Activcare at Rolling Hills Ranch

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Case Management Visit to follow up on an incident report submitted to Community Care Licensing (CCL) on May 4, 2026 regarding a resident (R1) having multiple falls resulting in a compress fracture. LPA was greeted by and met with Executive Director, Bee Bee Smith, to discuss the purpose of the visit. LPA toured the facility, conducted interviews and collected relevant records. Based on observations, review of records and interviews, R1 service care plan was updated to meet R1 needs. Staff followed reporting requirements regarding the fall incidents and are actively working with responsible party and medical providers to conduct the appropriate assessments and evaluations to meet R1's needs. No deficiencies were cited or observed on this date. An exit interview was conducted with Executive Director, Bee Bee Smith, who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 20, 2026

Allegation investigated: Neglect to resident resulting in unexplained serious injury

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA Hurt met with Executive Director Bonghabih, Shey, Smith, and Facility Gereontoligist/ Family Counselor Sophia Anguiano, and explained the purpose of today’s visit. Regarding the allegation Neglect to resident resulting in unexplained serious injury. Resident 1 sustained an unexplained serious injury while in care. The Department reviewed facility records, medical documentation, and conducted multiple staff and resident interviews. Records reflect that on 03/02/2022, Resident 1 was being assisted by a caregiver during a transfer from bed to wheelchair when she sustained a laceration to her left leg. Medical records confirm the injury required 16 staples for closure at Sharp Chula Vista Hospital. The investigation revealed that the facility-provided wheelchair had an exposed sharp metal rod protruding from the torn seat, which likely caused the laceration during the transfer. It was also determined that although Resident 1 had previously been identified as requiring two-person assistance with transfers due to weakness and edema, on the morning of the incident only one caregiver assisted her. Based on records reviewed and interviews conducted, there is sufficient evidence to determine that the facility staff failed to provide adequate care and supervision and failed to ensure that equipment provided to Resident 1 was safe for use. This resulted in a serious injury requiring medical attention. The preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. The following deficiencies are being cited (see LIC 9099D) from the California Code of Regulations, Title 22, and the California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on H&S Code section 1569.49(f). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted with facility staff Executive Director Bonghabih, Shey, Smith, and Facility Gereontoligist/ Family Counselor Sophia Anguiano, and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Feb 21, 2026 · control 08-AS-20220322083246

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 22, 2026

87464 Basic Services (f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). The following requirement has not been met as evidenced by: The facility neglected to provide proper care and supervision of Resident 1 leading to serious injury, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 21, 2026

Plan of correction: Administrator will ensure maintenance director checks equipment monthly for 3 months to ensure all equipment is safe and in good repair, also In service facility staff on recognizing and reporting any unsafe equipment, and also In Service training with staff on ensuring residents with 2 person assist are transferred safely, and submit to LPA by POC date 02/22/2026.

Allegation investigated: Lack of supervision, resulting in multiple falls

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. Upon arrival, LPA was greeted by Program Director, Karen Pultorak, to whom LPA identified herself and explained the purpose of the visit. Investigation Overview Community Care Licensing (CCL) initiated an investigation in response to a complaint received on July 25, 2025, alleging that lack of supervision resulted in R1 having multiple falls resulting in serious bodily injury. Specifically, it was alleged that R1 experienced multiple falls (three (3)) that resulted in serious bodily injuries requiring hospitalization. A Confidential Names List (LIC 811) was provided to facility staff to identify R1. (continue at LIC9099C) Substantiated (Continue from LIC9099) To investigate these allegations, the Department conducted an onsite facility inspection, reviewed facility and medical records, reviewed incident reports, and conducted interviews with facility management staff, direct care staff, and outside sources. The Department also reviewed medical provider records and hospital records covering the relevant time period. Through these investigative methods, the Department assessed the facility’s compliance with applicable laws and regulations and evaluated the care and supervision provided to R1. According to the complaint, staff failed to provide adequate supervision to R1, resulting in repeated falls, including a bathroom fall involving spilled mouthwash and a courtyard fall where R1 was found outside without staff present. It was further alleged that R1 sustained serious injuries including a cervical fracture and head injuries requiring emergency medical evaluation and treatment. Resident Background A review of R1’s facility and medical records showed R1 was admitted to the facility in 2021 and had diagnoses including dementia with cognitive impairment and unsteady gait. Records documented fall risk, wandering behavior, and need for assistance with activities of daily living, including bathing, dressing, toileting, and transfers. Medical assessments and physician records documented that R1 had an unsteady gait and was considered a fall risk. Records showed R1 sustained a cervical spine fracture in April 2025 and thereafter required use of a cervical collar and ongoing fall precautions. Physician follow-up notes repeatedly documented fall risk, neck injury, and continued need for monitoring and protective interventions. Facility Needs and Services Plans reviewed during the investigation documented that R1 was a high fall risk, required supervision, and that staff were to monitor R1 for changes in gait and balance, ensure use of assistive devices and cervical collar, supervise due to wandering behavior, and be aware of R1’s whereabouts at all times. (Continue at LIC9099C) (Continue from LIC9099C) Investigative Findings The Department reviewed facility records including resident assessments, Needs and Services Plans, incident reports, staffing information, and medical and hospital records. Records and interviews confirmed that R1 experienced three separate falls within approximately a three-month period resulting in injuries and hospital evaluations. First Fall — April 23, 2025 (Bathroom Incident): Facility incident reports and management interviews documented that R1 was being assisted by a caregiver in the bathroom with brushing teeth. Mouthwash was provided, the container was knocked from the caregiver’s hand, liquid spilled on the floor, and R1 stepped backward, slipped, and fell onto a walker. R1 sustained a laceration and neck injury and was transported to the hospital. Hospital records confirmed a cervical spine (C2) fracture. After returning to the facility, R1 was placed in a cervical collar and identified as high fall risk. The Needs and Services Plan was updated to include increased monitoring and fall precautions. Second Fall — June 8, 2025 (Bedroom Incident): Facility incident reports and medical records documented that during overnight rounds R1 was found on the floor next to the bed by staff. A medication technician assessed R1 and noted a head injury. R1 was transported to the hospital. Hospital and physician records documented head injury findings and continued cervical spine concerns, with continued cervical collar orders and fall precautions. Third Fall — July 19, 2025 (Courtyard Incident): Facility incident reports, staff interviews, and nursing interview confirmed that R1 was found on the ground in the courtyard with a walker overturned nearby. The fall was unwitnessed. Staff assessment documented a bump to the back of the head and R1 was transported to the hospital for evaluation. Hospital records confirmed emergency evaluation following an unwitnessed fall. Staff interviews confirmed that caregivers were not consistently present outside with residents and that residents were at times in the courtyard without direct staff supervision. (Continue at LIC9099C) (Continue from LIC9099C) Staff and Management Interviews: Management staff acknowledged the three falls and confirmed that R1 was identified as high fall risk after the first serious injury. Management reported that care plans were updated and increased monitoring was expected. However, staff interviews showed inconsistent recall regarding who was assigned to supervise R1 at the time of the courtyard fall. At least one staff member reported discovering R1 already on the ground outside without knowing how long R1 had been there. Nursing staff stated that caregivers are not always outside with residents due to other assigned duties inside the unit. Medical Records: Hospital and physician records confirmed repeated fall-related evaluations, cervical spine fracture, head injuries, continued cervical collar use, and repeated physician orders for fall precautions and supervision. Outside provider notes repeatedly referenced fall risk and the need for continued monitoring. R1’s Needs and Services Plans required supervision, wandering monitoring, fall precautions, and staff awareness of R1’s whereabouts at all times. Despite these written interventions, records and interviews confirmed that R1 was found alone after at least one unwitnessed outdoor fall and experienced repeated falls after being designated high fall risk. Conclusion Based on the evidence obtained through interviews, record reviews, and medical documentation, the Department determined there is sufficient evidence to substantiate the allegation that a lack of supervision resulted in R1 experiencing multiple falls resulting in serious bodily injury. Review of records disclosed that R1 was assessed as a high fall risk and required supervision and monitoring; however, supervision was not consistently provided. R1 sustained a cervical fracture and additional head injuries following unwitnessed or insufficiently supervised incidents. Continue at LIC9099C) (Continue from LIC9099C) The Department finds the allegation substantiated, meeting the preponderance-of-the-evidence standard. A deficiency was cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations and is detailed on LIC 9099-D. A Plan of Correction (POC) was developed with Program Director, Karen Pultorak. An immediate civil penalty of $500 was assessed today. In accordance with Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Community Care Licensing Division. An exit interview was conducted with Program Director, Karen Pultorak who was provided a copy of this report, the LIC 9099-D Deficiency Report, the LIC 811 Confidential Names List, LIC411, and the LIC 9058 Licensee Appeal Rights.the state’s words, verbatim · CDSS document, Feb 13, 2026 · control 08-AS-20250725155959

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 13, 2026

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) 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: Based on observations, records review, and interviews with staff and outside sources, licensee did not ensure that care and supervision was provided to meet R1 needs as outlined in R1’s service care plan. This posed an immediate health, safety, and personal rights risk to one 1 of 53 residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2026

Plan of correction: The licensee agreed to conduct staff training on regulations regarding providing care and supervision to meet residents' needs. Documentation of the training will be submitted to CCL by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by receptionist Samantha Barrientos. LPA discussed the purpose of the visit with Executive Director Bee Bee Smith. According to the facility’s license, there may be a maximum of 80 residents, all of whom may be non-ambulatory at any given time at the facility site. The facility is approved for 15 bedridden and 20 hospice residents. During today’s inspection, the facility’s current census is 51 residents living at the facility, of whom 51 were present at the facility site during the inspection. The facility comprises three sections, which may serve residents with similar care needs. LPA, accompanied by Executive Director Smith, toured the interior and exterior of the facility and inspected private shared, and individual rooms, kitchen, laundry, and maintenance areas. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings – chairs, lamps, drawers, etc. Doors, windows, toilets, and showers were in working order. LPA observed extra linens and hygiene supplies were present in the residents’ individual closets as well as the facility's linen closet. Personal Protective Equipment was present. The facility had sufficient space and equipment to facilitate dining, visitation, meetings, and activities. The facility’s ambient internal temperature was comfortable and compliant, at 73°F. Each room had its own designated thermostat to adjust the temperature to the residents' comfort. Hot water temperature at taps accessible to residents was also compliant. Level 1: sink in a private room restroom #1 delivered hot water at 115.3°F; sink in a shared room in restroom #2 delivered hot water at 111.9°F; [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] sink in a private room restroom #3 delivered hot water at 106°F; sink in a shared room in restroom #4 delivered hot water at 105.3°F; Level 2: sink in a private room restroom #5 delivered hot water at 115°F; sink in a shared room in restroom #6 delivered hot water at 110.7°F; The Club: sink in a shared room restroom #7 delivered hot water at 106.2°F; sink in a private room in restroom #8 delivered hot water at 107.8°F. There were at least 2 days of perishable food, and at least 7 days of non-perishable food present. The Facility Kitchen Manager conducts weekly orders to have ample food stock present. Cooking, dining equipment, and utensils were present, and all were safely secured and stored. The residents' dietary restrictions were managed by the facility’s Kitchen Manager, and according to the manager, staff are fully trained to ensure they are aware of residents' food restrictions. The chemicals in the kitchen area are located in a secure closet area away from food items. There were no toxic chemicals or poisons accessible to residents. Housekeeping and laundry are managed by the facility’s Environmental Service Director. Chemicals are secured in the housekeeping carts, and carts are stored in a locked area of the facility. Laundry is conducted in a locked area of the facility, where the facility stores its laundry chemicals. Medications were properly labeled, as required, and stored in locked areas. LPA inspected the medication room and found that medications were properly labeled and stored in a locked cabinet. The facility-maintained medication logs which LPA reviewed. No pools on the premises, but the facility did have a fountain in the front area of the facility, which had decorative rocks inside to ensure there was no body of water accessible. Per Executive Director Bee Bee Smith, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and the facility telephone were all working. Fire extinguishers were present (08) and serviced within the last 12 months, but one fire extinguisher located in the back locked area needed to be re-serviced. First aid kits were complete (06) and readily accessible. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809-C] LPA briefly spoke with staff and residents and reviewed staff and resident records. LPA's visit did not raise any licensing concerns. The files that LPA reviewed contained the required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility. There were no deficiencies observed or cited during today's annual inspection, but technical advisories were provided and may be seen on the LIC9102 pages of this report. An exit interview was conducted with Executive Director Bee Bee Smith to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received. LPA requested Executive Director Smith to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, and Emergency Disaster Plan LIC 610-E, to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.the state’s words, verbatim · CDSS document, Oct 16, 2025

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Program Director Karen Polturak, to discuss the purpose of the visit. LPA delivered an amended complaint report. No deficiencies were cited or observed on this date. An exit interview was conducted with Karen Polturak, who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jul 31, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Alyssa Ramirez conducted a case management visit due to a request to change the facility capacity. LPA was greeted by, identified herself to, and discussed the purpose of the visit with Business Manager Alondra . A Change of Capacity application was received by the Department on 8/9/24, in which the licensee requested capacity to be increased. The Fire Safety Inspection Request was approved by the local fire authority on 9/20/24. During today’s visit, LPA toured the facility and inspected requested double occupancy bedrooms. The facility sketch was consistent with the current layout of the facility. No immediate health and/or safety concerns were observed during today's visit. The completed change of capacity request will be forwarded to management for final review and approval. An exit interview was conducted with Smith, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Dec 16, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Bee Bee Smith The facility serves 60 non-ambulatory residents, age 60 and above, of which 15 may be bedridden, and currently has 45 residents in care. There is an approved Hospice Waiver for 20 residents. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected resident bedrooms. The facility was clean, sanitary, and in good repair. Client bedrooms contained the required furnishings. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water on the premises. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff/residents and reviewed multiple staff and resident records/files. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Smith, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Oct 24, 2024

Allegation investigated: Staff are forcing residents to wake from sleeping Staff are forcing residents to get out of bed Staff are forcing residents to leave their rooms

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Executive Director Bonghabih Smithand discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, LPA observations, interviews with facility staff, clients and outside agency. It was reported to CCL that facility staff are forcing residents to wake from sleeping, staff are forcing residents to get out of bed and staff are forcing residents to leave their rooms. Unsubstantiated Regarding the allegations, it was alleged that facility staff were instructed to wake up residents out of their sleep at 4:30am, groom the residents and force residents out of their rooms and into the dining room, in order to assist the next shift. It was reported that residents do not want to wake up that early and that residents are forced to sit in the dining room without anything to do but sit quietly. LPA observations revealed that LPA observed the “gray room” at 6am where residents gather in the morning. LPA observed music to be playing, staff interacting with residents by talking to them and offering them coffee and food such as oatmeal, boiled eggs and cereal. Residents appeared to be clean and fully dressed. No one appeared to be upset or disgruntled. Interviews with facility staff revealed that staff denied any residents being forced to be woken up and get out of bed. Staff denied being instructed to wake residents up at 4:30am and reported that the earliest residents start getting assisted with grooming is 5am. Staff reported that there are some residents who are early risers and they are assisted with grooming after 5am if they are awake and reported that no one is forced to be an early riser. Interviews with residents did not avail any concern surrounding being woken up too early or being forced out of bed/room. Interviews with outside sources did not reveal any concerns for allegations being investigated. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Smith. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Smith whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Aug 19, 2024 · control 08-AS-20240305121348

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Bonghabih Smith. Today's visit was in response to a licensee self-reported medication error. An Unusual Incident Report was received at the CCLD San Diego Regional Office on 4/11/2024. [See LIC 811 Confidential Names List for a description of residents]. Per the self-reported document, on 4/10/2024 staff (S1) administered resident’s (R1) medication. Prescription stated that R1 is to receive two (2) tablets, R1 was given one (1) pill instead due to the bubble pack only containing one pill. Medication error was acknowledged, and staff requested that pharmacy send correct bubble pack dose. During today’s visit, LPA performed a brief welfare check on residents, finding no safety concerns. LPA conducted interviews and reviewed records. Interview revealed that on 4/10/24, S1 overlooked the fact that the bubble pack contained one pill instead of 2 and incorrect dosage was administered to R1. On 4/15/2024, S1 was written up for “disregarding safety rules & practice” and counseled on 7 rights of medication administration. One (1) deficiency was cited per California Code of Regulations, Title 22, (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Executive Director. An exit interview was conducted with Executive Director, whose signature below confirms receipt of a copy of this report, the LIC811 and the Licensee Rights (LIC 9058 01/16).the state’s words, verbatim · CDSS document, Jun 7, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jul 7, 2024

(c) If the resident's physician has stated... that the resident is unable to determine his/her own need for nonprescription PRN medication,... facility staff...shall be permitted to assist the resident with self administration, provided...: (2) Once ordered by the physician the medication is given according Based on records and interviews, the licensee did not ensure that 1 of 43 residents were assisted as needed with prescription medications per physician's order on 4/10/2024, which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Jun 7, 2024

Plan of correction: Executive Director will ensure that S1 recieve's training on medication administration. Administrator will provide LPA with documentation of training to LPA by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Program Director Karen Pultorak. LPA also met with Executive Director Bonghabih “BeeBee” Shey, who arrived later during the visit. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/06/2023), involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a facility tour and welfare check on R1 and other residents in care. LPA reviewed and collected copies of pertinent care, hospital, and personnel records. LPA also interviewed relevant staff and outside sources and observed the facility’s mechanical lift machines. According to R1’s latest LIC602 Physician’s Report (dated 08/04/2023): R1 was diagnosed with “Advanced Dementia” and “Gait Disorder,” was wheelchair-bound, and required use of a “Hoyer Lift” machine to transfer from bed to wheelchair, and vice versa. The Needs and Services Plan which licensee authored on R1 reiterated that R1 was “non-weight-bearing” and “wheelchair bound.” Due to their baseline memory loss, R1 could not recall the above incident. However, records and staff interviews showed: On the morning of 11/29/2023, Staff #1 (S1), without the assistance of a teammate, used a Hoyer Lift machine to try to transfer R1 from bed to wheelchair. The two legs of the Hoyer Lift machine were not spread and locked in the wide-open position (to maximize stability) while R1 was suspended in the air (via the associated sling). During a subsequent pivot maneuver, the machine tipped over and R1 landed on the floor of their bedroom. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] During the landing, R1’s right arm / shoulder was pinned between a chair and a small dresser, which were nearby. A facility nurse quickly determined R1’s had pain and limited range of motion and phoned 911. R1 was sent to a hospital emergency room where they were diagnosed with a fracture of their right humerus (a bone in the upper arm). R1 was discharged back to the facility later the same day, with a sling for their arm and as-needed pain medication. Staff interviews unanimously showed: Even prior to this incident, licensee’s training expectations for its direct care staff included: a) use of the Hoyer Lift machine must be accompanied by assistance of at least two staff persons to ensure safety; and, b) the legs of the Hoyer Lift machine must be locked in the open-wide position prior to lifting a resident. Personnel and training records showed: Following the incident, Licensee performed written corrective action and coaching with S1 on 11/29/2023 and 12/06/2023. On 12/11/2023 and 12/13/2023, Licensee also retrained its larger direct care staff team on correct use of Mechanical Lifts; the training included a skills validation component. Manager and staff interviews, corroborated by the facility’s work schedule, showed: The AM shift on 11/29/2023 (when the incident occurred) was fully staffed at the caregiver, med tech, and nurse positions (i.e., there was no shortage of teammates available to S1 to ask for help with the Hoyer Lift machine). Following the incident, licensee inspected the specific Hoyer Lift machine and sling used during the incident and found them free of defects – LPA observation of said machine and sling, during today’s visit, confirmed this. S1 admitted to CCLD that their performance with the Hoyer Lift machine on 11/29/2023 did not display the level of competence necessary to ensure R1’s safety. Interviews of staff and outside sources showed: As R1 was being sent to the hospital on 11/29/2023, facility staff timely notified R1’s physician and responsible person (RP) of the incident via phone call, then sent a written LIC624 Incident Report to CCLD on 12/06/2023. However, the licensee did not send a copy of the LIC624 to R1’s responsible person, which was required to be done within seven days of incident occurrence. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] A preponderance of evidence exists to show that during the incident in question, licensee’s staff (S1) did not display competence necessary to meet a resident’s needs, which was material to R1 sustaining serious bodily injury. A preponderance of evidence exists to show that licensee did not fully meet reporting requirements. Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). An immediate civil penalty of $500 was also assessed (refer to the LIC421-IM). Plans of Correction was jointly developed with the licensee. LPA also provided Technical Assistance (TA) regarding another Hoyer Lift machine present at the facility, different than the one used by S1 during the above incident (refer to the LIC9102-TA). An exit interview was conducted with Shey, to whom a copy of this report, the LIC 809-D, the LIC421-IM, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Dec 15, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 16, 2023

87411 Personnel Requirements – General: “(a) Facility personnel shall at all times be…competent to provide the services necessary to meet resident needs.” This requirement was not met, as evidenced by: Based on interviews, the licensee did not ensure a facility personnel (S1) was competent to provide the services necessary to meet the needs of 1 of 42 residents (R1), which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 15, 2023

Plan of correction: Personnel and training records showed: Following the incident, Licensee performed written corrective action and coaching with S1 on 11/29/2023 and 12/06/2023. On 12/11/2023 and 12/13/2023, Licensee also retrained its larger direct care staff team on correct use of Mechanical Lifts; the training included a skills-validation component. These actions resolve the deficiency.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Dec 16, 2023

87211 Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident." This requirement was not met, as evidenced by: Based on records and interviews, 1 of 42 residents (R1) had an incident which threatened their welfare, safety, or health, and Licensee did not submit a written report of the incident to the person responsible for the resident within seven days of incident occurrence. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 15, 2023

Plan of correction: During today’s visit, Licensee E-mailed a copy of the written LIC624 Incident Report to R1’s responsible person. This action resolves the deficiency.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Business Office Manager Arion Rendo. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 11/15/2023). According to the LIC624: on 11/10/2023, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of R1.] R1 was located and brought back to the facility within two hours. During today’s visit, LPA performed a facility tour and welfare check on R1, finding they were safe. LPA reviewed and collected copies of pertinent facility and outside source records. LPA also interviewed R1, outside sources, and relevant staff. According to R1’s latest LIC602 Physician’s Report (dated 09/25/2023), R1 was diagnosed with dementia and their doctor determined that R1 was not safe to leave the facility unassisted. Interviews and records showed: On 11/10/2023, staff last saw and spoke with R1 inside the facility around 4:30 PM; R1 was calm then. Sometime between 4:50 PM and 5:00 PM, staff suspected R1 was not present and began looking for them. Inside the facility’s courtyard, a bench was seen turned upright on its end, placed near the courtyard wall. R1’s walker was beside the bench. Staff timely phoned law enforcement and R1’s responsible person and expanded the search radius to the surrounding neighborhood. Police located and returned R1 to the facility around 6:30 PM. R1 had a minor scratch on one finger, and redness on a knee, but was otherwise unharmed. Licensee had a written Absentee Notification Plan as part of R1’s record of care, and staff followed this plan during the incident. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] No deficiencies were observed or cited during today's visit. However, LPA issued one (1) Technical Violation regarding reporting requirements. An exit interview was conducted with Rendo. A copy of this report, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during the visit.the state’s words, verbatim · CDSS document, Nov 20, 2023

Allegation investigated: A lack of supervision resulted in a resident sustaining a fracture while in care

Licensing Program Analyst Becky Kennedy concluded the investigation which began on 3/16/2021. LPA Kennedy made an unannounced visit to the above facility today and was greeted by Karen Pultorak, Program Director. LPA advised Program DSirector Pultorak of the reason for today's visit and delivered the investigation findings on the above allegation. Investigation consisted of interviews with residents, staff, outside sources, record review, and tour of the interior and exterior facility. It was alleged that a lack of supervision resulted Resident 1 (R1) falling and sustaining a fracture. Investigation revealed, through records review, interviews with facility and hospital staff, and R1, that R1 was found on their bedroom floor on 12-31-20. R1 sustained a femoral neck fracture. Prior to the 12-31-20 incident, falling was concern for R1. Although R1 was able to get from their bed to the bathroom with the aid of a walker, to insure R1’s safety, R1 was supposed to use the call button so care staff could assist R1. On the night of R1’s fall, R1 did not call for assistance. R1 reported that they “fell out of bed.” Unsubstantiated R1 received a care and toileting check every two hours when appropriate care is provided. Documents reviewed confirm that R1 received regular care/toileting check less than two hours prior to the fall. R1 was discovered on the floor during a regular a check. After the fall, facility staff assessed and monitored R1 and sent R1 to the hospital for additional treatment. Based on interviews and the review of documents, it was determined that R1’s fall was not due to a lack of supervision and the finding is Unsubstantiated. An exit interview was conducted and a copy of this report, and appeal rights were given to Karen Pultorak.the state’s words, verbatim · CDSS document, Nov 6, 2023 · control 08-AS-20210104092711

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers was granted entry into the facility by Executive Director, Bonghabih Shey Smith, after identifying herself and stating the purpose of the inspection. The facility serves 60 non-ambulatory residents, age 60 and above, of which 15 may be bedridden, and currently has 41 residents in care. There is an approved Hospice Waiver for 20 residents. This is a one-story complex, comprised of four (4) wings and equipped with fully secured perimeters. LPA was accompanied by the Executive Director Shey Smith, during a tour of the facility, which was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, and food storage areas. There is a fire signal system in place and the carbon monoxide detectors were operational. The last disaster drill was conducted on October 2023. There is a water fountain located outside the entrance of the facility and made inaccessible with rocks filling the large pool of water at the base of the fountain. Exterior and interior passageways were free from obstructions. According to Executive Director Shey Smith, there are no weapons and/or ammunition stored on the premises. Pull cords were available in each resident units that were tested for functionality. Resident's room temperatures were within a comfortable range. Continued on 809-C Continued on 809 Each resident had clean and sufficient bed linens, towels, and washcloths. 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 nonskid strips were present in residents’ showers. Community showers was clean and in working order. Hot water temperature in residents’ bathrooms were compliant. Facility has a two-day supply of perishable 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. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closets. The medication room is secured and has a locked medication cart, medications were labeled and kept in compliance with label instructions. LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA Rodgers also conducted a thorough review of In-service training procedures. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. 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 and a copy of this report and Licensee/Appeal Rights - LIC 9058 (rev. 01/16) were provided to the Executive Director Shey Smith, whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Oct 27, 2023