The Commons at Dallas Ranch

Type of visit: Case Management - Other

On 09/04/26 at 12:54PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management visit to deliver the exemption denial for staff (S1). LPA met with executive director (ED) and explained the purpose of the visit. At 1PM, ED confirmed with LPA that S1 was terminated on 01/30/26. LPA observed ED sign S1's Exemption Denial Removal confirmation letter during visit. ED also stated that they received a copy of S1's exemption denial via email from CCLD on 09/03/26 and processed S1's separation / disassociation in the Guardian portal on 09/03/26. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 4, 2026

Type of visit: Required - 1 Year

On 08/26/26 at 1:15PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with executive director/administrator (ED/ADM) and explained the purpose of the visit. ADM has a current RCFE certificate # 6072997740 which expires on 11/18/2026. At 1:35PM, LPA toured the facility with ED/ADM including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 73 deg F. Hot water temperature was measured at 116 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguishers were observed fully charged and last inspected on 07/28/26. Fire and Earthquake drills are conducted every month. Updated copies of the following documents were obtained for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies observed in this inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 26, 2026

Type of visit: Case Management - Other

On 08/11/26 at 1PM, LPA D Panlilio met with facility's Resident Council who shared concerns regarding medication errors, response times with caregivers and transportation issues. Resident Council stated they have voiced their concerns with Executive Director (ED) and Regional Director (RD) for several months with no observed changes or resolutions to the ongoing issues raised. At 2PM, LPA attended the facility's August town hall meeting with Resident Council, other residents and staff. ED stated a new fall system will be implemented at the facility soon and will be scheduling informational meetings with residents to either opt in or out of the fall monitoring system. Per ED, the fall monitoring system is expected to be completed in November 2026. Other topics discussed were scheduled cleaning of air ducts, fans in the dining hall, kitchen hoods / air conditioning, trash collections/ disposal, in-service training of caregivers with bed making, inconsistent food quality /order taking using the POS tablets, newspaper delivery and laundry service. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 11, 2026

Allegation investigated: Facility staff do not ensure residents are served food of good quality

On 08/04/26 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with ED/Administrator (ED/ADM). LPA explained the purpose of the visit with ED. During investigation, LPA interviewed staff (ED, Kitchen Chef) and random residents (R1, R2, R3), toured the kitchen area and obtained the following documents: Personnel record (LIC500), Residents' roster, Kitchen maintenance records. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Facility staff do not ensure residents are served food of good quality. Investigation Finding: Unsubstantiated During investigation, LPA interviewed reporting party (RP), staff (ADM, Kitchen Chef (KC)) and toured the kitchen and common dining areas. RP stated that she observed the soup was below lukewarm on 05/12/26 and that the coleslaw salad and dressing served on 05/15/26 during lunch were warm instead of cold. On 05/27/26. LPA toured the kitchen area and observed small fresh salad small bowls with plastic covers stored inside the refrigerator with thermostat reading at 40 deg F. KC stated fresh salads are always stored in the refrigerator until service starts for lunch/dinner and are not left sitting on the kitchen counter for long periods of time. LPA also observed that soups were cooked and stored hot in large pots with thermostat measured temperatures at 190 deg F. On 05/27/26 at 3PM, LPA interviewed random residents (R1, R2, R3) who stated they were satisfied with the quantity and quality of food served at the facility – soups were served hot and salads were served cold. ED stated she did not receive any complaints from residents or visitors regarding the quantity or quality of food served during meals at the facility. KC stated she regularly holds monthly food meetings at the end of each month with residents and did not receive any food complaints from residents (05/29/26, 06/26/26, 07/31/26). Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility staff do not ensure residents are served food of good quality was found to be unsubstantiated. No deficiency cited during visit. Exit interview and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 4, 2026 · control 15-AS-20260518092723

Type of visit: Case Management - Incident

On 08/04/26 at 3:53PM, while at the facility for another reason, LPA D Panlilio discussed with Executive Director the medication error incident that was self reported on 06/26/26 wherein one Med Tech (MT1) accidentally gave the wrong medications to a resident (R4) at approximately past 6:40PM on 06/24/26. Staff called 911 and R4 was sent to the hospital for evaluation and treatment. R4 returned back to the facility on 06/25/26 at 4AM with no new medications. Hourly checks were executed by staff on R4 for 24 hours followed by additional alert charting for 5 days. All Med-Techs were in-serviced and retrained on proper medication administration procedures on 07/01/26. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 4, 2026

Allegation investigated: Staff did not allow residents access to hygiene products.

On 03/19/26 at 12:23PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM). LPA explained the purpose of the visit with ADM. This is an AMENDMENT of original complaint report dated 11/18/25. During investigation, LPA interviewed ED and Memory Care Director (MCD), toured the memory care unit and obtained the following documents: Personnel record (LIC500), Residents' roster, Resident's (R1) admission agreement, Needs & Services plan, 11/12/24 letter regarding visitor’s inappropriate behavior at facility. Continued on next page, LIC 9099-C Substantiated Allegation: Staff did not allow residents access to hygiene products Investigation Finding: Substantiated During investigation, LPA observed each memory care resident has their own private bathroom with a sink and a locked cabinet underneath where their personal hygiene items/toiletries such as shampoos, body wash, soap, toothpaste, conditioners, etc. are stored. Staff (former ED, MCD) confirmed with LPA that each memory care resident’s hygiene products are locked inside the cabinet and that memory care residents cannot access their own toiletries, soap, and personal hygiene items without the caregivers using a universal key to unlock the cabinet. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation that staff did not allow residents access to hygiene products was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided. Allegation: Staff confined resident to room Investigation Finding: Unsubstantiated During unannounced visits on 10/03/24, 11/22/24, 01/15/25, LPA observed memory care residents eat their meals in the common dining areas and participate in group recreational activities assisted by staff. During investigation, former Executive Director (ED) and Memory Care Director (MCD) stated that staff did not confine residents to their room. Staff stated that memory care residents are encouraged/assisted by staff to participate in daily meals and scheduled recreational activities. On 03/20/26 at 9AM, LPA spoke with third party (W1) who confirmed that on 09/29/24, RP grabbed her cell phone and inputted his contact information without her permission while sitting at a common area in the memory care unit. W1 stated she was very agitated with RP's aggressive behavior, immediately deleted the unwanted information he inputted in her cell phone and reported the incident to management. Former ED and Risk Manager (RM) stated that they had several discussions with RP regarding his disruptive and threatening behavior towards residents, guests and staff during his visits to the facility. After receiving more complaints from residents, guests and staff about RP’s aggressive behaviors, RM sent a final notice to RP dated 11/12/24 limiting his visits to R1’s apartment only. Review of resident’s (R1) signed Residency and Service Agreement dated 09/29/23 showed facility staff reserves the right to remove or deny entry to the Community to any visitor whom they determine to be disruptive or dangerous.” Par 23.g. Based on records review, interviews conducted, and observations made, the Department has investigated the above allegation that staff confined resident to room and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff confined resident to room is unsubstantiated. Exit interview conducted and a copy of this report provided to ED.the state’s words, verbatim · CDSS document, Mar 19, 2026 · control 15-AS-20250919081605

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(12) · Plan of correction due date: Apr 13, 2026

Residents in all residential care facilities for the elderly shall have all of the following personal rights: (12) To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money. This requirement was not met as evidenced by staff locking residents’ toiletries/personal hygiene items which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: By POC due date, ED agrees to allow memory care residents to keep and use their toiletries/personal hygiene items in their apartments. ED agrees to secure doctors' orders for each memory care resident who is not able to keep and use their own toiletries in accordance with Section 87468.1(a)(12).

Allegation investigated: Facility did not administer resident's medications in a timely manner Facility missed resident's blood pressure checks Facility did not follow-up with resident's primary care physician on discontinued medication and refills in a timely manner

On 02/12/26 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met and interviewed Assisted Living Director (ALD), Director of Nursing (DN), gathered information regarding the allegations and delivered investigation findings to ALD. LPA explained the purpose of the visit with ALD. During investigation, LPA conducted interviews with reporting party (RP), staff (ADM, ASLD) and obtained the following documents from ADM – Residents’ roster, Personnel Record (LIC500) / Work Schedules, Residents (R1, R2) admission agreements, needs & services plans, medication administration records, centrally stored medication logs, incident reports. Continued on next page, LIC 9099-C Substantiated Allegation: Facility did not administer residents’ medications in a timely manner Investigation Finding: Substantiated On 02/12/26 at 3PM, LPA interviewed staff (ALD, Director of Nursing, S1) who stated that residents’ (R1, R2) medications were not administered in a timely manner because of S1’s failure to prioritize timely medication administration to residents on 02/01/26 because of two emergencies that happened around 10:30AM. S1 stated the other Med Tech on duty was busy helping other residents with their medications and could not assist her. Review of email documents dated 09/30/25, 10/02/25, 01/20/26 and 02/01/26 showed staff failed to administer R1 and R2’s medications in a timely manner and R1 had to call staff to give R2’s medications. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that facility did not administer residents’ medications in a timely manner is substantiated. . Allegation: Facility missed resident’s blood pressure checks Investigation Finding: Substantiated During investigation, LPA interviewed reporting party (RP) and staff (ED, ASL Director, S1). RP stated that R2’s twice daily blood pressure checks (one in the AM and another in the PM) were not being done by staff. ALD stated staff failed to perform R2’s blood pressure checks daily due to a lack of better training to fulfill residents’ care requirements. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that facility missed resident’s blood pressure checks is substantiated. Continued on next page, LIC 9099-C pg1 Allegation: Facility did not follow up with resident’s primary care physician on discontinued medication and refills in a timely manner Investigation Finding: Substantiated Review of email documents dated 09/30/25, 10/01/25, 10/02/25 and 10/03/25 showed R1’s ER discharge instructions to a skilled nursing facility (SNF) on 08/13/25 stated to stop taking Lisinopril. The 08/25/25 discharge notes from SNF to the facility did not have Lisinopril on R1’s medication list. Staff continued to administer Lisinopril to R! and failed to timely follow-up with his primary care physician (PCP) to remove Lisinopril from his medication list. Also, review of email dated 01/26/26 showed staff gave RP a package of his medications dated August 2025 which RP stated dosage was never received. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that facility did not follow up with resident’s primary care physician on discontinued medication and refills in a timely manner is substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 15-AS-20260205131220

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 16, 2026

To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs This requirement was not met as evidenced by staff failing to timely administer residents’ medications which posed a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: By POC due date, ALD agrees to complete and submit in-service staff retraining certifications on residents’ timely medication administration by an accredited CCLD vendor in compliance with Section 87468.2(a)(4) regulation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 16, 2026

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by staff failing to timely assist resident with blood pressure checks which posed a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: By POC due date, ADM agrees to complete and submit in-service staff retraining certifications on residents’ medical care by an accredited CCLD vendor in compliance with Section 87465(a)(1) regulation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Mar 16, 2026

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by staff failing to timely follow up with residents’ primary care physician to timely discontinue and/or administer refilled medications which posed a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: By POC due date, ADM agrees to complete and submit in-service staff retraining certifications on residents’ proper medication administration by an accredited CCLD vendor in compliance with Section 87466 regulation.

Allegation investigated: Staff did not allow residents access to hygiene products

On 03/19/26 at 12:23PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM). LPA explained the purpose of the visit with ADM. This is an AMENDMENT of original complaint report dated 11/18/25. During investigation, LPA interviewed ED and Memory Care Director (MCD), toured the memory care unit and obtained the following documents: Personnel record (LIC500), Residents' roster, Resident's (R1) admission agreement, Needs & Services plan, 11/12/24 letter regarding visitor’s inappropriate behavior at facility. Continued on next page, LIC 9099-C Substantiated Allegation: Staff did not allow residents access to hygiene products Investigation Finding: Substantiated During investigation, LPA observed each memory care resident has their own private bathroom with a sink and a locked cabinet underneath where their personal hygiene items/toiletries such as shampoos, body wash, soap, toothpaste, conditioners, etc. are stored. Staff (former ED, MCD) confirmed with LPA that each memory care resident’s hygiene products are locked inside the cabinet and that memory care residents cannot access their own toiletries, soap, and personal hygiene items without the caregivers using a universal key to unlock the cabinet. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation that staff did not allow residents access to hygiene products was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 15-AS-20250919081605

Allegation investigated: Staff did not allow residents access to hygiene products

On 03/19/26 at 12:23PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM). LPA explained the purpose of the visit with ADM. This is an AMENDMENT of original complaint report dated 11/18/25. During investigation, LPA interviewed ED and Memory Care Director (MCD), toured the memory care unit and obtained the following documents: Personnel record (LIC500), Residents' roster, Resident's (R1) admission agreement, Needs & Services plan, 11/12/24 letter regarding visitor’s inappropriate behavior at facility. Continued on next page, LIC 9099-C Substantiated Allegation: Staff did not allow residents access to hygiene products Investigation Finding: Substantiated During investigation, LPA observed each memory care resident has their own private bathroom with a sink and a locked cabinet underneath where their personal hygiene items/toiletries such as shampoos, body wash, soap, toothpaste, conditioners, etc. are stored. Staff (former ED, MCD) confirmed with LPA that each memory care resident’s hygiene products are locked inside the cabinet and that memory care residents cannot access their own toiletries, soap, and personal hygiene items without the caregivers using a universal key to unlock the cabinet. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation that staff did not allow residents access to hygiene products was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 15-AS-20250919081605

Allegation investigated: Staff do not respond to resident’s call button in a timely manner

On 11/18/25 at 4PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM. During investigation, LPA obtained the following documents from administrator – personnel record, residents’ roster, admission agreements, needs & services plans, physicians’ orders, medication administration records, call logs, incident reports. Continued on next page, LIC 9099-C Substantiated Allegation: Staff do not respond to resident’s call button in a timely manner Investigation Finding: Substantiated During investigation, LPA conducted interviews of facility staff (ADM, S1, S2), authorized representative (POA) and reviewed residents’ (R1, R2, R3) documents. On 09/18/25, ADM confirmed with LPA that staff are not timely responding to residents’ calls when they are in the middle of assisting another resident when the call came through. ADM stated they have come up with a plan for staff to communicate with another staff for help so that the resident’s calling will not have to wait a long time for staff to respond. Based on the Department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not ensure medication was dispensed as prescribed was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Staff are not properly trained to care and supervise residents Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews of facility staff (ADM, S1, S2), authorized representative (POA) and reviewed staff training records. ADM confirmed with LPA that caregivers have current first aid training certifications but are not CPR certified. ADM stated only one staff per shift is CPR certified. ADM stated they are in the process of having more CPR certifications completed for other staff per shift. Review of staff records showed staff have current first aid certifications and 20 hours required annual on the job training certifications on assisted living and dementia care. On 09/18/25, LPA interviewed S1 who confirmed that on 09/06/25 she was the server on duty in the dining room. S1 stated resident (R2) choked on a piece of pancake when eating breakfast with other residents (R1, R3). R2 managed to clear the piece of pancake in his throat by drinking water given by staff during the breakfast meal. S1 stated R2 did not turn blue during the incident and that R2 was able to clear his throat with the water that he drank. Based on records review, interviews conducted, and observations made, the Department has investigated the above allegation that staff are not properly trained to care and supervise residents and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not properly trained to care and supervise residents is unsubstantiated. Allegation: Staff do not assist with resident’s basic ADLs Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews of facility staff (ADM, S1, S2), authorized representative (POA) and reviewed residents’ (R1, R2, R3) documents. Staff stated they assist each resident’s activities of daily living (ADLs) based on their level of care/ needs and services plans. Review of residents’ (R1, R2, R3) needs and services plans dated 11/22/24, 04/22/25 and 07/18/25 showed staff assist residents with ambulation 5X per day every day, scheduling medical appointments, bathing 1X per day every week, dressing 2X per day every day and status checks 12X per day every day. Based on records review, interviews conducted, and observations made, the Department has investigated the above allegation that staff do not assist with resident’s basic ADLs and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not assist with resident’s basic ADLs is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 15-AS-20250909132100

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(4) · Plan of correction due date: Nov 18, 2025

To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs... This requirement was not met as evidenced by staff failing to respond to resident’s call button in a timely manner which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: Deficiency corrected on 09/19/25. Administrator completed in-service retraining of all staff on timely responding to resident’s call button in compliance with Title 22 Section 87468.2 regulations.

Allegation investigated: Staff did not process resident’s insurance invoices in a timely manner for reimbursement

On 08/20/25 at 3:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with Administrator (ADM), gathered information regarding the allegation and delivered investigation finding to ADM. LPA explained the purpose of the visit with MOD. During investigation, LPA conducted interviews with staff (ADM, S1) and obtained the following documents from administrator – Residents’ roster, Personnel Record (LIC500) / Work Schedules, incident reports Continued on next page, LIC 9099-C Substantiated Allegation: Staff did not process resident’s insurance invoices in a timely manner for reimbursement Investigation Finding: Substantiated On 08/20/25 at 3:30PM, LPA interviewed Executive Director (ED) who confirmed that six residents' insurance invoices were not processed in a timely manner for reimbursement due to a change in management. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not timely process resident’s insurance invoices for reimbursement was substantiated. . Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 15-AS-20250819092244

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 20, 2025

To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs This requirement was not met as evidenced by staff failing to timely process residents' insurance invoices for reimbursements which posed a potential health & safety risk to client in care.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: Deficiency corrected during visit. ADM has communicated with the insurance companies of the six residents on 08/18/25 and has given documentation for immediate reimbursements to residents.

Allegation investigated: Staff does not ensure resident's medical information is confidential

On 08/07/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with Manager on Duty (MOD), gathered information regarding the allegation and delivered investigation finding to MOD. LPA explained the purpose of the visit with MOD. During investigation, the department conducted interviews with staff (MOD, S1, S2) and obtained the following documents from administrator – Residents’ roster, Personnel Record (LIC500) / Work Schedules, incident reports. Continued on next page, LIC 9099-C Substantiated Allegation: Staff does not ensure resident’s medical information is confidential Investigation Finding: Substantiated On 08/07/25 at 2:30PM, LPA interviewed staff (S1, S2) who confirmed that on 08/06/25, they publicly discussed resident’s medical information at the front desk which is a violation of residents’ personal rights. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff does not ensure resident’s medical information is confidential was found to be substantiated. . Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 15-AS-20250806155646

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Sep 5, 2025

To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement was not met as evidenced by staff failing to ensure resident’s medical information is confidential which posed a potential health & safety risk to client in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: By POC due date, ADM agrees to complete and submit in-service staff retraining certifications on residents’ personal rights by an accredited CCLD vendor in compliance with Section 87468.2(a)(1) regulation.

Type of visit: Required - 1 Year

On 07/11/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with executive director/administrator (ED/ADM) and explained the purpose of the visit. ADM has a current RCFE certificate # 6045557740 which expires on 07/24/27. At 1:15PM, LPA toured the facility with ED/ADM including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 74 deg F. Hot water temperature was measured at 115 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguishers were observed fully charged and last inspected on 10/17/24. Fire and Earthquake drills are conducted every month. Updated copies of the following documents were obtained for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies observed in this inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 11, 2025

Allegation investigated: Staff administered unauthorized medication to a resident while in care Staff disclosed personal information about a resident

On 05/15/25 at 1:57PM, Licensing Program Analyst (LPA) D Panlilio conducted a complaint visit, met with staff (ED, S1), gathered information relevant to the allegations and delivered investigation findings to ED. LPA explained the purpose of the visit with ED. During investigation, LPA obtained the following documents from ED: Resident roster, Staff roster (LIC 500), R1's admission agreement, Needs & Services Plan, Physician's report, Centrally stored medication logs, Medication administration records. Continued on next page, LIC 9099-C Substantiated Allegation: Staff administered unauthorized medication to a resident while in care Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff (ED, S1) and reviewed assisted living resident (R1) documents. S1 confirmed with LPA that she administered unauthorized medication belonging to another staff to R1 while in care because R1's prescription refill from the pharmacy was delayed. Review of R1’s medication administration records showed R1 received unauthorized medication on 04/16/25 at 12PM. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff administered unauthorized medication to a resident while in care was found to be substantiated. Allegation: Staff disclosed personal information about a resident Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff (ED, S1) and reviewed resident (R1) documents. S1 confirmed with LPA that she publicly discussed R1's medication with another staff on 04/16/25 in the open area close to the medication room which was adjacent to the visitor's living room/gaming area. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff disclosed personal information about a resident was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, May 15, 2025 · control 15-AS-20250513092441

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: May 30, 2025

Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by staff administering unauthorized medication to a resident which posed a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, May 15, 2025

Plan of correction: Executive Director agrees to complete and submit to CCLD in-service staff re-training certifications on proper administration of medications in compliance with Section 87465 regulations.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468,2(a)(2) · Plan of correction due date: May 30, 2025

To have their records and personal information remain confidential and to approve their release, except as authorized by law This requirement was not met as evidenced by staff publicly disclosing resident's personal information which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, May 15, 2025

Plan of correction: Executive Director agreed to complete and submit to CCLD in-service staff retraining certifications on personal rights of residents in compliance with Section 87468.2 regulations.

Allegation investigated: Staff did not afford a resident privacy while in care

On 02/05/25 at 01:10PM, LPA D Panlilio conducted a subsequent visit to amend the complaint deliverd on 01/15/25. LPA met with executive director (ED) and explained the purpose of the visit. During investigation, the department obtained the following documents from administrator – Personnel record (LIC500), Residents' roster, Resident's (R1) admission agreement, physician's reports, Needs & Services plans, appraisals, incident reports. Continued on next page, LIC 9099-C Exit interview conducted and copy of this report provided. Unsubstantiated Allegation: Staff did not afford a resident privacy while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff (ED, S1) & responsible party and reviewed resident (R1) documents and video recording dated 08/01/24. LPA interviewed reporting party (POA) who stated that on 08/01/24 at approximately 7:40AM a care provider was seen on video, inappropriately looking in R1's closets and dresser drawers (all of which contained her personal belongings and effects) without expressed permission by R1. LPA interviewed staff (S1) who stated that on 08/01/24, R1 was having breakfast at around 7:30AM in the common dining area when she was asked by R1 to get something from her room. She did not remember what the item was she was looking for and left the room. S1 denied violating R1’s privacy. Although the allegation that staff did not afford a resident privacy while in care may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, this allegation is unsubstantiated. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 5, 2025 · control 15-AS-20241121091034

Allegation investigated: Staff do not ensure adequate supervision is provided resulting in residents eloping from the facility Staff do not ensure residents medications are securely stored in the facility

On 01/22/25 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted a complaint visit, met with Director of Health Services (DHS), gathered information relevant to the allegations and delivered investigation findings to DHS. LPA explained the purpose of the visit with DHS. During investigation, LPA obtained the following documents from ED: Personnel record (LIC500), Residents' roster, Residents (R1, R2, R3, R4) admission agreements, face sheets, physicians' reports, reappraisals, Needs & Services plans, staff emergency /disaster drill quarterly records / training certifications, incident reports, house rules, staff personal rights training certifications. Continued on next page, LIC 9099-C Substantiated Allegation: Staff do not ensure adequate supervision is provided resulting in residents eloping from the facility Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible partes and reviewed resident (R2, R3) documents. Review of incident reports dated 10/16/23 showed that at 11AM two memory care residents (R2, R3) were able to push open the memory care delayed egress side door and managed to walk outside the parking lot without the alarm sounding due to a faulty delayed egress system. LPA interviewed responsible parties (POAs) who stated that R2, R3 were found by a third party who alerted staff to escort them back to the memory care unit. Staff did not know that they were missing. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff do not ensure adequate supervision is provided resulting in residents eloping from the facility was found to be substantiated. Allegation: Staff do not ensure residents medications are securely stored in the facility Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible party (POA) and reviewed resident (R1) documents. LPA reviewed video footage on 05/31/24 around 8:36PM which showed the memory care medication room door was unlocked/open with no staff present inside or outside the medication room. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff do not ensure residents’ medications are securely stored in the facility was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Staff did not ensure reporting requirements are being followed Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed residents’ (R2, R3) documents. Review of incident reports dated 10/16/23 showed staff reported two memory care residents (R2, R3) were found walking outside the parking lot of the assisted living front doors when they were able to open the memory care side door without the alarm sounding due to a faulty delayed egress system. A third party alerted staff who escorted them back to the memory care unit. Staff notified R2 & R3’s responsible parties, Community Care Licensing (CCL) and Ombudsman of the incidents. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure reporting requirements are being followed is unsubstantiated. Allegation: Licensee does not ensure staff are trained in emergency evacuation procedures Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (ED, DHS, WCD) who stated that the facility’s Emergency Disaster plan for the Elderly is reviewed and discussed monthly in staff meetings with assignments executed during an emergency evacuation – Environmental Director (EVD) to direct evacuation & person count, Director of Health Services (DHS) to handle first aid, Memory Care Director (MCD) to supply updated telephone emergency numbers, Wellness Program Director (WCD) to coordinate transportation & rally points, Business office manager (BOM) to notify responsible parties of any emergency evacuation and Executive Director to notify Community Care Licensing and other agencies. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that Licensee does not ensure staff are trained in emergency evacuation procedures is unsubstantiated. Continued on next page, LIC 9099-C1 Allegation: Licensee does not ensure fire evacuation drills are conducted quarterly Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (ED, DHS, S2, S3) who stated that fire and earthquake evacuation drills are conducted quarterly with written documentation kept for reference. Annual fire inspections were also conducted with the local fire department staff in addressing any issues with regards to fire safety and equipment. LPA reviewed quarterly fire evacuation drill records completed in 2023 and 2024. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not communicate with resident’s responsible party is unsubstantiated. Allegation: Staff do not ensure resident is accorded personal privacy Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (S2, S3, S4) who stated that they treat each resident with dignity and respect. They conduct status checks on each shift to ensure each resident’s needs are met such as diaper changes, toileting, dressing, grooming, transfers, bathing and personal hygiene. They denied violating residents’ privacy. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not ensure resident is accorded personal privacy is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 22, 2025 · control 15-AS-20240927112638

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(e)(7) · Plan of correction due date: Jan 22, 2025

Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents, including staff needed to escort residents who need supervision to leave the facility. This requirement was not met as evidenced by staff do not ensure adequate supervision is provided resulting in residents eloping from the facility which posed a potential health & safety risk to residents in carethe state’s words, verbatim · CDSS document, Jan 22, 2025

Plan of correction: Plan of Correction (POC) completed on 01/22/25. DHS submitted copies of staff re-training on Care of Persons with Dementia dated 10/16/24 in compliance with Title 22 Section 87705 regulations

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jan 22, 2025

Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication This requirement was not met as evidenced by staff failing to lock memory care medication room which posed a potential health & safety risk to residents in carethe state’s words, verbatim · CDSS document, Jan 22, 2025

Plan of correction: Plan of Correction (POC) completed on 01/22/25. DHS submitted copies of staff re-training dated 09/19/24 & 09/29/24 on proper medication management in compliance with Title 22 Section 87465 regulations.

Allegation investigated: Staff mismanaged resident’s medication

On 01/22/25 at 2:15PM, Licensing Program Analyst (LPA) D Panlilio conducted a complaint visit, met with Director of Health Services (DHS), gathered information relevant to the allegations and delivered investigation findings to DHS. LPA explained the purpose of the visit with DHS. During investigation, LPA obtained the following documents from ED: Personnel record (LIC500), Residents' roster, Resident's (R1) admission agreement, physician's reports, Needs & Services plans, hospital discharge reports (AVS), appraisals, Emails, Face Sheet, Progress Notes, Medication Administration records (September 2023 until current), incident reports. Continued on next page, LIC 9099-C Substantiated Allegation: Staff mismanaged resident’s medication Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible party (POA) and reviewed resident (R1) documents. Review of R1’s hospital discharge summary report (AVS) dated 09/27/23 - 09/29/23 time stamped 6:53PM showed R1 was diagnosed with acute confusional state. Attending hospital physician prescribed new anti-psychotic medication, 25mg Risperidone to be taken by R1 2X per day with instructions to stop administering bedtime anti-psychotic medication called Seroquel (Quetiapine 25mg) along with other medications. Review of emails between Executive Director (ED) and responsible party (POA) dated 08/16/24 and 09/27/24 confirmed that R1’s 09/27/23 -09/29/23 hospital discharge report time stamped 6:53PM was mis-filed in another resident’s binder. R1 received Seroquel (Quetiapine) until October 3rd which was replaced by Risperidone on October 4th when staff reviewed and noted R1’s AVS report dated 09/27/23 -09/29/23 on 10/03/23. Another refill of R1’s Seroquel (Quetiapine 25mg) was filled by R1’s pharmacy in December 2023. Review of R1’s medication administration records (MARs) written 12/16/23 showed R1 was administered two anti-psychotic medications, Seroquel (Quetiapine 25mg) and Risperidone 25 mg from 12/16/23 until 01/22/24. LPA observed no medication re-evaluation was conducted in December 2023 with R1's primary care physician to clarify if medication list is still valid. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff mismanaged resident’s medication was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, Jan 22, 2025 · control 15-AS-20241001164317

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(1) · Plan of correction due date: Jan 22, 2025

There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation. This requirement was not met as evidenced by staff mismanaged resident’s medication which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 22, 2025

Plan of correction: Plan of Correction (POC) completed on 01/22/25. ED submitted copies of staff re-training dated 09/19/24 & 09/29/24 to CCL on proper medication management in compliance with Title 22 Section 87465 regulation

Allegation investigated: Staff left resident on floor for an extended period of time

On 01/15/25 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted a complaint visit, met with Director of Health Services (DHS), gathered information relevant to the allegations and delivered investigation findings to DHS. LPA explained the purpose of the visit with DHS. During investigation, LPA obtained the following documents from DHS: Memory care resident roster (November 2024), Staff roster (LIC 500), R1's admission agreement, Needs & Services Plan, Assessment report, Physician's report, incident report. Continued on next page, LIC 9099-C Substantiated Allegation: Staff left resident on floor for an extended period of time Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible party (POA) and reviewed resident (R1) documents. Review of R1’s admission agreement showed he was first admitted at the facility on 11/25/24 in the Memory Care unit with a primary diagnosis of dementia. Responsible party (POA) stated that on 11/29/24 at approximately 11:30PM, she received a couple of voice messages from staff (S1) advising her that R1 had an unwitnessed fall in his room at around 10:30PM, was confused & lethargic and had blood on his left elbow. Review of hospital discharge summary report dated 11/30/24 to 12/07/24 showed R1’s was admitted for altered mental status due to dementia precipitated by dehydration rhabdomyolysis (muscle weakness due to a fall & can’t get up for an extended period of time). POA stated that R1 goes to bed at around 8PM daily. Review of incident report dated 11/29/24 showed R1 had an unwitnessed fall on 11/29/24 at around 10:30PM when the night shift staff conducted their status check rounds in the memory care unit. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff left resident on floor for an extended period of time was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Staff did not ensure resident was hydrated resulting in dehydration Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible party and reviewed resident (R1) documents. LPA interviewed staff (S2, S3) who stated that R1 was independent with his daily meals and was observed to eat and drink water & juice during mealtimes (3X per day) and offered drinks with snacks at 10AM and 2:30PM daily. They stated they offered him drinks frequently but sometimes he refused since he did not feel thirsty. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure resident was hydrated resulting in dehydration and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure resident was hydrated resulting in dehydration is unsubstantiated. Allegation: Staff did not communicate with resident’s responsible party Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (S2) who stated that they communicated with R1’s responsible party (POA) regarding R1’s behaviors (being quiet, wandering with coat under arm wanting to go home, un-witnessed fall and ER hospital visit on 11/29/24. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not communicate with resident’s responsible party and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not communicate with resident’s responsible party is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 15-AS-20250108082539

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jan 23, 2025

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by staff left resident on floor for an extended period of time which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2025

Plan of correction: By POC due date, DHS agrees to submit to CCL completed staff in-service retraining on proper care and supervison of residents in compliance with Title 22 Section 87466 regulations.

Allegation investigated: Facility did not have sufficient staff to meet the needs of the residents in care Resident sustained multiple unwitnessed falls resulting in injury Facility staff did not assist resident with activities of daily living in a timely manner

On 09/25/24 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit to amend the deficiency ( LIC 9099D) reports and remove the citations since the amended complaint allegations above were found to be unsubstantiated. LPA met with Director of Wellness (DOW) and explained the purpose of the visit. During visit, LPA collected original complaint reports and re-delivered amended reports as unsubstantiated. Nothe state’s words, verbatim · CDSS document, Sep 25, 2024 · control 15-AS-20230516162748

Allegation investigated: Staff did not follow proper COVID-19 control protocols Staff did not prevent resident from developing pressure injuries while in care Staff did not properly care for resident’s pressure injuries Staff did not ensure that facility is free of pests

On 09/20/24 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with the director of Wellness (MOD) to deliver the findings of above allegations. LPA explained the purpose of the visit with MOD. On 09/05/24 at 3:15PM LPA interviewed staff (ED) and obtained the following documents: Residents’ roster with contact information, Personnel record (LIC500), residents (R1, R2, R3, R4, R5) pre-placement appraisals, admission agreements, Face Sheets, ID/Emergency Information, Needs & services plans, Physician’s reports, Doctors’ orders, Centrally stored medications & medication administration records (MARs), Reappraisals, Incident reports, maintenance/pest control schedules. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Staff did not follow proper COVID-19 control protocols Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of staff (ED, S1) and reviewed facility’s spot COVID-19 line list report which showed COVID-19 positive residents and staff from 07/24/24 until 08/28/24. Review of the COVID-19 report showed that 4 staff tested positive for COVID-19 on 07/24,07/26, 7/29, 7/30 in Assisted Living and 2 residents in memory care on 08/02 and 08/05. All reported COVID-19 positive staff and residents were isolated until all symptoms were cleared and showed negative test results. On 09/05/24 at 3:30PM, LPA toured the facility with executive director (ED). LPA observed all on duty staff, visitors and some residents wearing face masks, hand sanitizers available for use in common areas. LPA observed facility clean, odor free and in good repair. LPA observed staff follows their COVID-19 infection control plan daily to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with ED as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed one central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. LPA observed COVID-19 signages posted throughout the facility to promote handwashing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff, visitors and residents Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged occurred. Therefore, the allegation that staff did not follow proper COVID-19 control protocols is unsubstantiated. Continued on next page, LIC 9099-C1 Allegation: Staff did not prevent resident from developing pressure injuries while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of staff (ED) who stated that there are 2 memory care residents (R1, R2) diagnosed with Stage 2 pressure injuries. Review of R1’s needs & services plant dated 05/28/24 and physician’s report dated 06/24/24 show that staff conducts regular status checks on R1 4 times per shift, requires extensive multiple psychosocial interventions due to sundowning behaviors, requires total assist with bathing, dressing, toileting, ambulation to all meals and activities, medications and all transfers for safety. R1’s primary care physician (PCP) ordered home health care team to treat R1’s stage 2 wound on her coccyx twice a week. LPA also reviewed R2’s hospice records from 12/04/23 until current which showed R2’s stage 2 coccyx pressure injury is being treated by home health agency 3 times per week and that care was coordinated with staff with instructions to contact hospice agency immediately for any change in condition observed. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not prevent resident from developing pressure injuries while in care is unsubstantiated. Allegation: Staff did not properly care for resident’s pressure injuries Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of staff and reviewed resident’s (R1) call logs and incident reports. Review of memory care residents (R1, R2) medical records, assessments and hospice records show that staff provided proper wound care treatment for R1 and R2 as prescribed by their primary care physicians and home health care team. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not properly care for resident’s pressure injuries is unsubstantiated. Continued on next page, LIC 9099-C2 Allegation: Staff did not ensure that facility is free of pests Investigation Finding: Unsubstantiated During investigation, LPA reviewed pest control reports dated 11/14/23, 01/04/24, 01/07/24, 08/02/24 which showed that staff (ED) hired a professional extermination company to treat and fumigate the memory care unit for bed bug re-infestation which originated from one of resident’s recliner and wheelchair on 01/07/24. LPA also interviewed staff (ED, S1) who stated that one memory care resident loves to throw bird seed outside the memory care area close to the open field. Staff confirmed with LPA that 2 mice were observed in the kitchen and one resident's memory care bedroom area. LPA confirmed with staff (ED, S1) that the mice infestation was resolved by plugging the holes in the memory care kitchen and resident’s unit on July 30,2024. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure that facility is free of pests is unsubstantiated. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 20, 2024 · control 15-AS-20240826121316

Allegation investigated: Facility did not have sufficient staff to meet the needs of the residents in care Resident sustained multiple unwitnessed falls resulting in injury Facility staff did not assist resident with activities of daily living in a timely manner

On 09/20/24 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with manager on duty (MOD) to amend and re-deliver investigation findings of above allegations. LPA explained the purpose of the visit with MOD. During investigation, the department obtained the following documents from administrator – Resident roster with contact information, Personnel record (LIC500), pre-placement appraisal, admission agreements, needs & services plans, physician’s reports, Doctors’ orders, Activities of daily living schedules (ADLs), reappraisals, incident reports, notifications to authorized representative(s) / physicians of change in condition, Level of Care Notes, Hospital discharge reports. Continued on next page LIC 9099-C Unsubstantiated Allegation: Facility did not have sufficient staff to meet the needs of the residents in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff and residents. Staff (S1) stated although they were short staffed during this period, residents were given their medications, feedings, showers, diaper changes and activities of daily living (ADLs) daily. LPA interviewed other residents (R2, R3) at the facility. R2 stated that both himself and R3 reside in the same apartment at the facility for over 2 years and that R3 is totally dependent and requires total care. R2 stated that the response times of the caregivers were sometimes delayed due to short staffing. However, the staff did a good job in delivering meals, giving weekly showers, diaper changes and following COVID-19 safety protocols. He stated that both him and his wide did not contract COVID-19 while at the facility. Although the allegation that facility did no have sufficient staff to meet the needs of the residents in care may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, this allegation is unsubstantiated. Allegation: Resident sustained multiple unwitnessed falls resulting in injury. Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s admission agreement showed he was first admitted at the facility on 01/21/2020. R1’s Incident reports dated 03/25/20, 04/01/20, 04/29/20, 08/26/20 and 10/28/20 showed that staff reported R1 had unwitnessed falls in his bedroom and bathroom. On each of these incidents, staff assessed R1 for injuries and when no injuries were found, staff assisted him back to his bed and continued to monitor him. Staff notified his responsible party (POA) and his primary physician (PCP) of each incident. On 11/17/20 at 06:42 AM, staff found R1 on the floor next to his bed. Staff immediately called 911 because they observed R1 grabbing the back right side of his head and notified his responsible party (POA) and primary care physician (PCP). Paramedics took him to the hospital for evaluation and treatment. R1 underwent surgery to reduce the bleed on his brain. R1 was transferred to a skilled nursing facility after discharge from the hospital and did not return to the facility. Although the allegation that resident sustained multiple unwitnessed falls resulting in injury may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, this allegation is unsubstantiated. Continued on next page, LIC 9099-C1 Allegation: Facility staff did not assist resident with activities of daily living in a timely manner. Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Staff (S1) stated resident (R1) required a 1 person total assist in bathing (2X per week) and total medication assist. He also required standby assist with transfers and minimal assist with prompting, cueing & reminding, independent with toileting, preparation of grooming items, ambulated independently with a walker to and from activities, meals and was a fall risk. R1’s level of care was a Level 3. Review of R1's incident reports submitted to CCL by staff dated 03/25/20, 04/01/20, 04/29/20, 08/26/20, 10/28/20 show R1 had several un-witnessed falls. R1 told staff that he was trying to get up and slid down from the bed while going to the bathroom. Med tech checked R1 and no injury was observed. R1 denied pain. Med tech and care staff helped him get up and lay him down the bed. Staff notified authorized representative and primary care physician of each incident. On 11/17/20 at 06:42 AM, staff found R1 on the floor next to his bed. Staff immediately called 911 because they observed R1 grabbing the back right side of his head and notified his responsible party (POA) and primary care physician (PCP). R1 was sent to the hospital for evaluation and treatment. Although the allegation that facility staff did not assist resident with activities of daily living in a timely manner may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, this allegation is unsubstantiated. No deficiencies cited during visit. Exit interview conducted and copy of this report provided. Allegation: Facility staff did not assist resident with toileting Investigation Finding: Unsubstantiated During investigation, the department reviewed R1’s signed appraisal report dated 01/23/20 and needs & services plan dated 05/05/20 which showed that R1 was assessed as independent with toileting, grooming, dressing and meals. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not assist resident with toileting and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not assist resident with toileting is unsubstantiated. Allegation: Facility staff did not inform resident's physicians and family of change in resident's condition. Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s incident reports dated 03/25/20, 04/01/20, 04/29/20, 08/26/20 and 10/28/20 showed staff notified R1’s authorized representative (POA) and primary care physician (PCP) of these incidents involving R1’s unwitnessed falls in his bedroom and bathroom. Review of R1’s incident report dated 11/17/20 showed staff observed R1 grab the side of his head after an unwitnessed fall inside his bedroom. Staff called 911 and sent R1 to the hospital due to a change in condition. R1’s POA and PCP were both notified of the incident on 11/17/20.Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not inform resident’s physician and family of a change in resident’s condition and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not inform resident’s physician and family of a change in resident’s condition is unsubstantiated. Continued on next page, LIC 9099-C1 Allegation: Facility staff did not follow resident's care plan. Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s needs and services plans dated 05/05/20 and 07/27/20 showed staff provided R1 with his physician ordered special diet and daily medications, documented and reported to R1’s PCP of any missed doses or R1’s refusal of medications and total assistance with exit seeking behaviors by constantly monitoring R1 for attempts to leave the community. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did follow resident’s care plan and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not follow resident’s care plan is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 5, 2024 · control 15-AS-20230516162748

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Sep 5, 2024

Complaint investigation finding was amended to unsubstantiated. Deficiency removed 09/05/24.the state’s words, verbatim · CDSS document, Sep 5, 2024

Plan of correction: Complaint investigation finding was amended to unsubstantiated. Deficiency removed 09/05/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87413(a)(1) · Plan of correction due date: Sep 5, 2024

Complaint investigation finding was amended to unsubstantiated. Deficiency removed on 09/05/24.the state’s words, verbatim · CDSS document, Sep 5, 2024

Plan of correction: Complaint investigation finding was amended to unsubstantiated. Deficiency removed on 09/05/24

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.2(c) · Plan of correction due date: Sep 5, 2024

Complaint investigation finding was amended to unsubstantiated Deficiency removed on 09/05/24the state’s words, verbatim · CDSS document, Sep 5, 2024

Plan of correction: Complaint investigation finding was amended to unsubstantiated. Deficiency was removed on 09/05/24

Allegation investigated: Staff are mismanaging resident medication Staff are not meeting resident needs

On 08/07/24 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the finding of above allegations. LPA explained the purpose of the visit with ADM. During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, admission agreements, medication administration logs (MARs), Centrally stored medication records, Assessments, Physicians’ orders, staff work schedules. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Staff are mismanaging residents’ medications Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews of staff and reviewed random residents (R1, R2, R3) signed medication administration records (MARs) which showed staff daily administered residents’ prescribed and over the counter medications as ordered by their primary care physicians (PCPs). Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff are mismanaging residents’ medications and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are mismanaging resident medication is unsubstantiated. Allegation: Staff are not meeting resident needs Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of staff and random residents (R1, R2, R3). Reporting party (RP) also confirmed that residents are getting their daily medications from staff even though they are not always on time. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff are not meeting residents needs and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not meeting residents’ needs is unsubstantiated. No deficiencies cited on this complaint. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 15, 2024 · control 15-AS-20230413104539

Allegation investigated: Staff did not ensure medication was dispensed as prescribed Staff did not ensure medication records were properly maintained

On 08/15/24 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the finding of above allegations. LPA explained the purpose of the visit with ADM. During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, admission agreement, physicians report, needs & services plans, physicians’ orders, medication administration records, centrally stored medication logs, incident reports. Continued on next page, LIC 9099-C Substantiated Allegation: Staff did not ensure medication was dispensed as prescribed Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of incident report dated 05/18/23 showed R1’s medications were not being administered as prescribed. A signed and dated medication list from R1’s primary care physician (PCP) indicated R1 should only be taking 75mg of a prescribed medication instead of the 150mg administered by staff. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not ensure medication was dispensed as prescribed was found to be substantiated. Allegation: Staff did not ensure medication records were properly maintained Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Director of Health Services (DHS) confirmed with LPA that facility staff did not make the proper changes in their electronic medication system (Quick Mar) after resident’s (R1) responsible party alerted them that the wrong dosage was charted and given to R1. DHS stated that medication errors occurred due to staff failing to contact R1’s authorized representative (POA) and primary care physician (PCP) in clarifying a change in the medication administration records which were accepted without proper verification of physician’s orders. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not ensure medication records were properly maintained was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, Aug 15, 2024 · control 15-AS-20230518144816

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(d)(1) · Plan of correction due date: Aug 15, 2024

) Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication This requirement was not met as evidenced by staff did not ensure medication was dispensed as prescribed which posed a potential health & safety risk to residents in carethe state’s words, verbatim · CDSS document, Aug 15, 2024

Plan of correction: Deficiency cleared during visit. Administrator completed in-service retraining of all staff on incidental medical care in compliance with Title 22 Section 87465 regulations on May 2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(3) · Plan of correction due date: Aug 15, 2024

A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response This requirement was not met as evidenced by staff did not ensure medication records were properly maintained which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 15, 2024

Plan of correction: Deficiency cleared during visit. Administrator completed in-service retraining of all staff on incidental medical care in compliance with Title 22 Section 87465 regulations on May 2023.

Allegation investigated: Staff are not providing adequate housekeeping services to residents Staff are not ensuring residents are provided with toiletries

On 08/15/24 at 2:25PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM. During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, admission agreements, housekeeping records. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Staff are not providing adequate housekeeping services to residents Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of staff, reviewed housekeeping schedules and toured the memory care unit with executive director (ED). LPA inspected random toilets in the memory care unit and observed toilets in good repair, clean, free of mold and did not have urine/feces odors. Review of housekeeping schedules for 07/29/24 until 09/01/24 showed memory care unit cleaned daily by housekeeping staff. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff are not providing adequate housekeeping services to residents and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not providing adequate housekeeping services to residents is unsubstantiated. Allegation: Staff are not ensuring residents are provided toiletries Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of staff and reviewed random residents’ (R1, R2, R3, R4) admission agreements. Executive Director (ED) stated residents are responsible for their own toiletries and incontinent supplies. Review of random residents (R1, R2, R3, R4) admission agreements showed facility is not responsible for furnishing or paying for any health care items or services not expressly included in the admission agreement such as medical supplies and incontinence products. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff are not ensuring residents are provided toiletries and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not ensuring residents are provided toiletries is unsubstantiated. No deficiencies cited on this complaint. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 15, 2024 · control 15-AS-20240807144128

Type of visit: Required - 1 Year

On 8/15/24 at 1PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with staff (ADM, HSM) and explained the purpose of the visit. At 1:15PM, LPA toured the facility with HSM including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 76 deg F. Hot water temperature was measured at 116 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguishers were observed fully charged and last inspected on 10/23/23. LPA reviewed 5 staff and 5 resident files. Updated copies of the following documents were obtained for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies observed in this inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 15, 2024

Allegation investigated: Facility illegally evicted a resident in care Facility did not ensure that resident's call system was operable

On 08/07/24 at 2:15PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the finding of above allegations. LPA explained the purpose of the visit with ADM. During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, admission agreement, call logs, communication records regarding resident’s (R1) inappropriate behaviors towards staff, eviction notice, conference meeting logs with responsible party, incident reports. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Facility illegally evicted a resident in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of staff and reviewed R1’s signed admission agreement dated 08/18/20 which showed that the facility manager (ED) may terminate the signed agreement at any time upon thirty days written notice to the resident (R1). A written 30-day eviction notice was delivered to R1 on 02/06/24 by ED due to R1's failure to comply with the general policies of the community after multiple verbal & written warnings and conference meetings were held by ED with R1 and responsible party to resolve the inappropriate behaviors displayed by R1 towards staff from 03/2022 until 01/2024. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility illegally evicted a resident in care is unsubstantiated. Allegation: Facility did not ensure that resident’s call system was operable Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of staff and reviewed resident’s (R1) call logs and incident reports. Executive Director (ED) stated that R1 had an un-witnessed fall early AM in his bathroom on 05/04/23. ED stated that R1's call pendant was not working that day and immediately had maintenance repair the call pendant the same day. Review of R1’s incident report dated 05/04/23 showed staff notified R1’s authorized representative (POA) and primary care physician (PCP) of incident involving R1's un-witnessed fall in independent living and that R1 was sent to the hospital for evaluation on 05/04/23. R1’s call logs dated 05/04/23 showed staff checked and cleared R1's activated call pendant at 9AM and 3PM. ED stated monthly checks are conducted on all residents' call pendants to ensure that they are operable. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility did not ensure that resident’s call system was operable is unsubstantiated. No deficiencies cited on this date. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 7, 2024 · control 15-AS-20240223165313

Allegation investigated: Staff did not keep the facility free from bedbugs Staff did not keep the facility free of pest

On 08/07/24 at 3:55PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, gathered information and delivered investigation findings to executive director (ED). LPA explained the purpose of the visit with ED. During investigation, the department interviewed staff and obtained the following documents from ED – personnel record, residents’ roster, communications to residents and responsible parties with regards to bed bug infestation, exterminator reports and scheduled treatments, incident reports. Continued on next page, LIC 9099-C Substantiated Allegation: Staff did not keep the facility free from bedbugs Investigation Finding: Substantiated During investigation, LPA interviewed staff (ED) who confirmed that there was a bed bug infestation in one of the resident's apartment in assisted living on 11/14/23. Staff relocated R1 and R2 into a temporary apartment with a new mattress while their apartment was fumigated and treated. ED stated that when R1 moved to the memory care unit on 01/04/24, bed bug re-infestation was found in his recliner and wheelchair on 01/07/24. ED stated that a few apartments have been identified as needing treatment due to re-infestation and fumigation has been scheduled with an exterminator company to resolve the issue. Review of written notice of bed bug treatments dated 08/02/24 confirmed the presence of bed bugs at the facility. ED stated that to ensure the effectiveness of the treatment, all residents' beddings and clothes will be hot-water washed and residents temporarily relocated for a few hours while fumigation was completed. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not keep the facility free from bed bugs was found to be substantiated. Allegation: Staff did not keep the facility free of pest Investigation Finding: Substantiated During investigation, LPA interviewed staff (ED, S1) who stated that one resident loves to throw bird seed outside the memory care area close to the open field. Staff confirmed with LPA that 2 mice were observed in the kitchen and one resident's memory care bedroom area. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not keep the facility free of pest was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, Aug 7, 2024 · control 15-AS-20240730142411

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 7, 2024

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by bed bug infestation in memory care which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 7, 2024

Plan of correction: Deficiency cleared during visit. On 08/07/24, ED submitted to LPA a written beg bug treatment schedule with exterminator company to resolve re-infestation issue in memory care dated 08/05/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(d)(3) · Plan of correction due date: Aug 7, 2024

All persons shall be protected against hazards within the facility. This requirement was not met as evidenced by presence of pest in the memory care areas which posed a potential health & safety risk to residents in carethe state’s words, verbatim · CDSS document, Aug 7, 2024

Plan of correction: Deficiency cleared during visit. LPA confirmed with staff (ED, S1) that the mice infestation was resolved by plugging the holes in the memory care kitchen and resident's unit on July 30, 2024.

Type of visit: Case Management - Incident

On 08/01/2024 at 11:15 AM, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 06/14/2024. LPA met with Executive Director (ED), Brittany Karlinski and explained the purpose of the visit. The incident report received stated that Resident (R1) eloped from the side exit door of the memory care unit at around 8:15 AM on 06/14/2024. The incident report indicate that another Resident (R2) observed R1 walking out the back door and that the staff located R1 outside across the street. LPA interviewed Staff (S1) that stated there were 3 (three) memory care caregivers and 1 (one) Med Tech scheduled during that time. S1 stated that R1 exit the side door which is located on the east side of the facility building. S1 stated that the alarms went off when the door was breached and that R2 went to staff to inform. S1 stated that the caregivers were on the opposite side of the area where R1 eloped and were currently occupied with breakfast and other tasks with other residents in memory care. S1 stated that after R2 informed the staff, the staff immediately went outside and found R1 standing outside across the street. S1 stated that staff brought R1 back to the facility and that R1's responsible party was notified. S1 stated they had a care meeting with the family and suggested that R1 be placed on a 1:1 assistant. S1 stated that R1 was placed on a 1:1 assist on 06/14/2024 from 7AM to 7PM daily. LIC809-C Continued... LIC809-C Continued.... LPA obtained a copy of resident's (R1) Physician's Report, Staff Schedule for 06/14/2024, Staff Schedule (06/10/24, 06/16/24), R1's Preplacement Appraisal (03/28/24), Resident Assessment (05/26/24, 06/28/24), Needs and Services Plans (05/31/24, 07/08/24), Physician's Orders (08/01/24), Service Plan (07/09/24), Health and Safety Assessment (07/09/24) and copies of Wander Management System and Elopements (12/01/23) policies. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of appeal rights and this report was provided to ED.the state’s words, verbatim · CDSS document, Aug 1, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 8, 2024

To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidence by: Based on interview and record review, the licensee did not comply with the section cited above by staff not responding timely before R1 eloped outside the building and across the streets which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 1, 2024

Plan of correction: Administrator submitted copies to CCLD of In-Service training meetings that address Delayed Egress, Elopement Drill, WanderGuard Alarms, Elopement Policy and Elopement Drills (All Shifts) which were conducted on 06/06/24, 06/18/24, 06/19/24, 06/22/24, 06/23/24 and 07/31/24. Deficiency cleared during visit.

Type of visit: Case Management - Incident

On 08/01/2024 at 1:00 PM , Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 06/18/2024. LPA met with Executive Director (ED), Brittany Karlinski and explained the purpose of the visit. The incident report received stated that Resident (R1) has been delinquent with their monthly rent since their move-in date. The incident report indicated that the resident's Responsible Party (RP) was offered payment arrangements. However, RP has continued to not make the monthly payments by the due dates. LPA interviewed Staff (S1) that stated the community offered two (2) payment plans and that the payments continued to be missed payments. S1 stated that payments are due on the 1st of each month and late fees are assessed after the 5th of each month. In addition, S1 stated that RP also has not complied with the payment plans that was offered. LPA obtained a copy of R1's Admission Agreement and Resident Detail Ledger for 12/29/2023 thru 04/04/2024. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 1, 2024

Allegation investigated: Staff do not follow proper food sanitation and safety practices

On 6/13/2024 at 9:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegation above. LPA met with Executive Director, Brittany Karlinski and explained the purpose of the visit. During the investigation, LPA interviewed 5 staff. LPA reviewed and obtained documents including staff roster, in-service training for kitchen staff, food handling certificate, and dining service policy. Interview with staff revealed that cooks and prep staff would wash their hands and change gloves at the beginning of each tasks such as handling raw meats or handle different foods. Staff stated cooks and prep staff would change gloves between task and have not witness staff using same gloves all day. LPA observed the kitchen has different size gloves available and hand washing stations at various locations in the kitchen. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 13, 2024 · control 15-AS-20240606091130

Allegation investigated: Multiple residents fell due to staff neglect Staff are not isolating COVID-19 residents Staff are not providing adequate food service to residents Staff are not using proper sanitizing methods Staff are not responding to residents call buttons in a timely manner Staff are not cleaning residents rooms

On 02/15/24 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegation. LPA explained the purpose of the visit with ADM. During investigation, the Department obtained the following documents from the facility – personnel record, residents’ roster, admission agreements, physicians reports, needs & services plans, Physicians orders, COVID infection control plan, COVID Contra Costa Public Health (CDPH guidance) records, staffing agency records/work schedules, housekeeping schedules, call logs, meal schedules. Continued on next page, LIC-9099C Unsubstantiated Allegation: Multiple residents fell due to staff neglect Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Staff (S1) stated resident (R1) is checked 4 times per shift since she is identified as a fall risk. She requires 1 person total assist in bathing (2X per week), total assist in dressing, preparation of grooming items, toileting, wheelchair escort to and from activities, meals, transfers, medication assist and is a fall risk, Her care is a level 5. Review of R1's incident reports submitted to CCL dated 11/16/22 (8:15PM), 12/31/22 (12AM), 02/19/23 (6PM) and 02/28/23 (7PM) show R1 had several un-witnessed falls. R1 told staff that she was trying to get up and slid down from the bed. Med tech checked R1 and no injury was observed. R1 denied pain. Med tech and 3 care staff helped her get up and lay her down the bed. Staff notified authorized representative and primary care physician. Review of R2's incident reports submitted to CCL dated 11/28/22 (3AM), 12/03/22 (8PM), 12/24/22 (2AM) show R2 had several un-witnessed falls. While doing rounds and safety checks, med tech and care staff found R2 on the hallway floor close to his room. R2 stated he was walking using his walker and lost his balance and fell. Med tech and care staff checked R2 for injury. R2 stated he did not hit his head. Staff called 911 and R2 was sent to the hospital for evaluation and treatment. Staff also notified authorized representative and primary care physician (PCP). R2 came back to the facility with no new orders or diagnosis. A PCP follow-up video call was done on 12/29/22. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of multiple residents fell due to staff neglect and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation of multiple residents fell due to staff neglect is unsubstantiated. Continued on next page, LIC 9099-C1 Allegation: Staff are not isolating COVID-19 residents Investigation Finding: Unsubstantiated During investigation, LPA observed positive residents quarantined and separated from negative residents during prior unannounced visits on 12/19/22 and 02/17/23. LPA also observed staff temporarily suspending all communal activities and meals in accordance with Public Health guidelines on infection control. Review of staff COVID statements letters showed staff followed Public Health infection control guidelines in implementing quarantine requirements until released from COVID -19 surveillance by Public Health, Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff are not isolating COVID-19 residents and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not isolating COVID-19 residents is unsubstantiated. Allegation: Staff are not providing adequate food service to residents Investigation Finding: Unsubstantiated During investigation, LPA confirmed with residents (R2, R3) that they are provided 3 meals plus snacks and drinks by staff who stated that residents’ meals (breakfast, lunch, dinner, snacks, drinks) were delivered daily during COVID outbreaks when communal dining and activities were temporarily suspended. Staff confirmed with LPA that they followed COVID-19 Public Health guidelines wherein meal trays or boxed lunches were delivered to assisted living residents’ apartments during mealtimes and in between snacks. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of staff are not providing adequate food service to residents and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not providing adequate food service to residents is unsubstantiated. Continued on next page, LIC 9099-C2 Allegation: Staff are not using proper sanitizing methods Investigation Finding: Unsubstantiated During investigation. LPA observed staff cleaning and disinfecting tables, chairs, floors, bathrooms, reception areas during unannounced visits on 12/19/22 and 02/17/23. LPA observed the facility to be clean, in good repair and well ventilated. LPA observed a universal screening station at the front desk where visitors, staff and residents are routinely checked for COVID-19 symptoms. Hand sanitizers, face masks, gloves were observed available at the front desk. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of staff are not using proper sanitizing methods and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not using proper sanitizing methods is unsubstantiated. Allegation: Staff are not responding to residents’ call buttons in a timely manner Investigation Finding: Unsubstantiated During investigation, LPA confirmed with residents (R2, R3) that staff responded timely to call buttons when activated. ADM stated staff are required to respond to call lights within 15 minutes and failure to do so will result in an investigation and potential disciplinary action. Review of staff in-service meeting notes dated 11/11/22 and 12/16/22 required staff to respond to residents’ call button within 15 minutes with med techs as back-up. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of staff are not responding to residents’ call button in a timely manner and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not responding to residents’ call buttons in a timely manner is unsubstantiated. Continued on next page, LIC 9099-C3 Allegation: Staff are not cleaning residents’ rooms Investigation Finding: Unsubstantiated During investigation, LPA conducted an unannounced health & safety check on 03/30/23 at 12:55PM and observed random residents’ rooms (105V, 104V, 113V) to be clean, odor free and in good repair. Prior unannounced visits on 12/19/22 and 02/17/23 showed residents’ rooms to be clean and in good repair. Review of facility’s housekeeping schedules from 11/2022 until 03/30/2023 showed sufficient housekeeping staff ( 5 housekeepers and 2 maintenance staff) performing housekeeping chores daily. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff are not cleaning residents’ rooms and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not cleaning residents’ rooms is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 15, 2024 · control 15-AS-20230308161607

Allegation investigated: Questionable death Staff do not dispense medication to residents in a timely manner

On 02/15/24 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegation. LPA explained the purpose of the visit with ADM. During investigation, the Department obtained the following documents from the facility – personnel record, residents’ roster, admission agreement, physicians report, needs & services plans, Physicians orders, narrative charting, medication worksheets, death report. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Questionable death Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s medical documents showed that on 12/06/22, R1’s doctor received a fax from facility staff (S1) who notified him about R1’s cough and congestion. Staff requested for cough syrup and an appointment with the doctor. Lab tests were ordered and a chest x-ray was performed on 12/06/22. The results of the chest x-ray showed R1’s lungs were clear and the pleura unremarkable. On 12/06/22, staff (S2) also notified the doctor when R1 developed a fever and staff gave R1 Tylenol which reduced her fever to normal. Staff continued to monitor R1 and on 12/07/22 at approximately 0500 hours, R1 passed away. Documents obtained do not suggest R1’s death was a result of neglect or lack of care for suspicious circumstances from facility staff. Review of death report showed immediate cause of death was acute hypoxic respiratory failure. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of questionable death and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation of questionable death is unsubstantiated. Continued on next page, LIC 9099-C1 Allegation: Staff do not dispense medication to resident in a timely manner Investigation Finding: Unsubstantiated Review of R1’s centrally stored medication logs and medication administration records dated 06/27/22 showed that staff totally assisted R1 with prescribed medications daily. Staff documented medications, central storage and assistance with residents in their electronic database which recorded daily intake of prescribed medications by residents, reports to doctors of any resident medication refusal or any missed dosages and any changes to residents’ physicians’ orders. Prior interviews conducted by LPA on 03/08/23 with staff (S1) and residents (R2, R3) confirmed that staff gave total assistance with daily prescribed medications and dispensed medications to residents in a timely manner. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of staff do not dispense medication to resident in a timely manner and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not dispense medication to resident in a timely manner is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 15, 2024 · control 15-AS-20230324115547