The Reutlinger Community

Type of visit: Case Management - Other

On 8/4/2026 at 9:30AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a case management visit to get exemption request denial documentation signed. LPA met with Executive Director (ED), Mary Goldhoff and explained the purpose of the visit. During visit, LPA verified that person one (P1) is not employed at the facility and that the facility received the exceptional denial for P1 dated 7/17/2026. ED signed confirmation of removal during the visit and noted that P1 was never employed by the facility. No deficiencies are being cited on this date.the state’s words, verbatim · CDSS document, Aug 4, 2026

Type of visit: Required - 1 Year

On 7/21/26 at 11:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director (ED), Mary Goldhoff and explained the purpose of the visit. The facility’s fire clearance was approved for all may be non-ambulatory with 5 bedridden. LPA toured the facility with ED including but not limited to random residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured between 105.0-120.0 degrees Fahrenheit. Freezer measured at 0 degrees Fahrenheit and refrigerator measured at 30 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 12/8/2025. Emergency Disaster Plan was last posted on 6/2/2026. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 5/23/2026 LPA reviewed 5 residents records. LPA reviewed 5 staff records. LPA reviewed a sample of resident’s medications. Updated copies of the following documents were requested for facility file and are to be mail to CCL by 8/1/2026: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 21, 2026

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 1/30/2026 at 9:30AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a case management visit to deliver an immediate exclusion letter. LPA met with Executive Director, Hanh Ta and explained the purpose of the visit. During visit, LPA hand delivered the immediate exclusion letter for S1 to Executive Director, Hanh Ta. Executive Director states that S1 is not currently employed at the facility and will be immediately removed from the facilities Guardian Roster. No deficiencies are being cited on this date.the state’s words, verbatim · CDSS document, Jan 30, 2026

Type of visit: Case Management - Other

On 12/2/2025 at 9:30AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a case management visit to deliver an immediate exclusion letter. LPA met with Executive Director, Hanh Ta and explained the purpose of the visit. During visit, LPA hand delivered the immediate exclusion letter for S1 to Executive Director, Hanh Ta. Executive Director states that S1 is currently employed at the facility and will be immediately removed from the schedule and informed not to return. No deficiencies are being cited on this date.the state’s words, verbatim · CDSS document, Dec 2, 2025

Type of visit: Case Management - Incident

On 8/7/2025 at 1:00PM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit in regards to incident report received on 8/5/2025. LPA met with Resident Care Director, Nelsa Alferos and explained the reason for the visit. Based on the incident report received on 8/5/2025, resident (R1) eloped from the facility. During visit, LPA reviewed R1's file including medical assessment, physician's notification, and care plan. R1's physicians report stated that they can not leave unassisted. Resident Care Director (RCD) states that S1 disabled the wander guard alarm when they saw R1 outside because they thought they were being picked up by family because there was a car in front of the facility. However R1 was not being picked up and required assistance. S1 does not provide care to residents and has since been informed not interact with residents. RCD states that R1 did have a wander guard. R1 was located and returned unharmed and has since been moved to memory care. Police and responsible party notified. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 7, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 14, 2025

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...require such additional staff for the provision of adequate services. This requirement is not met as evidence by: Based on report of resident with physcians report that states resident can not leave unassisted eloping from facility because the staff were not competent in their condition and disarmened the wander guard when the resident exited the facility unassisted the above regulation was not met which posed an immediate safety risk to person in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: Staff received an inservice and all other staff are also being updated on procedure POC Clear

Type of visit: Case Management - Incident

On 6/25/2025 at 2:20PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 6/20/2025. LPA met with Executive Director, Julie Mammad and Assistant Resident Care Director, Dolores Prince. LPA informed them the reason for the visit. Based on the incident report received on 6/20/2025, resident (R1) took R2's medications. R1's family and doctor were notified. Med tech will receive training on medication administration. During visit, LPA interviewed staff and reviewed R1's file including medical assessment, physician's notification, and care notes. Staff stated R1 was monitored for 3 days after taking the incorrect medications and was observed with no ill effects. Facility had a meeting with residents, family, and staff regarding medication administration and regulatory requirements. Med tech was given some additional training and will receive more training in later days. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jun 25, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 3, 2025

Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are qualifications...and competency to meet their needs. This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not administering the correct medications to the resident which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Jun 25, 2025

Plan of correction: Facility contacted R1's doctor right away after incident and R1 had no ill effects from R2's medications. Executive Director (ED) has agreed to conduct additional training to med tech. ED will provide training materials and completion document to CCLD by POC date.

Type of visit: Case Management - Other

On 6/16/2025 at 9:30 a.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit due to receiving an eviction notification for R1. LPA met with Executive Director, Julie Mammad and explained the purpose of the visit. R1 was admitted to the facility on 3/21/2024. R1 has dementia diagnosis and lives in the assisted living section of the facility. ED states that R1 has been seeing a psychiatrist for aggressive behaviors. ED has been working with R1's responsible party to get medication adjustment, 1:1 care, and possibly moving to memory care. ED states that there has been some pushback on these changes from the RP. R1's behaviors have began to effect other residents personal rights. ED states that they issues the eviction notice because they are not able to meet R1's needs currently unless their RP agrees to adjustments. ED states that currently they are still trying to work with R1 and the RP to find a feasible solution but that if none are agreed upon they will not be able to meet the needs and services of R1. LPA requested that ED send over the correspondences with RP and incident reports for R1's behaviors to support the merit for eviction. No deficiencies cited at this time. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 16, 2025

Type of visit: Required - 1 Year

On 6/16/25 at 10:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Julie Mammad and explained the purpose of the visit. The facility’s fire clearance was approved for all may be non-ambulatory with 5 bedridden. LPA toured the facility with Julie Mammad including but not limited to 10 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 110.4, 107.7, 110.1 degrees Fahrenheit. Freezer measured at -15 degrees Fahrenheit and refrigerator measured at 36 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 12/5/2024. Emergency Disaster Plan was last posted on 1/2/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 5/13/2025 At 2:00 pm, LPA reviewed 6 residents records. At 3:00 pm, LPA reviewed 6 staff records and 5 of 5 required have current first aid training and associated to the facility. At 11:40am, LPA reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 16, 2025

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On 04/2/2025 at 12:15 p.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit due to receiving a self report of suspected abuse (SOC341) of a resident having been verbally abused by staff. LPA met with Executive Director, Julie Mammad and explained the purpose of the visit. R1 was admitted to the facility on 4/23/2017. R1 does not have a dementia diagnosis and lives in the enhanced assisted living section of the facility. The facility conducted their own investigation and spoke with R1. R1 stated that S1 did speak to them inappropriately. However, ED did state that R1 was not able to readily identify S1 and stated that they think that is who spoke to them inappropriately. ED states that R1 has a history of making false claims against caregivers and speaks down to the staff. ED states that they interviewed R2 and R3 who states that S1 never speaks inappropriately. LPA interviewed R1, R4, and R5. R1 states that staff spoke to them inappropriately and told them to drop dead. When LPA asked R1 the name of the staff R1 was unable to provide a name. LPA also asked R1 to describe the staff that was rude to them and they were unable to. LPA also observed that R1 is very hard of hearing. LPA was unable to speak to R1 because they could not hear LPA even when voices were raised significantly so LPA had to type out the questions to converse with R1. S1 works NOC shift and interacts with residents seldom unless care is required throughout the night. Neither the facility or LPA were able to confirm if any staff were rude or verbally abusive to R1 No deficiencies cited at this time. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 2, 2025

Type of visit: Case Management - Incident

On 03/12/2025 at 9:00 a.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit due to receiving a self report of suspected abuse (SOC341) of a resident having fallen in their room and caregivers not appropriately assessing. LPA met with Executive Director, Julie Mammad and explained the purpose of the visit. R1 was admitted to the facility on 2/22/25. R1 is in memory care . Report indicates that R1 had a fall on 3/3/2025 at approximately 3:23am and S3 was notified at 3:31am. S3 called S1 and S1 went to check on R1. Camera footage confirms that S1 went to check on R1 at 3:32am. S2 was on shift at the same time as S1 and was assigned to R1's room. After S1 checked on R1 they notified S2 that R1 was in bed asleep. S1 checked on R1 again at 3:34am. At 6:04 am S2 checked on R1. No injuries were reported until morning ADL's when it was discovered that R1 had blood on their pillow and R1 was sent out to the emergency room. LPA observed the video footage of R1's fall and them getting back into bed as well as the checks done by staff. S1 and S2 both received additional training as a result of this incident and were put on suspension pending an investigation. It was found that S1 did promptly check on R1 but that S1 should have woken R1 up to have a full assessment done. Both S1 and S2 received verbal warnings and in service training. R1 is currently back at the facility and is in physical therapy. No deficiencies cited at this time. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 12, 2025

Allegation investigated: Staff mistreated resdient Resident was prevented from accessing their food

On 11/27/2024 at 9:00 AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver findings in regard to the allegations above. LPA met with Executive Director (ED), Julie Mammad and explained the purpose of the visit. During the investigation the LPA interviewed S1, S2, S3, S4, and ED on 7/30/2024. S1, S2, and S3 relayed similiar stories to LPA. S1, S2, S3 all stated that S5 would "bully" the residents and that they would make mean nicknames for the clients and write it in their charts. However upon review of charts LPA found no evidence of such entries. Report continues on LIC 9099-C Unsubstantiated While interviewing S1, S2, and S3 LPA observed that there were chats on WhatsApp between all the caregivers including S5. However LPA was unable to obtain proof of the claims made by S1, S2, and S3 and their accounts appeared rehersed, leading LPA to question their credibility. LPA also interviewed the ED. ED acknowledged prior issues between S5 and S1, S2, and S3. ED described S5 as assertive but stated that they were always respectful and attentive to residents. ED noted that S5's assertiveness would sometimes rub other staff the wrong way. LPA also attempted to interview S4 but S4 stated that they had never worked with S5. S4 stated that they had no relevant knowledge to contribute regarding S5. LPA was unable to interview any residents as they all reside in memory care and have dementia. LPA also discussed with the ED if there were any incidents or reports regarding R1, R2, and R3 and found that any allegations made regarding these residents were internally investigated and that none of the investigations were substantiated and no injuries were ever found on any of the residents in care. LPA was unable to find any time that residents were not allowed to access their food besides through the interviews with S1, S2, and S3 whom LPA questioned their credibility. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 27, 2024 · control 15-AS-20240718145544

Type of visit: Case Management - Annual Continuation

On 7/18/2024 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to continue 1-Year Annual Required inspection. LPA met with Skilled Nursing Administrator, Brian Kallio and explained the purpose of the visit. Executive Director was off at the time of visit. The facility’s fire clearance was approved for all may be non-ambulatory with 5 bedridden. LPA toured the facility with Skilled Nursing Administrator including but not limited to 6 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 117.4, 106.2, 114 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Freezer temperature measured at 0 and refrigerator temperature measured at 36 degrees F. Fire extinguishers were last serviced 12/4/2023 No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 18, 2024

Type of visit: Required - 1 Year

On 7/11/2024 at 12:30 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Skilled Nursing Administrator, Brian Kallio and explained the purpose of the visit. Executive Director was off at the time of visit. The facility’s fire clearance was approved for all may be non-ambulatory with 5 bedridden. Smoke detectors are interconnected with sprinklers and observed throughout the facility. Fire and Disaster Drill was last conducted on 6/13/2024. Emergency Disaster Plan was last posted on 2/21/2024 LPA reviewed 7 residents records. LPA reviewed 5 staff records and 5 of 5 are associated to the facility.Training for staff providing ADLs is current and up to date. LPA reviewed a sample of resident’s medications. The annual inspection is not complete. LPA will return to complete the inspection and tour the facility at a later date. No deficiencies cited during visit. Exit interview conducted and a copy of this report providedthe state’s words, verbatim · CDSS document, Jul 11, 2024

Allegation investigated: Staff violated residents' personal rights by not allowing visitors

On 5/15/2024 at 9:00 AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a complaint investigation and deliver findings in regard to the allegations above. LPA met with Executive Director (ED), Julie Mammad and explained the purpose of the visit. During the visit LPA interviewed S1. S1 informed LPA that a visitor had been harrassing them which is why that visitor was asked not to visit temporarily. LPA obtained documentation of the ED stating that a visitors visitations rights were temporarily suspended. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Substantiatedthe state’s words, verbatim · CDSS document, May 15, 2024 · control 15-AS-20240507110256

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: May 15, 2024

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(11)To have their visitors... provided that the rights of other residents are not infringed upon. This requirement was not met as evidence by: Based on interviews and documentation obtained from RP the executive director restricted visitations for residents which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 15, 2024

Plan of correction: Executive Director has removed all restrictions and limitations to all visitors.

Type of visit: Case Management - Other

On 01/17/2024 at 9:40AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a case management visit in regards to an incident report received on 11/17/2023 and SOC341's received 11/29/2023 and 12/11/2023 . LPA met with Resident Care Coordinator (RCC), Jetrey Inarda and explained the purpose of the visit. Director of Social Services, Olga Leynov and Quality and Compliance Nurse, Janelle Jones also attended visit. Based on the incident report received on 11/17/2023, resident (R1) was given the incorrect medications. Facility notified medical doctor (MD) and R1’s responsible party (RP). R1 was monitored for ill effects but none were noted. Med tech received additional training to avoid medication errors. During visit, LPA reviewed R1's file including physicians report, care notes, and incident report. LPA spoke with RCC and was informed that the medication mix up was a result of S1 picking up a bowl of soup that contained R3s medication. S1 then gave the soup to R1. It is confirmed that the medication in the soup was R3's bowel regiment medication. LPA was informed that S1 received 8hr medication training, a write up, and shadowing. The facility also implemented a labeling system for residents food, facility wide competency training's for med-techs, and that quality compliance nurse now comes to do training's and audits four times a month. LPA also toured the facility kitchen areas to ensure proper labeling of food. As a result of this incident LPA administered a Technical Violation. Report continues on LIC 809-C Based on the SOC341 received on 11/29/2023 on 11/28/2023 S2 was heard yelling at R2. S3 reported hearing S2 yell something along the lines of "You are always yelling and wanting to be prioritized but I am busy too and have to feed other people." to R2. It was reported that R2 requested that S2 change her pants because R2 had dropped tooth paste on them. S2 inittially did not change R2 and scrubbed her pants with water to get out the stain. R2 stated that, "(S2) wanted their way and I wanted my way, but eventually S2 did change my pants" During visit LPA intervied R2 and found that they are happy and satisfied with the facility . LPA also reviewed Facility 5 day investigation conclusion and it states that S2 no longer works with and monitors R2 and has been reassigned. S2 also received the following training's: "Respect & Dignity; Resident's Rights; Elder Abuse; Communications with patients, residents and clients. R2 has had no ill effects of this incident and no psychosocial disturbances. LPA went over the importance of residents rights and effective communication. Based on SOC341 received 12/11/2023 R4 choked a visitor. Care staff then redirected R4. R4 attempted to enter another residents room when their visitor tried to stop R4, R4 proceeded to choke them. During visit LPA reviewed R4's care plan and found that R4 did not require a one on one and has since passed away. R4 was on hospice and was diagnosed with Dementia among other diagnoses. Visitor was also informed that for any future interactions to notify staff instead of interacting with residents directly. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Jan 17, 2024