Activcare at Bressi Ranch

Allegation investigated: Staff did not seek timely medical care for resident.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Natasha Perez. On 09/30/2025 it was alleged that staff did not seek timely medical care for Resident 1 (R1). The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. It was alleged that medical care for Resident 1 (R1) was delayed after an injury to R1's left wrist from unknown origin was evident. Staff members interviewed were directly involved or aware of what occurred the day of incident. Staff informed that the facility's LVN was asked to check R1's wrist due to observed swelling upon final status checks on NOC shift. Staff interviews were inconsistent regarding the level of swelling, discoloration/bruise, and pain level R1 was observed to have the day of incident. Staff 1 (S1) informed that R1's wrist was swollen, but R1 did not complain of pain. (Continued on LIC9099 p.2) Substantiated (Continued from LIC9099 p.1) Staff 2 (S2) informed that R1's wrist was swollen, bruised, and R1 stated, "Ouch", pointing to their wrist multiple times, but did not appear to be in extreme pain. Staff 3 (S3) stated that R1's wrist was swollen, not bruised, and R1 moaned slightly upon their wrist being moved, but did not seem to be in extreme pain. Staff informed that R1 was diagnosed with a wrist fracture at the hospital later that day. Outside source interviews were conducted with R1's Responsible Person and Emergency Contact regarding the incident (OS1 and OS2). The outside sources informed that they were notified of R1's wrist injury and were subsequently present the morning of incident and took photos of R1's swollen/bruised wrist. OS1 and OS2 informed that the facility contacted R1's hospice agency for assessment, but due to the Labor Day holiday the hospice agency was unable to provide an on-site x-ray until 09/02/2025, which would have been two days after R1's injury. Facility staff then requested an x-ray order from R1's hospice doctor so the facility-contracted x-ray company could conduct an on-site x-ray, which would have taken an additional 3-4 hours. The outside sources inquired if it would be faster for R1 to be seen in the emergency room rather than wait for the mobile x-ray, to which staff affirmed. OS1 and OS2 then transported R1 to the hospital themselves. The outside sources informed that upon initial notification of R1’s injury, staff informed that R1's injury was not severe, and the facility did not offer to send R1 to the hospital the day of incident. The outside sources informed that R1 suffered a delay in medical care due to the attempts to secure an on-site x-ray instead of sending R1 to the hospital directly. Review of facility records evidenced R1's wrist to be swollen, bruised, and showing evidence of pain. Facility Care Notes the day of incident stated, "Resident woke up with a swollen L hand. Seems to be painful to touch. Slight bruising noted." The Unusual Incident/Injury Report submitted by the facility regarding the incident stated, "On 08/31/2025 at 6:00 AM resident seen and examined during grooming and dressing rounds by caregiver. Resident was up walking in [their] room. Caregiver noticed [their] L hand/wrist was very swollen. Called nurse to assess. Some pain to touch." The Unusual Incident/Injury Report further stated that R1 did not recall what happened and the cause of injury was not apparent, R1’s bed was in the low position, R1's Responsible Party (RP) was made aware, R1 was given pain medication, and the hospice nurse assessed R1's wrist. The report further informed that RP drove R1 to the hospital rather than wait for mobile x-ray and assessment by on-call hospice doctor. Photos taken day of injury of R1's wrist showed swelling and purple discoloration to the inner side of R1's wrist and thumb. The facility sent a fax marked as urgent to R1's hospice agency with communication that informed of R1's swollen left hand stating, "Seems to be painful to touch" and that a photo of R1's wrist was sent. (Continued on LIC9099 p.3) (Continued from LIC9099 p.2) The facility requested advisement from R1's hospice agency. A visit note from R1's hospice agency on 08/31/2025 stated, "L wrist is swollen w/bruising inside thumb area. No apparent signs of pain. Pt able to use hand evidenced during the meal… able to hold fork w/o signs of complications." The visit note stated that R1's hospice doctor was notified and the hospice nurse was awaiting new orders to rule out fracture, as they were "not able to fully assess articulation". In different handwriting at the bottom of this hospice note was written, "1102 A.M. [RN] called, per MD, no new order, continue to monitor" and "1345 [POA] took [R1] to ER for x-ray." Facility Care Notes on 08/31/2025 additionally stated that R1 left for the ER at 1:45pm. The Emergency Room Report on 08/31/2025 showed that R1's arrival time to the hospital was 1418. R1's medical records for this admission showed that R1 suffered an "Acute displaced and angulated intra-articular distal radius fracture." R1 was unable to be qualified as a valid historian for interview due to cognition. Interviews and records showed that R1's injury was first observed at approximately 5:40am, the facility attempted to assist R1 by contacting R1's hospice agency and requesting approval for the mobile x-ray. The time elapsed between the injury being first observed and R1 leaving with OS1 and OS2 for the hospital was approximately 8 hours, 5 minutes. Records and interviews evidenced that R1’s wrist showed signs of bruising, swelling, and R1 indicated pain by pointing to their hand, stating “Ouch” multiple times and moaning when their wrist was moved. The evidence does not show that the facility attempted to assist R1 with a more expedient form of medical care such as calling 911 or an ambulance for direct medical transport to the hospital. The evidence shows that the facility continued to attempt to obtain an on-site x-ray for R1 after R1's hospice agency informed that their on-site mobile x-ray would not be available for two days. The evidence shows that R1's responsible party and emergency contact made the decision to have R1 go to the hospital in lieu of waiting additional time for the mobile x-ray, and transported R1 to the hospital themselves. Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation occurred and is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. At this time, per Health and Safety Code Section 1569.2(c), an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with Executive Director Natasha Perez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099 p.1) A hospice nurse also came to the facility once per week to conduct overall assessments. Although R1 was ambulatory and their family requested for R1 to walk for exercise, R1 additionally had a wheelchair to further reduce falls. Staff consistently informed that R1 was brought out to the dining room/activity area during the day for increased staff supervision and meals with other residents. Staff informed that R1 was checked on approximately every 2 hours for toileting with status checks in between, per their care plan. The incident in question occurred during NOC shift between approximately 4:00am and 5:40am. The staff member (S1) who first observed R1's wrist to be swollen informed that R1 was sleeping during the 4:00am status check, but was observed awake, standing, and holding onto a rail in their bathroom during the 5:40am check. At the 5:40am check, S1 noted R1's swollen wrist while assisting R1 with toileting, and R1 did not answer when asked what happened that caused the injury. S1 then elevated the observation to the on-shift supervisor and informed the oncoming AM shift caregiver. R1 was unable to be qualified as a valid historian for interview due to cognition. Outside source interviews were conducted with R1's Responsible Person and Emergency Contact. The outside sources reported that R1 suffered frequent falls at the facility, most of which were unwitnessed and resulted in minor injuries without the need for medical attention. The outside sources confirmed that R1 was placed on Hospice and utilized a wheelchair as well as a low hospital bed with half rails. Records review corroborated staff statements. R1's Physician's Report for Residential Care Facilities for the Elderly (RCFE) showed that R1 suffered from a major neurocognitive disorder and recurrent falls. R1's Resident Care Summary listed that R1 needed assistance with Activities of Daily Living (ADLs), minimal help with transfers, and moderate help with mobility such as one-person assistance, hand holding, monitoring/assistance with using assistive devices due to noncompliance, escorts to meals/activities, and safety checks 4 times per shift. R1's Hospice records showed that R1 was admitted into Hospice due to worsening in condition, restlessness, weight loss, and frequent falls. The evidence shows that the facility, with the support of R1's family and Hospice, took several steps to mitigate R1’s falls due to their declining health. The evidence additionally shows that status checks for R1 had been conducted by staff prior to the incident. In addition, it remains unknown how R1's injury occurred, since they were not found on the floor and were unable to explain what happened due to cognitive impairment. (Continued on LIC9099 p.3) (Continued from LIC9099 p.2) Based on interviews, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Natasha Perez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 11, 2026 · control 08-AS-20250930163141

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Apr 10, 2026

87465(a)(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: Based on interviews and records, Licensee did not assist R1 with timely medical arrangements based on their condition. This posed an immediate health risk to 1 of 67 persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Executive Director agreed to conduct and in-service with staff regarding timely medical and reporting/care. This will include specific situations where Hospice agencies are involved. Proof of training will be provided via sign-in sheet by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Executive Director Jason McDonald. The facility's license shows a maximum capacity of eighty (80) non-ambulatory residents, ages 60 and above. The facility is approved for 25 bedridden and 30 hospice residents. During today’s inspection there were 59 residents in care. LPA and Executive Director toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Executive Director Jason McDonald, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Jason McDonald to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 6, 2025

Allegation investigated: Licensee denied resident visitation.

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit to conduct a complaint investigation and delivered findings regarding the above mentioned allegation. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit to Executive Director Jason McDonald. On 04/29/2025, the Department received a complaint where it was alleged that a visitor (identified as V1) for a resident (identified as R1) was denied visitation by the facility on the date of April 26th, 2025. The Department’s investigation consisted of unannounced facility visits, records review, and interviews with staff, residents, and outside sources. [Continued on LIC 9099-C] Substantiated [Continued from LIC 9099] Multiple staff interviews revealed that an internal communication was sent to staff informing them that V1 was to no longer be allowed visitation for R1 due to wishes from R1’s Power of Attorney (POA). Per interviews with staff and Outside Sources, visits from V1 triggered R1 and caused increased aggression from R1 and refusal to take daily medications. While one staff interview indicated that V1 was allowed entry on April 26th and informed that day of the facility’s plan to deny V1 future visits, another staff interview revealed that V1 was informed while visiting the facility on April 19th and denied entry to the facility on the 26th. File review of visitation logs for R1 corroborate that V1 was given entry to the facility the 19th and no entries were noted for the 26th. Additional file review of R1’s records reveal that R1’s POA does not have express permissions to restrict R1’s visitation. Outside sources interviewed revealed that the facility was informed to deny V1 from visitation based on POA wishes and that the facility has moved to deny V1 visits, despite not having legal authorization to do so. Resident interviews did not reveal any concerns about visitation. Based on LPA's review of records, interviews with staff, residents, and outside sources, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A Deficiency is being cited per California Code of Regulations, Title 22, Division 6 on the attached 9099D. An exit interview was conducted with Executive Director McDonald to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 08-AS-20250429101105

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Aug 14, 2025

(11)To have their visitors, [. . .] permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not ensure that visitors for R1 were allowed entry, resulting in a personal rights risk to 1 out of 68 residents in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: Licensee will conduct review/retraining with staff on residents rights, including visitation, and submit proof to LPA by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Jason McDonald to discuss the purpose of the visit. Today's visit is in response to the self reported incident for Resident 1, who suffered injuries from an unknown source. LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Executive Director Jason McDonald, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jan 22, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Nacole Patterson and Arian Golbakhsh conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by and discussed the purpose of the visit to Executive Director Jason McDonald. The facility's license shows a maximum capacity of 80 non-ambulatory residents, ages 60 and over. The facility is approved for twenty five (25) bedridden and thirty (30) hospice residents. During today’s inspection there were 72 residents in care. LPAs and Executive Director Jason McDonald toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Executive Director Jason McDonald, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed staff and clients, and reviewed facility records. The files reviewed by LPAs contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Jason McDonald to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 30, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Executive Director, Jason McDonald, after identifying themselves and stating the purpose of the inspection. This facility serves eighty (80) residents 60 and above; all may be non-ambulatory. LPA was accompanied by Executive Director McDonald during a tour of the facility. A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. Signal systems are in place and operational. PPE supplies are onsite. No bodies of water are on premises. Passageways were free from obstructions. According to Executive Director McDonald, there are no weapons and/or ammunition stored on the premises. Facility does feature delayed egress doors as well as a locked perimeter. Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are stored in locked closets. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars and Non-skid strips. Hot water temperature in residents’ bathrooms were compliant. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room not assessable to residents. Centrally stored medications were properly stored and locked in cabinets. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions. Staff records review verified that all staff records were complete and compliant. Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPAs conducted a thorough review of In-service training procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted with Executive Director McDonald, to whom copies of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. Their signature on this form acknowledges receipt and a copy of the report was given to Executive Director McDonaldthe state’s words, verbatim · CDSS document, Nov 21, 2023