Aldersly

Allegation investigated: Personal Rights - Facility Did Not Allow Resident's Family to Visit

At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a complaint investigation regarding the above allegation and met with Business Office Manager, Eliana Lopez (BOM). Heath and Wellness Director (HWD), Melanie Fenn, arrived during visit at approximately 9:50AM. During the course of the investigation, the Department reviewed documents, conducted interviews, and made observations. The following allegation was investigated, "Personal Rights - Facility did not allow resident's family to visit." Complaint alleged that facility staff did not allow Visitor 1 (V1) to enter the facility to see Resident 1 (R1) in March 2026. Interview conducted with HWD revealed that R1 had a restraining order in place against V1 but were unsure if the restraining order had expired. Per HWD, V1 was not allowed to visit R1 due to financial concerns Continued on LIC90999 Substantiated Continued from LIC9099A identify the month that this observation was made. Review of Community Care Licensing (CCL) report, dated 08/20/2025, stated that the facility had a visit conducted by the Department to address the facility's expansion of their Marselisborg building and address the facility's change of capacity. Per report, the visit was to see if the facility's expansion was ready to be licensed by the Department. During visit conducted on 08/20/2025, the facility's new license was granted. On 10/03/2025 and 10/21/2025, facility had their annual inspection visit conducted. Review of inspection notes showed that the facility had evacuation chairs at each stairwell at the time of inspection. During visit conducted on 06/04/2026, it was observed that that there were two evacuation chairs located in the Assisted Living building, two evacuation chairs located in the expansion building/Marselisborg building, and one evacuation chair located in the Extended Care building. Based on record review and observations made, this allegation is Unsubstantiated. "Facility not meeting resident's care needs" - Complaint alleged that R1 had a fall in February 2026 and facility staff did not clean R1's bathroom and left fecal matter on the bathroom floor after their fall. Complaint also alleged that R1's meal trays were not removed from their room for up to six hours when they were in Extended Care, and that R1 never received treatment from their breathing machine while in Extended Care. Review of R1's progress notes showed that R1 was in Extended Care from 02/11/2026 to 04/20/2026, and moved to Assisted Living on 07/28/2026. An interview with R1 was conducted. Per R1, they resided as an Independent Living resident until the beginning of August 2026 when they moved to the facility's Assisted Living. During the interview, R1 stated that the facility staff made them feel special and and felt that their needs were being met. Per R1, when they would have an accident in Independent Living, they would call for assistance and facility staff would help with cleaning right away. When asked if the facility staff took a long time to remove food trays from their room, R1 stated that they felt that facility staff did a good job. An interview with R1's responsible party was conducted. Per responsible party, the facility goes above and beyond for R1 to make sure that they are okay and well taken care of. Responsible party also stated that they have no concerns with the services provided, and said that the staff ensure that R1's room is clean and that they are informed of any incidents that have occurred with R1. Continued on LIC9099C Continued from LIC9099C Review of R1's medication list showed that R1 had the following medications prescribed for help with breathing. Wixela Inhub 250-50 MCG BLST W/DEV: give 250-50MCG/ACT aerosol powder breath activated by inhalation two times per day every day. Inhale 1 puff by mouth twice daily. Albuterol Sulfate 2.5MG/3ML vial: give (2.5MG/3ML) vial Nebulization Solution by Inhalation as needed. Use 1 Vial via nebulizer every six hours as needed for wheezing/shortness of breath Albuterol Sulfate HFA 90MCG HFA AER AD: give (108/90 base) MCG/ACT Aerosol Solution by Inhalation as needed every 4 hours. Inhale 2 puffs into the lungs every 4 hours as needed for cough and wheezing. Interview with HWD stated that R1 does not have a breathing machine and used inhalers to help with their breathing. Interview with R1 confirmed that they do not use a breathing machine and use inhalers to help with their breathing. Per R1, they have a PRN or "as needed" inhaler prescribed to be used when they need it. R1 revealed that they do not tell the facility staff when they administer the "as needed" inhaler since they keep it in their walker. R1 also stated that they were not aware they had a routine inhaler prescribed for twice a day and stated the facility staff have not been administering this routine medication to them. Review of R1's electronic medication administration record (EMAR) for February, March, and April 2026, showed that R1's routine inhaler was administered or refused by R1. Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated. "Staff Not Properly Trained on Transferring Residents" - Complaint alleged that the facility staff did not know how to transfer R1 to and from the toilet. Interview with R1 stated that they felt safe when facility staff were helping or transferring them. Review of facility records showed that on 10/08/2025, the facility conducted a training on fall prevention and transferring for Assisted Living, Memory Care, and Extended Care facility staff. Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated. Continued on LIC9099C Continued from LIC9099C "Neglect/Lack of Supervision" - Complaint alleged that R1 had a fall in February 2026 and that facility staff did not check on them after their fall. Interview with R1 stated that that they had a fall while they were in Independent Living and the staff came to help them. R1 stated that after their fall, facility staff came to check on them, and asked if they had any pain or if they were okay. Review of R1's Progress Notes showed that on 01/22/2026, R1 had a fall. Per notes, R1 denied hitting their head and other extremities. R1 also denied being in pain and declined to have additional medical attention. Progress notes showed that R1 was checked on in the following days. Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents. Continued from LIC9099 raised by R1's responsible party. Interview conducted with Resident Care Manager (RCM), revealed that on 06/03/2026, V1 was at the facility. RCM was unsure if V1 was escorted off the property or if they chose to leave the property on their own once it was determined they were on-site. Per RCM, they did not know why V1 was not allowed at the facility, but had been informed that V1 was not allowed to visit with R1. A review of R1's file was conducted. R1's file showed that on 07/14/2023, a restraining order against V1 was put in place and had an expiration date of 07/13/2024. Further review showed that R1's file did not have a current restraining order in place to prohibit V1 from visiting with R1. Based on record review, interviews conducted, and observations made, this allegation is Substantiated. A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 31, 2026 · control 21-AS-20260529141335

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Sep 11, 2026

87468.1 Personal Rights of Residents in All Facilities: (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11) To have their visitors...permitted to visit privately during reasonable hours and without prior notice... This requirement was not met as evidenced by: Based on record review and interviews conducted, Licensee did not comply with the section cited above and did not allow V1 to visit with R1. This is a potential health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Licensee to conduct an in-service training with all staff members on the topic of resident rights, visitation, and when a visitor would be restricted or prohibited from the facility. Training to include: Supporting Documents, Date of Training, Topic, Staff Names, Staff Roles, and Staff Signatures. Proof of training and supporting documents to be submitted to CCL by POC due date of 09/11/2026.

Type of visit: Case Management - Deficiencies

At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Deficiencies visit and met with Business Office Manager, Eliana Lopez. Health and Wellness Director, Melanie Fenn, arrived during visit at approximately 9:50AM. During the course of Complaint Investigation: 21-AS-20260529141335, it was discovered that the facility did not have a physician's order on file for R1 to have their PRN or "as needed" inhalers in their room/in their walker. Interview conducted with R1 revealed that they keep their "as needed" inhaler in their walker and do not tell the facility staff when they have used it. Review of records showed that the facility manages R1's medications and therefore R1's inhalers should be secure. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 31, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 11, 2026

87465 Incidental Medical and Dental Care: (a)A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews conducted and record review, facility did not comply with the section cited above and did not ensure that there was a physician order in place to allow R1 to keep their "as needed" medications in their room/in their walker instead of being secure in the facility medication cart.the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Licensee to obtain needed physician orders for R1 to keep their inhalers in their room. Licensee to also conduct an in-service training on medication and documentation for all medication technicians. Training to include: Supporting Documents, Date of Training, Topic, Staff Names, Staff Roles, and Staff Signatures. Proof of training, supporting documents, and proof of R1's physician orders to be submitted to CCL by POC due date of 09/11/2026.

Allegation investigated: Insufficent staffing to meet resident's care needs in a timely manner Staff mismanaged resident's medication Facility did not ensure maintenance of resident’s personal care equipment Staff do not have proper training

At approximately 8:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a complaint investigation regarding the above allegations and met with Health and Wellness Director, Melanie Fenn. During the course of the investigation, the Department reviewed documents, conducted interviews, and made observations. There is an allegation of "Insufficent staffing to meet resident's care needs in a timely manner" - Complaint alleged that Resident 1 (R1) has waited about 20 minutes to receive help with their Activities of Daily Living (ADLs). Per report, this wait time was observed when R1 resided in the facility’s Assisted Living and clarified that R1 moved to the facility’s Extended Care in February 2026. Complainant was unable to provide a timeframe of when R1 waited 20 minutes for help. Continued on LIC9099C Unsubstantiated Continued from LIC9099 Per interview with Health and Wellness Director (HWD), facility does not track or have records of resident pull cord logs in Extended Care. HWD explained that pendant logs were only for Assisted Living residents. Interview with Resident Care Manager stated that there is an expectation that pendants are responded to by facility staff within 5 minutes. Review of R1’s care plan dated 08/28/2024 stated that they need assistance with their ADLs. Per R1’s care plan, they needed assistance with ambulation, transfers, bathing, incontinence, and dressing/grooming but did not indicate if any of these care needs required two staff members for assistance. Review of R1’s pendant call records for November 2025, December 2025, and January 2026 showed that there were 100 entries with a wait response time of over 5 minutes. 37 out of 100 entries had a wait time of between 10 minutes and 27 minutes. 8 of 100 entries had a wait time of over 30 minutes with wait times recorded between 39 minutes and 96 minutes. These wait times occurred on the following dates: 11/08/2025, 11/19/2025, 11/24/2025, 12/05/2025, 12/12/2025, and 12/22/2025. Review of facility time sheets and staff schedules for these identified dates showed that facility had appropriate staffing. Based on record review, observations, and interviews, this allegation is Unsubstantiated. There is an allegation of "Staff mismanaged resident's medications." - Complaint alleged that facility did not have R1’s nebulizer or albuterol. Per complaint, R1’s albuterol was unavailable and therefore facility staff were “borrowing” the medication from another resident. Complaint was unable to provide additional information such as which resident the facility staff was borrowing albuterol from or when the albuterol was borrowed. Complainant stated that R1 received physician orders for the nebulizer equipment and albuterol medication on 01/07/2026 and 01/20/2026. Complaint stated that R1 did not have albuterol or their nebulizer on 02/04/2026, but did have their nebulizer available on 02/11/2026. Complainant further alleged the following: R1 had a rectal suppository medication for hemorrhoids and it was not available, facility was not following R1’s torsemide medication order stating that the facility was to check R1’s blood pressure before administering the medication, and that facility removed R1’s half bed rails even though R1 had a physician's order for it. Per Complainant, R1 received an order for half bed rails in May 2025 but the bed rails were removed in February 2026 when R1 moved to the facility’s Extended Care area. Complainant stated that R1 received a new order for half bed rails on 01/07/2026. Albuterol and Nebulizer: Review of R1’s progress notes for 01/07/2026 stated that R1’s physician would order nebulizer and albuterol treatments. Review of R1’s file showed an order dated 01/07/2026 for two medications: Turmeric and Albuterol. Continued on LIC9099C Continued from LIC9099C R1's albuterol medication order stated, “Use 3mL via nebulizer every 4 hours as needed for quick relief of asthma symptoms. (3mL = 1 vial).” On 02/05/2026, R1 received a new albuterol order which stated, “Administer 1 dose every 4 hours as needed for acute shortness of breath or wheezing.” R1’s progress notes stated that R1 was monitored for changes in their breathing and was offered treatments if observed. Per notes, R1 was administered or offered their “as needed” breathing treatments on the following days: 01/09/2026, R1 received their nebulizer treatment after being observed to have SOB (Shortness of Breath) in the afternoon. 01/12/2026, R1 was observed to have SOB but refused both their nasal spray and nebulizer treatment. 01/26/2026, R1 received inhaler due to experiencing SOB during physical therapy visit. 02/12/2026, R1 received nebulizer treatment after being observed to have worsened respiratory symptoms and increased weakness. Review of R1’s centrally stored medication and destruction record (LIC622) indicated that the facility received R1’s Albuterol on the following dates: Filled on 10/20/2025, expiration date 01/2027, with 3 refills Filled on 11/25/2025, expiration date 04/2027, with 2 refills Filled on 02/18/2026, expiration date 03/31/2027, with 0 refills Interview conducted with HWD stated that R1’s pharmacy sent the facility albuterol in two different forms: albuterol in a glass vial which required a syringe to administer, and albuterol in a plastic vial that had a twist off tube. Per HWD, facility staff did not use the albuterol in the glass vial and continued to administer R1’s albuterol in the plastic tube that is allowed in licensed facilities. 3 of 3 staff interviews conducted stated that they haven’t administered albuterol from another resident to R1. Torsemide: Complainant informed the Department that documentation of R1’s blood pressure (BP) for the Toresmide parameters was located. Review of documents showed that R1 had blood pressure and vitals taken in February and March 2026. Review of R1’s after visit summary and medication list dated 02/25/2026 stated that R1 received an order for Torsemide which stated, “Torsemide 20mg tab: Take 1 tablet by mouth daily.” There was no indication of any parameters stated in the medication order. Review of R1’s face sheet information and medication list updated 03/11/2026 stated, “Torsemide, 20MG Tablet – give 20MG tablet by mouth, one time per day, every day. Take one tablet by mouth every day." There was no indication of any parameters listed in the medication order. Continued on LIC9099C Continued from LIC9099C 3 of 3 staff interviews conducted stated that vitals such as blood pressure, are to be taken once a month, unless otherwise instructed. Bisacodyl Rectal Suppository: Review of R1’s physician orders dated 04/09/2024 and 02/15/2026 showed that R1 had an PRN or “as needed” medication for Bisacodyl Rectal Suppository 10MG (Bisacodyl), which stated, “Insert 1 suppository rectally as needed for constipation.” Review of R1’s after visit summary and medication list dated 02/25/2026 indicated that there was no longer an order listed for a PRN Bisacodyl Rectal Suppository. Review of R1’s electronic medication authorization record (EMAR) showed that the suppository order was discontinued in February 2026 and therefore was not needed. EMAR further stated that R1 did not require a suppository in January 2026. Bed Rails: Review of facility’s policy dated 03/2025 stated that “…residents needing bed mobility devices are provided with safer alternatives to bed side rails…Bed rails of any type, e.g. full, half, quarter, etc. shall NOT be used in any LCS (Life Care Services) Community.” Per facility procedure, any licensed physical/occupational therapist shall be made aware of the “No Bed Rails” policy at the time of a resident’s evaluation to ensure that bed rails not recommended. Review of R1’s LIC602/medical assessment dated 04/25/2025 stated that for transfers, R1 was to utilize a Sit-to-Stand Machine and use a front wheeled walker. Review of R1’s discharge paperwork and after visit summary dated 01/03/2026 did not indicate any new orders related to bed rails. Review of R1’s progress notes stated that on 01/06/2026, facility held a care conference to discuss multiple areas of care including physical therapy and occupational therapy. Notes stated that R1 continued to use the sit-to-stand machine with no changes. Review of R1’s discharge paperwork dated 02/15/2026 under “Inpatient Physical Therapy Evaluation” stated that R1 previously used a hoyer lift. It further stated that R1’s goals were to assess transfers with a hoyer lift and wheelchair management. Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated. There is an allegation of "Facility did not ensure maintenance of resident’s personal care equipment." Complaint alleged that facility lost R1's APP overlay and that only the motor was in place. The Department was provided with the following timeline: R1's APP overlay was provided by Kaiser and was first observed to be gone on 02/04/2026. R1 went to the emergency room on 02/03/2026 and their APP overlay was observed to be gone on 02/11/2026. On 02/18/2026, R1's physical therapy and occupational therapy located and installed R1's APP overlay. R1 then went to the hospital from 02/19-02/25/2026. On 02/27/2026 it was observed that R1's APP overlay was not on the bed. Per Complainant, an order was placed with Kaiser for a replacement, and R1's responsible party stated the overlay had Continued on LIC9099C Continued from LIC9099C been delivered. On 03/02/2026, the overlay was not observed on R1's bed. On 03/04/2026, a new order was made for a replacement which was delivered on 03/10/2026. Interview conducted with HWD stated that R1's APP overlay was taken by the paramedics when they were sent to the hospital. Per HWD, two staff members were present during this incident. Multiple attempts to interview these staff members were made to obtain more information but were unsuccessful. Interview conducted with Staff Member 3 (S3) stated that durable medical equipment is coordinated through the resident's home health agency while their medical provider is responsible for obtaining the order. Per interview, the facility's process for replacing missing equipment is to reach out to the party or provider who supplied it to arrange for a replacement. During visit on 03/12/2026, a light blue bubble overlay was observed on R1's bed. Based on interviews conducted and observations made, this allegation is Unsubstantiated. There is an allegation of "Staff do not have proper training." Complaint alleged that facility staff didn't seem to know how to manage R1's foley catheter. Per Complainant, it had been observed that R1's catheter tubing was not attached or secured to their leg, and that the catheter urine bag was noted to be full on two separate occasions. Review of R1’s discharge paperwork dated 02/15/2026 stated that R1 had a referral to Urology following placement of their foley catheter. Review of R1's LIC602/medical assessment dated 02/15/2026, stated that R1 had a foley catheter in place. Review of R1's progress notes stated that R1 returned to the facility on 02/25/2026 with an in-dwelling catheter in place. This pogress note stated that R1's home health agency would manage R1's catheter. Interview conducted with HWD stated that there hasn't been any training for caregivers, medtechs, or CNAs (Certified Nursing Assistants) on catheter care as the assigned home health agency would be responsible for managing it. HWD later stated that they believe catheter care training had been done before through an outside agency like hospice, but was unable to locate proof of documentation. Staff interviews were conducted. 3 of 4 staff interviews conducted stated that they have received training on catheters. 1 of 4 interviews stated they had not received training on catheter care. 1 of 4 interviews stated that they did not receive their catheter training from the facility and received catheter training from another source. 2 of 4 interviews stated they received catheter training but were unable to state if it had been provided by the facility or from another source. 4 of 4 staff interviews all stated that if a resident has a catheter, they are to empty the bag. 2 of 4 staff interviews also stated they are to ensure the bag is positioned correctly or attached to the resident's leg. Review of staff training on Relias indicated that staff received training on how to assist with resident ADLs. Interview with Business Office Manager and HWD were unable to confirm if the ADL training module had a section covering catheter care. Continued on LIC9099C Continued from LIC9099C Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 21-AS-20260304141943

Allegation investigated: Unlawful Eviction

At approximately 8:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a complaint investigation regarding the above allegation and met with Health and Wellness Director, Melanie Fenn, and Executive Director, Mike Sharkey. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation of “Unlawful Eviction.” Complaint alleged that Resident 1 (R1) was unlawfully evicted from the facility. Per complaint, R1 moved to the facility on 10/24/2025 and went to the hospital on 10/26/2025 due to aggressive behavior. On 10/28/2025, R1 and their responsible party were informed that R1 was not welcome back to the facility and that their personal items needed to be removed. Continued on LIC9099C Substantiated Continued from LIC9099 Review of R1’s pre-appraisal dated 10/20/2025 stated that R1 did not have any known behaviors of aggression or violence. Review of R1’s medication list stated that they have a PRN or “as needed” medication for agitation or delirium. Review of R1’s medication authorization record showed that R1 received their PRN for agitation on 10/25/2025. There was no record of R1 receiving their PRN medication for agitation on 10/24/2025 as written in the facility communication log. Review of R1’s communication log indicated that R1 moved to the facility on 10/24/2025. Review of documentation for 10/24/2025 – 10/26/2025 showed that R1 was noted to be restless and agitated. Communication log noted that on 10/26/2025, R1 hit staff when they tried to provide incontinence care. R1’s communication log also stated that R1 was provided their PRN or “as needed” medication for agitation on 10/24/2025 and 10/25/2025. Email correspondence provided to the Department corroborated this information and noted that facility staff attempted to give R1 their PRN medication for agitation but spit it out on 10/26/2025, Interview conducted with Health and Wellness Director (HWD) stated that the facility was not capable of caring for R1 because they required a higher level of care. Per interview, a reassessment for R1 was done and R1’s responsible party was informed in-person and via telephone of the new behaviors being observed at the facility. Interview further revealed that it was discussed to have additional private caregivers to help assist with R1’s behaviors. Per HWD, the process of eviction was not discussed because R1’s responsible party decided to move them out of the facility. Interview conducted with Memory Care Coordinator (MCC) stated that they contacted R1’s responsible party multiple times a day to inform them of R1’s observed behaviors such as throwing furniture or running at residents. Interviews conducted with HWD and MCC revealed that these conversations with R1’s responsible party were not documented or written anywhere because the events happened very quickly over the course of a few days. Interview conducted with R1’s responsible party stated that R1 did not have any behaviors while living at home and that facility informed them of R1’s behaviors such as throwing food and being violent towards facility staff a few days after they moved to the facility. Per interview, the facility did not discuss with them about R1 requiring a higher level of care or needing additional caregivers for help. Per interview, no additional documents regarding R1 and their care were reviewed or signed apart from the admissions agreement. Review of R1’s file showed that facility conducted a reassessment on 10/30/2025 for R1 regarding their observed behaviors of aggression and violence. It was observed that this reassessment was not signed by Continued on LIC9099C Continued from LIC9099C their responsible party acknowledging the changes in care. Review of facility notes stated that R1 went to the hospital on 10/29/2025. Notes further state that R1 was no longer receiving services on 10/31/2025. There are no additional documentation or notes proving that the facility contacted R1’s responsible party to discuss the changes in care or behaviors. It was also observed that R1, their responsible party, and Community Care Licensing (CCL) did not receive a 30-day eviction notice as required by regulation. Title 22 Regulations under Eviction Procedures, 87224(a)(4) states, “87224 Eviction Procedures: (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required… (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident." Based on interviews conducted, record review and observations made, these allegations are Substantiated. A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Executive Director. Signature on form confirms receipt of documents. Continued from LIC9099 Based on documents reviewed, this allegation is Unsubstantiated. A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 24, 2026 · control 21-AS-20251031160138

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Mar 6, 2026

87224 Eviction Procedures: (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...This requirement was not met as evidenced by: based on record review, interviews, and observations, Licensee did not ensure that R1 received a proper eviction after it was identified they required a higher level of care. This poses a potential health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 24, 2026

Plan of correction: Licensee to conduct an in-service training with managerial/supervisory staff reviewing Eviction Procedures. Training to include the following: Date, Topic, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date 03/06/2026.

Type of visit: Case Management - Annual Continuation

At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1 Year Required Visit, and met with Business Office Manager, Eliana Lopez, and Health and Wellness Director, Melanie Fenn. Facility has an approved fire clearance and total capacity of 172 Non-Ambulatory Residents, where 12 can be bedridden. Facility has an approved hospice waiver for 8 individuals. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Upon arrival, LPA was informed that there were 14 residents in Assisted Living, 17 residents in Memory Care, 3 residents in Extended Care, and 48 Independent Living residents for a total of 82 residents in care. LPA was also informed that there were 27 staff members on-site. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA finished review of staff files and resident files. All files were well organized and contained the required documentation. LPA reviewed 6 resident medications. LPA observed that 1 of 6 residents had 3 medications that were not centrally stored as required (deficiency cited, regulation 87465(h)(6)). During medication review in Extended Care, LPA observed that the medication cart keys were accessible and the cart itself was unlocked and accessible to guests and residents in care (deficiency cited, 87465(h)(2)). LPA also observed that noon medications were pre-poured in Memory Care. Per discussion with Medication Technician, the noon medications were poured at around 9AM (technical violation issued, LIC9102, regulation 87465(h)(5)). Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), LIC9102 (Technical Violation/Advisories) Plan of Corrections, and Appeal Rights discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 21, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At approximately 8:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1 Year Required Visit, and met with Resident Care Manager, Sourabh Singh. Executive Director, Mike Sharkey, arrived during visit at approximately 1:00PM. Facility has an approved fire clearance and total capacity of 172 Non-Ambulatory Residents, where 12 can be bedridden. Facility has an approved hospice waiver for 8 individuals. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Upon arrival, LPA was informed that there were 13 residents in Assisted Living, 15 residents in Memory Care, 3 residents in Extended Care, and 45 Independent Living residents for a total of 76 residents in care. LPA was also informed that there were 22 staff members on-site. At approximately 9:00AM, LPA reviewed the Facility's Staff Roster with Resident Care Manager and found that all staff members on site were background cleared and associated to the facility per regulation. LPA followed up on an incident report that was self-submitted to Community Care Licensing (CCL). Incident Report 1/SOC-341: CCL received an incident report and SOC-341 report from the facility on 10/02/2025. Reports stated that on 10/01/2025, Facility's Safely You Video System alerted Staff Member 1 (S1) of Resident 1 (R1) having a fall but they did not check on R1 until 2 hours later. Reports further stated that R1 did not have any injuries due to the fall and S1 was terminated following the incident. Facility made all appropriate notifications per regulation. LPA obtained documents related to the incident. Continued on LIC809C Continued from LIC809 LPA conducted a walk-though of the facility with Resident Care Manager and Executive Director and observed the following: Facility consists of multiple buildings for Assisted Living and Memory Care. Facility has an Extended Care unit which is a separate wing for Assisted Living residents that require a higher level of care. Facility also has independent living units on the property. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a Infection Control Plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 9 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected December 2024. Facility smoke detectors are hard wired and connect directly to the local fire station. Facility's sprinkler system were last inspected August 2025. Facility's last emergency/disaster drill was conducted September 2025. LPA began resident file review. LPA unable to complete Annual Visit. Annual Continuation Visit to be conducted at a later date. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director and Resident Care Manager. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 3, 2025

Type of visit: Case Management - Other

At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management – Other Visit and met with Executive Director, Mike Sharkey, and Health and Wellness Director Melanie Fenn. The purpose of today’s visit is to inspect the facility’s completed expansion. On 08/13/2025, the facility received an approved fire clearance and change of capacity. Facility’s fire clearance and capacity has been updated to a total of 172 Non-Ambulatory Residents, where 12 can be bedridden. LPA conducted a physical plant walkthrough of the new expansion and observed the following: Facility expansion is a four story building with 35 bedrooms. Per Executive Director, the new expansion is for independent living residents. Bathrooms were equipped with necessary grab bars. Water temperatures for a sample size of 8 sinks were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected March 2025. Facility’s emergency pull cord system was being tested and reconfigured during LPA’s visit. Facility’s change of capacity is approved for licensure, effective today, 08/20/2025. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director and Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 20, 2025

Allegation investigated: Personal Rights Lack of staffing resulting in resident falls Reporting requirements Facility did not follow COVID protocols during an outbreak

At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with and Wellness Nurse, Melanie Fenn. During the course of the investigation, LPA requested and reviewed documents, conducted interviews, and made observations. LPA investigated the following allegations, “Personal Rights, Reporting Requirements, Facility did not follow COVID protocols during an outbreak, and Lack of Staffing resulting in resident falls.” “Personal Rights” – Complainant alleged that facility staff shove and push Resident 1 (R1) and other residents to get them to go somewhere. Complainant also alleged that R1 has poor hygiene because R1 has been observed with food on their face before and after meals and has been observed with dirty hands/nails and wearing dirty/stained clothes. Review of R1’s Functional Assessment dated 03/21/2024 indicated that Continued on LIC9099C Unsubstantiated Continued from LIC9099 they needed assistance with bathing and dressing, but was able to eat, walk and go to the bathroom independently. Review of R1’s Care Plan dated 08/08/2024 indicated that R1 could ambulate with a walker, required stand-by assist during showers, and needed verbal prompting and reminders for grooming and personal hygiene tasks. Interviews conducted with involved parties revealed conflicting statements. 8 of 9 interviews conducted stated that they did not observe R1 or other residents to be handled roughly. 2 of 9 interviews stated that R1 was observed to be in dirty clothes and have dirty hands and nails while 2 of 9 interviews were unable to provide additional information regarding R1’s care. 5 of 9 interviews stated that R1 was always observed to be clean and presentable. This allegation is Unsubstantiated. “Reporting Requirements” - Complainant alleged that facility did not contact R1's responsible party timely after a fall where R1 hit their head. Review of facility incident report received by the Department on 01/08/2025 showed that R1 had a fall on 01/07/2025 and showed that R1’s responsible party was contacted on 01/08/2025 by phone. On 04/07/2025, the Department received email correspondence from the Complainant where they retracted their statement that R1’s responsible party was not contacted. Per email received, R1’s responsible party was contacted on 01/08/2025 and was left a voicemail by the facility. Per Title 22 Regulations, 87211(a)(1)(4), the facility notified the Department within the appropriate time frame of 7 days of the incident occurring. This allegation is Unsubstantiated. “Facility did not follow COVID protocols during an outbreak” – Complainant alleged that facility did not follow COVID infection protocols during an outbreak that occurred July 2024. Review of Department’s system did not show reports of a COVID outbreak in July 2024 at the facility. Per California Department of Public Health, for employers, an outbreak was defined as “3 or more cases of COVID-19.” Interviews conducted with involved parties revealed conflicting statements. Some interviews stated that the facility had COVID at the end of July 2024 but were unable to recall how many cases there were while other interviews stated that the facility had two COVID cases or less at end of July 2024. Another interview stated that there was a COVID outbreak at the end of July 2024. This allegation is Unsubstantiated. Continued on LIC9099C Continued from LIC9099C “Lack of Staffing resulting in resident falls” – Complainant alleged that facility is understaffed and cannot provide the supervision that R1 requires. Complainant stated that a private caregiver was hired to help R1. Review of R1’s Service Plan dated 08/08/2024 indicated that R1 had a history of falls and required assistance or verbal reminders when transferring or walking due to having an unsteady gait. Interviews conducted also revealed conflicting statements regarding R1’s care needs. Some interviews stated that R1 only required a stand-by assist or verbal prompting for their ADLs (Activities of Daily Living) while other interviews stated that R1 required two-person assistance with certain ADLs such as showers. Review of R1’s Service Plan does not state that R1 was a two-person assist. LPA conducted interviews with involved parties and received conflicting statements. 4 of 9 interviews conducted stated they felt that there wasn’t enough staffing because they had to wait to be let out of the facility or could not provide or recall additional information related to staffing concerns. 5 of 9 interviews stated that the facility had enough staff for R1’s care needs. This allegation is Unsubstantiated. Based on interviews conducted, record review, and observations made, these allegations are Unsubstantiated. A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 1, 2025 · control 21-AS-20250109161946

Type of visit: Case Management - Annual Continuation

At approximately 9:20AM, Licensing Program Analysts (LPAs) Felias and Stevenson arrived unannounced to continue a 1 Year Required Visit, and met Health and Wellness Director (HWD), Melanie Fenn. Executive Director (ED), Mike Sharkey, arrived during visit at approximately 11:30AM. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Upon arrival, LPAs was informed that there were 32 residents in Assisted Living and Memory Care with 28 Independent Living residents for a total of 60 residents in care. LPAs was also informed that there were 26 staff members on-site. LPAs reviewed the Facility's Staff Roster with HWD and found that all staff members on site were background cleared and associated to the facility per regulation. LPAs reviewed staff files and resident medication. During staff file review, LPAs observed that 5 of 5 staff files had CPR certification, and 4 of 5 staff files were missing proof of first aid certification. Health and Safety Code 1569.618(c)(3), states that at least one staff member on-site is required to have first aid and CPR certification training. Per discussion with HWD, there is a nurse on every shift that has their first aid certification. LPAs observed proof of first aid certification for facility nurses during visit. HWD and ED informed LPAs that they will ensure all staff have their first aid certification (technical advisory issued, LIC9102, Health and Safety Code, 1569.618(c)(3)). Medication was centrally stored and secure. During visit, LPAs were informed that facility has a new Executive Director, Mike Sharkey, as of 12/30/2024. LPAs requested Administrator paperwork to be submitted to the Santa Rosa Regional Office in order to process the change of administrator. LPAs requested the following documents to be submitted for review: Administrator Documents · LIC 308 (Designation of Facility Responsibility) · Active and Current Administrator Certificate · First Aid Certificate · Administrator Resume · LIC 500 (Personnel Report) Continued on LIC809C Continued from LIC809 Administrator Documents Continued · LIC 501 (Personnel Record) · LIC 503 (Health Screening Report - personnel) · Proof of Negative TB test · LIC 9182 (Criminal Record Exemption Transfer Request) · Copy of Driver's License or Passport that is not expired · Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations) LPAs are requesting the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Updated Liability Insurance Active and Current Administrator Certificate Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 02/15/2025. No Deficiencies Cited during visit. Exit interview conducted. Copy of report, LIC9102 (Technical Advisory/Violation) discussed and provided to Executive Director and Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 15, 2025

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

Type of visit: Required - 1 Year

At approximately 10:20AM, Licensing Program Analysts (LPA) Felias arrived unannounced to conduct a 1 Year Required Visit, and met with Executive Director/Administrator, Shannon Brown, and Health and Wellness Nurse, Melanie Fenn. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Upon arrival, LPA was informed that there were 35 residents in Assisted Living and Memory Care with 28 Independent Living residents for a total of 63 residents in care. LPA was also informed that there were 26 staff members on-site. At approximately 10:45AM, LPA reviewed the Facility's Staff Roster with Health and Wellness Nurse and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 11:30AM, LPA conducted a walk-though of the facility with Health and Wellness Nurse and observed the following: Facility consists of multiple buildings for Assisted Living and Memory Care. Facility has an Extended Care unit which is a separate wing for Assisted Living residents that require a higher level of care. Facility also has independent living units on the property. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a Infection Control Plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 8 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected January 2024. Facility smoke detectors are hard wired and connect directly to the local fire station. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected January and August 2024. Facility's last emergency/disaster drill was conducted September 2024. LPA followed up on incident reports that were self-submitted to Community Care Licensing (CCL). Continued on LIC809C Continued from LIC809 Incident Report 1: CCL received an incident report from the facility on 05/03/2024. Report states that on 05/02/2024, Resident 1 (R1) was found outside on facility grounds by the Assisted Living building. Facility made all appropriate notifications per regulation. Review of R1's physician's report and care plan indicates that they are unable to leave unassisted but they do not have a dementia diagnosis. Incident Report 2: CCL received an incident report from facility on 06/19/2024. Report states that on 06/19/2024, Resident 2 (R2) was found on the floor. R2 was not observed to have any visible injury. Facility staff observed that R2 seemed to have had alcohol and found wine in R2's room. Facility identified that the wine was brought in by R2's family. Facility made all appropriate notifications per regulation. Review of R2's physician report indicates that they have a diagnosis of mild cognitive impairment. Incident Report 3: CCL received an incident report from the facility on 08/26/2024. Report states that on 08/26/2024, Resident 3 (R3) was found outside across the street. Per report, facility alarm system and R3's wander bracelet was operational and functional during incident. Facility identified that the garden exit was inoperable and needed a new lock. Facility had maintenance examine and secure the identified exit. Facility made all appropriate notifications per regulation. Review of R3's physician's report and care plan indicates they are unable to leave unassisted and has a dementia diagnosis (deficiency cited, see LIC809D and LIC421IM, Regulation 87705(b)(2)). At approximately 1:10PM, LPA reviewed resident files. Resident Files were all found to be well organized, thorough and contained the required documentation. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **A Civil Penalty in the amount of $1,000.00 is being issued today due to a repeat violation of Regulation 87705(b)(2) within a 12-month period. (See LIC421IM).** LPA unable to complete Annual visit. Annual Continuation visit to be conducted at a later date. Exit interview conducted. Copy of report, LIC809D, LIC421IM (civil penalty), LIC811 (Confidential Names), Plan of Corrections Letter, and Appeal Rights discussed and provided to Health and Wellness Nurse. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 15, 2024

Allegation investigated: Facility failed to meet resident's care needs

At approximately 10:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Executive Director/Administrator, Shannon Brown, and Health and Wellness Nurse, Melanie Fenn. During the course of the investigation, LPA Felias requested and reviewed documents, conducted interviews, and made observations. There is an allegation that Facility failed to meet resident's care needs. Reporting Party alleges that facility did not meet Resident 1’s (R1’s) care needs by not showering R1, not providing incontinence care to R1, and not giving R1 their suppository medication. Reporting Party also alleges that the lack of care resulted in R1 contracting sepsis from a urinary tract infection resulting in hospitalization. LPA conducted interviews with involved individuals. Per interviews, LPA was informed that a care conference meeting was conducted with the facility to address concerns regarding R1’s care. Continued LIC9099 Unsubstantiated Continued from LIC809 LPA was also informed that facility performed an enema for R1 after a suppository was requested. Supporting documents related to R1’s care was requested but per interview, were no longer available for LPA to review. LPA was unable to interview staff members that provided care to R1 during the time frame of January 2022 to June 2022, because the staff members were no longer employed at the facility or were unable to recall details related to R1. Review of R1’s Physician Report dated 12/28/2021 stated that R1 had a diagnosis of dementia and chronic kidney disease. Review of R1’s Functional Capability Assessment dated 12/31/2021, stated that R1 had a history of UTI and required total assistance with Activities of Daily Living (ADLs). Review of R1’s Communication Log stated that on 06/04/2022, R1 was assessed by facility staff where it was determined that R1 had a change in condition. Facility contacted Emergency Personnel to have R1 evaluated. LPA did not observe any other notes regarding R1’s care prior to this incident. R1’s Physician’s Orders dated 03/21/2022 indicated that R1 was able to receive a suppository, as needed, if their Milk of Magnesia was ineffective. There was no documentation to indicate that R1 needed a suppository and if it was given. Due to lack of evidence and available documentation, LPA is unable to determine if a violation of Title 22 Regulations occurred, therefore this allegation is Unsubstantiated. A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 29, 2024 · control 21-AS-20231115131419

Type of visit: Case Management - Incident

At approximately 10:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management – Incident visit and met with Executive Director/Administrator, Shannon Brown, and Charge Nurse, Melanie Fenn. The purpose of the visit is to follow up on incident report that were self-reported to Community Care Licensing (CCL). Incident Report 1: CCL received an incident report from the facility on 02/22/2024. Report states that on 02/21/2024, Resident 1 (R1) was observed to have a stage two coccyx wound. Facility provided first aid. Facility made all appropriate notifications per regulation. Per conversation with Administrator and Health and Wellness Nurse, R1 was observed to have the stage two wound on 02/21/2024. Per Physician communication, R1 is to be referred to Accent Care to receive an evaluation and specialist care. LPA was informed that Accent Care has already begun to oversee R1's wound care. Facility is communicating with Accent Care regarding R1's wound treatment and is documenting appropriately. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director and Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 29, 2024

Type of visit: Case Management - Annual Continuation

At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Executive Director/Administrator Shannon Brown, and Health and Wellness Director Melanie Fenn. Upon arrival, LPA was informed that there were 67 Residents in care and 9 staff members on-site. At approximately 9:45AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA reviewed staff files, resident files and resident medications. Files were found to be well organized, thorough, and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was found to be centrally stored and secure. LPA conducted interviews. LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Saturday, 01/06/2024. Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Dec 6, 2023

Type of visit: Office

An Informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager (LPM) Kimberley Mota, Licensing Program Analyst (LPA), Caitlynn Felias, and Administrator/Executive Director, Shannon Brown, and Health and Wellness Director, Melanie Fenn. The purpose of the Informal meeting was to address an incident that occurred on 09/13/2023 where Resident 1 (R1) went missing during a community outing at approximately 12:45PM. R1 was found safe in a nearby neighborhood at approximately 7:45PM. Items addressed during today’s meeting: · Facility’s procedures regarding community outings, resident elopements and absence without leaves (AWOLs) · Staff Training for residents with dementia and elopements · Incident Report received by Community Care Licensing (CCL) on 10/16/2023. Incident Report received stated that Resident 2 (R2) eloped from the facility on 10/15/2023. R2 was found by local police approximately two blocks away from the facility. Facility made all notifications per regulation. Review of R2’s Physician Report and Care Plan indicated that they are unable to leave the facility unassisted (This deficiency has been cited, see LIC809D and LIC421IM, Regulation 87705(b)(2)). Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **A Civil Penalty in the amount of $1,000.00 is being issued today due to a repeat violation of Regulation 87705(b)(2) within a 12-month period. (See LIC421IM).** Exit interview conducted. Copy of report, LIC809D, LIC421IM, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 18, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Oct 19, 2023

87705 Care of Persons with Dementia: (b) In addition to the requirements as specified in Section 87208... plan of operation shall address... residents with dementia, including: (2) Safety measures to address behaviors such as wandering... This requirement is not met as evidenced by: Based on documents reviewed, the Licensee did not comply with the section cited above. Resident 2 (R2) eloped from facility and was found 2 blocks away. R2’s Physician Report states they have dementia. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: Licensee to submit a written plan of updated procedures for elopement prevention. Licensee to submit documentation regarding delayed egress doors and to conduct an In-service training with all care staff regarding Elopement Procedures by POC due date of 10/19/2023. In-service training to include the following: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date of 10/29/2023.