LPA by Executive Director Alika Cassilla, that bottled water was provided to all residents in Independent Living and Assisted Living during the time the repairs were being made. According to the Executive Director Alika Casilla, updates regarding the work on the water pipes was provided to the residents regularly through the Echo system which every resident, other than Memory Care, has available to their rooms. Five (5) of six (6) of the IL residents interviewed stated that they did not have any issues with the way the facility handled the situation. Although the general consensus was that it was inconvenient, residents felt the facility was handling the situation quickly. Community Care Licensing (CCL) does not have jurisdiction to enforce regulations on the Independent Living units of the facility. Based on the investigation, LPA was unable to identify any deficiencies in the maintenance of the property on the Assisted Living (AL) side of the facility that CCL does have jurisdiction. The facility was actively repairing an unforeseen water system failure quickly, and although residents did have some inconveniences the facility acted timely and responsively and was providing water to residents. Continued from 9099-C This agency has investigated the complaint allegations “Facility does not have running water” and “Staff not providing residents with water”. After interviews, observations, and other investigation the agency has found that the allegations were Unsubstantiated,, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies were cited.the state’s words, verbatim · CDSS document, Sep 26, 2025 · control 21-AS-20250804122404

Type of visit: Case Management - Incident

At approximately 1:30 PM, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Maria Burton. The purpose of the visit was to follow up on self-reported incident that were submitted to Community Care Licensing (CCL). CCL received an incident report on 07/18/2025. Review of the report stated that on 07/13/2025 Resident 1 (R1) left the facility unattended and was found by a bystander off the University Retirement Community (URC) campus who stated, according to the Incident Report, that R1 appeared to be lost. R1 asked the bystander to take him back to facility who brought R1 back and notified staff. R1's Physician's Report at the time of the incident stated that R1 is unable to leave the facility unattended. R1 has, since the incident, been re-assessed and new Physician's Report now states R1 may leave facility unattended. Due to staff being unaware of and/or unfamiliar with R1's restriction to leave facility unattended R1 was able to leave URC without supervision. Deficiency cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Administrator and Appeal rights were given.the state’s words, verbatim · CDSS document, Sep 26, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 26, 2025

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: Based on incident report and interview, facility did not provide supervision to R1 resulting in an elopement. The absence/lack of supervision is an immediate risk to the Health, Safety and Rights of resident in carethe state’s words, verbatim · CDSS document, Sep 26, 2025

Plan of correction: Administrator to ensure that all AL residents assessments are reviewed thoroughly and staff will be notified of residents who are unable to leave facility unattended. Administrator to submit statement that all AL resident records have been reviewed and staff are aware of residents' status of leaving the facility by 9/29/25.

Allegation investigated: Staff do not ensure that residents have adequate hygiene supplies Staff do not follow infection control practices

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to complete the complaint investigation and deliver findings regarding the above allegations. On 2/5/2025 and 3/28/2025 LPA Nakagawa made an inspection of the facility, touring both Assisted Living and Memory Care, and common areas of the facility including the large dining room upstairs, the downstairs entry, the library area and the entry to the outdoor pool, and the mailboxes. LPA spoke with staff (S1 – S9) asking if there were adequate hygiene supplies for residents for proper hygiene and infection control practices. Nine (9) out of (9) staff stated that there were adequate supplies, including soap, paper towels, gloves, masks and hand sanitizer. Continued on 9099-C Unsubstantiated Continued from 9099..... S1 stated “that there are ample supplies.” S2 provided an invoice showing that adequate supplies are ordered by the facility. LPA inspected storage areas for each department (housekeeping, Assisted Living, Memory Care) and found adequate supplies of gloves, cleaning supplies, toilet paper, paper towels, hand soap and PPE- with additional supplies stored in the basement. On 3/28/2025 LPA inspected the Memory Care Unit and six (6) out of the six (6) apartments inspected had soap, paper towels, covered trash cans and toilet paper. Three apartments in Assisted Living were also inspected and found adequate hygiene supplies in three (3) of three (3) units. In addition, LPA spoke with three (3) of three (3) residents who stated they were satisfied with the supply of hygiene supplies and that staff made sure they were well stocked. Therefore, the allegation that Staff do not ensure that residents have adequate hygiene supplies is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. In addition, the complaint alleges that Staff do not follow infection control practices. LPA visited the facility on 2/5/2025 and 3/28/2025 and found required Infection Control Protocols in place. Staff S3 stated that Staff receive trainings regularly and are provided with PPE to ensure safety for themselves and the residents. Signs are up reminding staff to wash hands regularly and hand sanitizer is available throughout the building. Five (5) Staff in Caregiving and Housekeeping were interviewed: five (5) of five (5) staff stated that they follow infection control practices, receive training, and have enough PPE available. They were asked if they would feel comfortable requesting another staff member to follow infection control practices if they were not and they stated “Yes, for their safety and the safety of the residents, they would.” In addition, the facility provides sick leave for staff when they are ill, so they do not come to work when they may be contagious. In addition, the facility regularly reports any outbreaks of possible infectious disease to CCL and the CDPH as required, and follows the protocols and procedures requested by the departments. Therefore, the allegation that staff do not follow infection control practices is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Mar 28, 2025 · control 21-AS-20250131093814

Type of visit: Case Management - Other

***This report is being amended due to an appeal being granted *** Licensing Program Analyst (LPA) Jill Nakagawa arrived on 09/18/2026 for an unannounced Case Management visit to follow up on self-reported incident submitted to Community Care Licensing on June 14, 2024. LPA met with Maria Burton via phone and explained the purpose of the visit. On July 1, 2024, the Department conducted a Case Management visit to follow up on a self-reported incident submitted to Community Care Licensing on June 14, 2024. According to the Incident Report and Case Management Visit on June 11, 2024, at approximately 4:50 a.m. Resident (R1) was found outside in the facility parking lot with an overturned wheelchair nearby. R1 sustained a pelvic fracture and required hospitalization. Documentation indicates facility staff recognized R1’s increasing care needs and were conducting hourly checks. In addition, staff had been in contact with R1’s responsible party due to R1’s increase in care needs and need for additional supervision. At that time, R1’s responsible parties had been reluctant to place R1 in an increased supervised environment as requested by the facility. Although the incident is serious, the Department has determined that the facility was addressing the change in R1’s condition. No deficiencies or civil penalties were issued at today’s visit. Report signed for Maria Burton by Maria Rodriguez, RCFE Manager.the state’s words, verbatim · CDSS document, Mar 28, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jill Nakagawa arrived on March 28, 2025 for an unannounced Case Management visit to follow up on self-reported incident submitted to Community Care Licensing on June 14, 2024. LPA met with Maria Burton and explained the purpose of the visit. On July 1, 2024, the Department conducted a Case Management visit to follow up on a self-reported incident submitted to Community Care Licensing on June 14, 2024. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section §15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facilities lack of supervision on June 11, 2024, when R1, who was identified as not being able to leave the facility unassisted, was found at approximately 4:50 a.m. outside the facility in the parking lot on the ground with a wheelchair upside down next to them. R1 sustained a pelvic fracture and required hospitalization. Today March 28, 2025, the Department is issuing a civil penalty per Health and Safety Code §1569.49 for a violation that the Department constitutes as serious bodily injury resulting in the hospitalization of a resident, in the amount of $10,000. Exit interview conducted. A copy of the report has been issued. Appeal rights provided. Facility representative and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Mar 28, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 12/10/2024 at University Retirement Community at Davis to conduct an Annual Inspection. The facility is a CCRC which is licensed for 500 residents. There are currently 48 residents residing in Assisted Living and Memory Care. LPA met with Maria Burton and toured the facility, including Memory Care, Assisted Living, common areas, kitchen, outdoor recreation areas, auditorium, beauty salon, The Nook (a small store) and dining areas. The facility is undergoing renovations and remodeling, so the entrance to the facility has been altered, but still safely accessible. Assisted Living currently has 35 residents. Memory Care currently has 13 residents. All rooms in Memory Care were clean and a comfortable temperature. Bedrooms were clean and appointed to highlight the personalities of the occupant. Room temperatures ranged from 71-74 degrees F. Six apartments in Assisted Living were inspected and found to be clean and well-maintained, with water temperatures measuring within regulation of 105-120 degrees F. Residents expressed that they were well-taken care of. The library and one of the downstairs dining areas was not in service due to the renovations. The upstairs dining room, was clean with tables set and ready for the upcoming dinner seating. The kitchen was clean and sanitary, with an ample supply of perishable and non-perishable foods. All kitchen equipment was clean and safely stored. Independent Living currently has 260 residents who live in the main building, apartments and cottages on the premises. The Licensee has an approved dementia plan of operation and an Infection Control Plan. Fire system is checked monthly by staff and an inspection of the Automatic Fire Sprinkler System was checked by independent fire protection company on 06/25/2024. Fire extinguishers were serviced on 02/15/24 and were fully charged. Assisted Living and Memory Care conducted a Fire Drill on 11/27/2024. Elevators were inspected 04/10/24. Continued from 809.... LPA reviewed the requirement that files must be available at all times. Administrator stated that CCL would have access through HR and IT with only momentary wait time while access was granted. LPA inspected 5 resident files and 5 staff files via the computer and found them to be complete, including residents' Care Plans and Staff training records. LPA received a copy of the latest Certificate of Liability Insurance. LPA requested an updated LIC500 for Assisted Living and Memory Care. No deficiencies were found at the time of inspection. No citations issued. Exit interview conducted with Maria Burton, Administrator.the state’s words, verbatim · CDSS document, Dec 10, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a case management inspection regarding an incident report submitted to Community Care Licensing (CCL) received on 6/14/2024. On 6/11/2024 resident R1 was found by staff outside of building at 4:50 AM beside an overturned wheelchair. Staff contacted emergency services and family was notified. R1 was tranported to hospital. LPA requested medical records and documentation regarding R1's assessment and care plan. LPA to follow up with Administrator at a later time. No citations issued at the time of inspection.the state’s words, verbatim · CDSS document, Jul 1, 2024

Allegation investigated: Staff are not ensuring that facility grounds are maintained in a safe manner for resident(s) in care

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced and met with Maria Burton, Administrator to deliver findings of a complaint investigation regarding the allegation "Staff are not ensuring that facility grounds are maintained in a safe manner for resident(s) in care. LPA toured the facility and interviewed staff. LPA observed during the facility tour on 12/19/2023 that the allegation listed in the complaint is located on the Independent Living (IL) portion of the facility. Continued on 9099-C Unfounded Continued from 9099..... Community Care Licensing (CCL) does not have jurisdiction to enforce regulations on that portion of the facility. Based on the investigation, LPA was unable to identify any deficiencies in the maintenance of the property on the Assisted Living (AL) side of the facility that CCL does have jurisdiction. This agency has investigated the complaint allegation "Staff are not ensuring that facility grounds are maintained in a safe manner for resident(s) in care". After interviews, observations, and other investigation the agency has found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies were cited.the state’s words, verbatim · CDSS document, Dec 19, 2023 · control 21-AS-20231218124819

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jill Nakagawa (JN) arrived unannounced on 12/01/2023 at University Retirement Community at Davis to conduct an Annual Inspection. The facility is a CCRC which is licensed for 500 residents. LPA JN met with Maria Rodriguez, RCFE Manager and toured the facility, including Memory Care, Assisted Living, common areas, kitchen, outdoor recreation areas, library, auditorium, beauty salon, The Nook (a small store) and dining areas. Assisted Living currently has 35 residents. Memory Care currently has 10 residents. All rooms were clean and a comfortable temperature. Room temperatures ranged from 69 -71 F. The upstairs dining room, which had been recently renovated was clean and decorated for the holidays. The kitchen was clean and sanitary, with an ample supply of perishable and non-perishable foods. All kitchen equipment was clean and safely stored. Independent Living currently has 260 residents who live in the main building and also in cottages on the premises. The Licensee has an approved dementia plan of operation. An Infection Control Plan was submitted. Fire system is checked monthly by staff and an inspection of the Automatic Fire Sprinkler System was checked by independent fire protection company on 06/30/2023. Fire extinguishers were serviced on 02/15/23 and were fully charged. Continued on 809-C. Continued from 809 LPA requested the following documents by 12/15/2023: LIC500 Resident Roster for AL and MC Proof of Liability Insurance LIC308 There were no deficiencies. No citations issued. Exit interview conducted with Christie Dewar, AL/MSU Resident Care Manager..the state’s words, verbatim · CDSS document, Dec 1, 2023