Allara Senior Living

Type of visit: Required - 1 Year

On 7/23/2026 Licensing Program Analyst (LPA) LaVette Farlow made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA was greeted and granted entry by Concierge Darlene Seno. LPA was escorted to the private dining room to work. LPA later met with Facility Executive Director, Roger Endert and Director of Health and Wellness, Jessica Padron. The facility is a Residential Care Facility for Elderly (RCFE), Licensed capacity is (120) current census (109). LPA Farlow was accompanied by Jessica to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected residents bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms, and showers. The water temperature in the shower tested at 118.9 degrees F. LPA was unable to get an accurate reading from the residents sink due to the sink having a motion sensor and the water did not run for a sufficient amount of time. A Technical Advisory issued. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inside Med-Room inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. LPA did observe a storage self with expired can good that needed to be destroyed and removed. The Director of Culinary Services advised LPA that those items are no longer in inventory and we are in the process of destroying them. The Director had the items removed immediately. A Technical violation issued. LPA conducted a tour of the Memory Care unit, during the tour LPA observed a knife on the counter on the side of the microwave and a pair of scissors in the kitchen drawer unsecured. Jessica immediately secured both items. A Deficiency cited. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed eleven (11) resident files for admission agreements, updated physician reports, TB test results and needs and services plans. LPA Farlow also reviewed eleven (11) staff files for First Aid/CPR certification, criminal record clearance, training, health screening and TB test results. Residents and staff files appeared to be maintained. Medications were audited at random for several residents in care. LPA observed that one (1) residents centrally stored medication data did not match with the medication being dispensed. Also, LPA observed another resident bubble pack has a medication still remaining in the bubble pack that wasn't issued on the 21st of July, and there wasn't an explanation to explain why the resident did not receive the medication. Deficiencies cited. Based on the observations made during today’s visit, two (2) deficiencies, one (1) technical violation and one (1) technical advisory were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report LIC809, LIC809C, LIC809D, and appeal rights was discussed and provided to Roger Endert, Executive Director and Jessica Padron, Director of Health and Wellness.the state’s words, verbatim · CDSS document, Jul 23, 2026

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 - Health Checks

Licensing Program Analyst (LPA) LaVette Farlow arrived at the facility unannounced to conduct a Case Management- Health and Safety check. This case management visit is in response to a Special Incident Report (SIR) submitted to the Community Care Licensing Office on 04/08/26. LPA was greeted and granted entry into the facility by Sandra Guzman, Lead Concierge. Sandra notified the Business Office Director Becky Morales-Melo of LPA's arrival and later meet with LPA. LPA introduced self and explained the purpose of the visit. On 04/07/2026, it was reported that staff 1 (S1) violated resident 1 (R1) personal rights by speaking to them inappropriately, grabbing R1 in an aggressive manner, and toasting R1 personal belongings. During today's visit, LPA discussed the incident and events surrounding the investigation with Becky. LPA conducted a health and safety check, toured the facility, and reviewed records. During record review and staff interview it was revealed from the conclusion of the facilities internal investigation a total of three staff were terminated or resigned from the facility. A Deficiency was issued during this visit. An exit interview was conducted where this report LIC809, LIC809D and appeal rights were, reviewed, discussed and then provided to Business Office Director, Becky Morales-Melo.the state’s words, verbatim · CDSS document, Apr 22, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 15630(b)(1) · Plan of correction due date: Apr 22, 2026

Welfare and Institutions Code section 15630(b)(1) Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed... of an incident that reasonably ...physical abuse, as defined in ...or neglect, or is told by an elder or dependent adult that he or she physical abuse, ...report the known or suspected...within two working days. Based on interviews, the facility staff did not comply with the section cited above by not ensuring the staff adhere to the mandating reporting requirement which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Administrator agreed to conduct an in-serve on reporting requirement with staff and the Health and safety code for abuse 15630.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) LaVette Farlow arrived at the facility unannounced to amend findings for 56-AS-20240918154011. LPA introduced self and stated the purpose of the visit to Jessica Padron. During today's visit, LPA amended the report and discussed the updated findings. No deficiencies were observed during this visit. An exit interview was conducted where this report was, reviewed, discussed and then provided to, Jessica Padron.the state’s words, verbatim · CDSS document, Oct 2, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) LaVette Farlow made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Facility Executive Director Matt Ryan and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE), Licensed capacity is (120) current census (108). LPA Farlow was accompanied by Building Service Director, Daniel Belk and Resident Care Director, Jessica Padron to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected residents bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms, and kitchen to be at 112.2 and 107.5 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inside Med-Room inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed nine (9) resident files for admission agreements, updated physician reports, and needs and services plans. LPA Farlow also reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report LIC809 and LIC809C was discussed and provided to Matt Ryan, Executive Director and Jessica Padron, Resident Care Director.the state’s words, verbatim · CDSS document, Sep 22, 2025

Allegation investigated: Staff handles resident in a rough manner. Staff did not provide 60-day notice prior to rent increase.

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to deliver findings on the allegations mentioned. LPA met with Administrator Matt Ryan and explained the purpose of the visit. The investigation consisted of interviews with facility staff, outside parties, resident and records review. Regarding allegation staff handles resident in a rough manner, The evidence collected was insufficient to substantiate the allegation. Photographs taken by outside parties over time documented various bruises and scratch marks on R1’s arms and legs. According to care staff, R1 often sustained these injuries due to the way they moved around in their wheelchair and swinging arms behind it. Care staff reported that R1’s arms and legs sometimes got caught on their wheelchair, requiring assistance, and these incidents often led to marks and bruises. R1 stated they received good care at the facility and that everyone treated them well. R1 mentioned that all the marks on them were accidental and denied being hit by anyone. Unsubstantiated There is no documentation of a fall or incident prior to 1/6/2023. Interviews with former facility staff recall an incident around that date in which R1 may have fallen while being assisted by a staff person. An interview with R1 reported that a caregiver was assisting them and stated that the caregiver was unable to support R1 properly, leading to the fall. R1 fell on the wheelchair hitting the side of their body on the arm rest and fractured the ribs. R1 reported being in pain and called a family member to seek medical treatment. The lack of documentation shows that the facility staff neglected to get R1 medical care in a timely manner. The facility did not document the incident, provide timely medical care, nor communicated the incident to R1’s family. The Licensee is cited per violation of Title 22, California Code of Regulations. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that an additional civil penalty may be assessed based on Health and Safety Code § 1569.49. The above allegation(s) is found to be SUBSTANTIATED. A deficiency is being issued per California Code of Regulations, Title 22. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. An exit interview was conducted where this report (LIC 9099), LIC 9099D, LIC 421IM was discussed, and a copy was provided, along with a copy of the appeal rights to Administrator Matt Ryan Regarding the allegation that staff did not provide a 60-day notice prior to the rent increase, interviews with facility staff indicated that rent increases occurs every year on April 1st. However, R1's rent was increased in the month of October, however the increase was due to the level of care being increased from a Level 7 to a Level 8. Per the admission agreement the increase of care is effective immediately. Therefore, the alleged allegations has been determined Unsubstantiated. Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Administrator Matt Ryan.the state’s words, verbatim · CDSS document, May 22, 2025 · control 56-AS-20230927162154

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 7, 2025

87468.2 (a) (4) Additional Personal Rights of Residents in Privately Operated Facilities:(a)(a) 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 is not met as evidenced by: Based on interviews conducted and record review, while facility staff assisted R1, staff lost balance and caused R1 to sustain injuries. This violation posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: The licensee shall conduct in-service training to all staff in regard to the residents’ personal rights. Proof will be submitted to the Department by POC due date

Allegation investigated: Staff do not distribute residents' medications as prescribed Staff handled resident in a rough manner

On 05/15/2025 at 1:30PM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA discussed the purpose of the visit with Resident Care Director, Jessica Padron. The investigation consisted of interviews and record review. In regards to the allegation of staff do not distribute residents' medications as prescribed: LPA interviewed ten (10) staff, (5) residents and relatives of residents. All of staff have denied the allegation stating that they have been trained and follow the facility policy if an error is made with medication. Staff stated that most residents are aware of what medications are needed and when they need to be taken. Residents stated that they received their medication and do not have any concerns. The relatives of residents have stated that their family member receives their medication as prescribed. LPA audited residents’ medication and reviewed the Medication Administration Record (MAR) and did not observe any issues or concerns. Based on interviews, observation and record review, this allegation is UNSUBSTANTIATED. Unsubstantiated In regards to the allegation of staff handled resident in a rough manner: LPA interviewed ten (10) staff, five (5) residents and relatives of residents. All of the staff that were interviewed denied the allegation of handling resident in a rough manner. Residents are treated kindly and with respect. Residents and their relatives have stated that staff are great and treat the residents well. They denied witnessing staff handle residents in a rough manner. Based upon interviews, this allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where this report LIC9099, LIC9099C was discussed and a copy was provided to Business Office Director, Helen Jaquez.the state’s words, verbatim · CDSS document, May 16, 2025 · control 56-AS-20250422164144

Allegation investigated: Staff did not assist resident(s) with personal care

Licensing Program Analyst (LPA) LaVette Farlow arrived to facility to conduct a complaint investigation regarding the above allegation. LPA Farlow met with Executive Director Matt Ryan and explained the elements of the complaint. Regarding the allegation that Staff did not assist resident(s) with personal care. LPA interviewed eight (8) out of eight (8) staff and the interview reveal that staff are assisting residents with personal care. Inteview with S5, and S6 revealed that S8 is not assisting staff with resident in care or is not available to assist staff. LPA interviewed eleven (11) out of eleven (11) residents in care. Eleven out of eleven resident in care revealed that they did not have any concerns or issues with staff providing personal care. LPA interview revealed that 5 out of 11 resident needed assistance with showers, in and out of wheelchair, or in and out of bed. LPA's interview with those 5 residents in care stated that staff are very helpful and assistance them without any issues. During todays visit LPA observed staff assisting residents in care and ensuring their personal needs were met. ***continued on LIC 9099C*** Unsubstantiated Based on the information obtained there is not enough evidence that staff did not assist resident(s) with personal care. Therefore, the allegation are deemed UNSUBSTANTIATED at this time. Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report LIC 9099 and LIC9099C was discussed, and a copy was provided Melissa Oseguera, Vibrant Life Director, at the end of the visit.the state’s words, verbatim · CDSS document, Apr 24, 2025 · control 56-AS-20250422081702

Allegation investigated: Staff do not ensure that resident's personal belongings are safeguarded Staff do not ensure that residents' rooms are clean and sanitary Staff do not ensure that residents' incontinence needs are being met

Licensing Program Analyst (LPA) LaVette Farlow arrived to facility to conduct a complaint investigation regarding the above allegations. LPA Farlow met with Executive Director, Matt Ryan and explained the elements of the complaint. Allegation 1: Staff do not ensure that resident's personal belongings are safeguarded: Regarding the first allegation staff do not ensure that resident's personal belongings are safeguarded. LPA's investigation revealed that 11 out of 12 resident reported not having any issues or concerns with staff safeguarding their personal belongings. R1 reported that Staff 11 (S11), changed the way the mail was received and deliver and R1 did not give consent to the changes. Interview with S11 revealed the changes were made by the hospice company to ensure the residents items were secured and safeguarded. S11 also stated the staff that normally handle the mailing process was on leave. S11 stated R1 items were secured in my office. LPA interviewed 11 out of 11 staff regarding the allegation of staff do not ensure resident personal belongings are safeguarded. ***continued on LIC 9099C*** Unsubstantiated 11 out of 11 staff stated they haven't heard or experienced any problems with residents personal belongings not being safeguarded. Throughout the investigation process, it was found that the allegation #1 Staff do not ensure that resident's personal belongings are safeguarded is UNSUBSTANTIATED. Based on the fact that resident items were secured in staff office due to staff being on leave and changes were made from hospice staff to ensure items are secured. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation 2: Staff do not ensure that residents' rooms are clean and sanitary. LPA interviewed 12 out of 12 residents in care and it was revealed that residents are pleased with staff cleaning their rooms and assisting with sanitation needs. Residents stated staff come to clean once a week or as needed. Residents stated staff clean the kitchen, bathrooms, vacuum, take out the trash, do the laundry and change the sheets. LPA interviewed 11 out of 11 staff and it was revealed that staff ensure residents rooms are clean. Staff stated the take out the trash, change sheets, and tidy up. Housekeeping complete a deep cleaning weekly. LPA toured several resident apartment during my visit and based on my observation residents apartment were clean and sanitation maintained. Based on the investigation process, it was found that the allegation #2 Staff do not ensure that resident's room are clean and sanitary is UNSUBSTANTIATED. Based on staff and resident interviews and LPA's observation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation 3: Staff do not ensure that residents' incontinence needs are being met. LPA interviewed 12 out of 12 residents in care and it was revealed that 12 out of 12 residents require minimal or no assistance with incontinence needs. 5 out of 5 residents stated that staff assist them without any problems or issues. LPA interviewed 11 out of 11 staff and it was revealed that staff ensure residents incontinence needs are met. Staff stated it may take a moment to get to a residents room because we are assisting another resident in care, but we make it a point to clean all residents and assist with incontinence needs. Based on the investigation process, it was found that the allegation #3 Staff do not ensure that resident's incontinence needs are being met is UNSUBSTANTIATED. Based on staff and resident interviews. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted where this report LIC 9099 and LIC9099Cs was discussed, and a copy was provided Melissa Oseguera, Vibrant Life Director, and Christin Farrell, Generation Program Director, at the end of the visit.the state’s words, verbatim · CDSS document, Apr 24, 2025 · control 56-AS-20250110144612

Allegation investigated: Personal rights Staff did not give medications according to physician's orders.

Licensed Program Analysts (LPA) Lavette Farlow, conducted an unannounced visit to the facility to conduct a investigation. LPA was granted entrance into the facility by front desk staff. LPA identified self to staff. LPA was escorted to private dinning room where I was introduce to the Interim Administration Ted Burgess and discussed the purpose of the visit. LPA conducted interviews with staff and residents, reviewed and obtained documents and did a walk-through of the facility. First allegation, Personal rights. LPA conducted interviews with staff, LPA asked staff if resident's personal rights were being violated, all indicated that no resident's personal rights are being violated. LPA asked if anyone had observed staff yelling at residents in care, and not treating residents with dignity and respect, all denied witnessing other staff violate residents in care and not treating them with dignity and respect or yelling at residents. LPA asked if staff violated residents privacy rights by not knocking on residents in care door prior to entering their room or apartment or by not announcing themselves prior to entry in residents in care room or apartment, all denied witnessing staff violate residents privacy and stated we all knock and announce ourselves prior to entry. LPA conducted interviews with resident, LPA asked 9 residents if their personal rights were being violated, 8 out of 9 residents indicated that their personal rights are not being violated by staff. LPA asked resident if they have witnessed staff violate resident personal rights, 8 out of 9, stated that they have not witnessed staff violate other resident’s personal rights while in care. During the LPA's tour and investigation, LPA made several attempts to make contact with R1 by knocking on the door and ring doorbell, but R1 did not hear the doorbell due to R1 not having hearing aid in place. R1 instructed me to come closer so, R1 could hear me and asked that I give R1 a moment so R1 could put the hearing aid on. Unsubstantiated Second allegation is Staff did not give medications according to physician's orders. LPA conducted interviews with staff, LPA asked staff if residents are complaining about not receiving there medication or staff did not give medications according to physician's orders, all indicated that residents in care receive all scheduled medication. Although there is a chance that a resident might receive the medication 15-30 minutes before or after the scheduled time due to the medication rounds. LPA asked staff if they have witnessed other staff not give medications according to physician's orders, all stated that they have not witnessed other staff not administer medication according to the physician's orders. LPA conducted interviews with residents and asked clients if they are receiving their medication as schedule and according to physician's orders, and during my investigation if was found that some residents administer their own medication and the others stated they received the medication as schedule daily. Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated. Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided Interim Administrator Ted Burgess at the end of the visit.the state’s words, verbatim · CDSS document, Nov 5, 2024 · control 56-AS-20241029144831

Allegation investigated: Staff did not follow residents DNR

Licensed Program Analysts (LPA) Lavette Farlow, conducted an unannounced visit to the facility to conclude an investigation and deliver findings. LPA was granted entrance into the facility by staff. LPA identified self to staff and discussed the purpose of the visit. LPA was escorted to private dinning room where I was introduce to the Interim Administration Ted Burgess and discussed the purpose of the visit. During today's visit LPA conducted interviews with staff, reviewed and obtained documents and did a walk-through of the facility. First allegation, It is alleged that staff did not follow resident DNR orders (Do Not Resuscitate). Interviews with staff, witnesses, and upon reviewing of residents facility file revealed that R1 did have a DNR order at time of death dated 12/22/2023. It was also, revealed that staff did attempt CPR and to resuscitate resident in care. Substantiated Based upon investigation findings, the allegation is found to be substantiated. Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Citation issued on the attached LIC 9099D in accordance with Title 22, Div 6, Chap 8.the state’s words, verbatim · CDSS document, Nov 5, 2024 · control 56-AS-20240918154011

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.73(c)(2) · Plan of correction due date: Nov 19, 2024

1569.73(c)A facility that has obtained a hospice waiver.. department...call emergency response services at the time of a life-threatening emergency... (2) The resident has.. advance directive, ...Section 4605 of the Probate Code, requesting to forego resuscitative measures.this was not met by.. Licensee did not comply with the section cited above by not ensuring staff were aware of residents in care DNR orders for R1 which resulted in staff taking resuscitation measure which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 5, 2024

Plan of correction: Facility will certify on LIC 9098 that Administrator and staff have reviewed and understand regulation section1569.73 (c)(2). Also, implement other measure to notify staff who has a DNR.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Beena Singh and Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPAs met with Facility Resident care Director-Jessica Padron and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) Level 3, Licensed capacity is (120) current census (104). (LPAs) Beena Singh and Paola Guerrero was accompanied by Facility Executive Leadership, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPAs inspected residents bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. LPAs measured and observed the water temperatures in the bathrooms to be at 119.8 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inside Med-Room inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPAs reviewed four (6) resident files for admission agreements, updated physician reports, and needs and services plans. LPAs Beena Singh and Paola Guerrero also reviewed five (6) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. PNI funds were counted for and matched with the ledger. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Resident care Director Jessica Padron.the state’s words, verbatim · CDSS document, Oct 24, 2024

Allegation investigated: Staff did not provide resident's records to authorized representative.

On 06/27/2024 at 09:30 AM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility to initiate and deliver findings for the mentioned allegation. LPA Brown was greeted and granted entry by a staff and LPA Brown met with Business Office Director Helen Jaquez. Executive Director (ED) Patricia Gustin was contacted and arrived during the visit. LPA Brown met with ED Gustin and LPA Brown informed ED Gustin of the purpose of the visit. The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The allegation indicates that Staff did not provide resident's records to authorized representative. LPA Brown obtained evidence to corroborate the allegation above. Interviews with Staff #1 (S1), Staff #2 (S2) and Staff #3 (S3) all indicated that they submitted the documents requested to their legal department. S1 reported to LPA Brown that they submitted the complete file requested to their legal department on 06/19/2024. ***Continuation in LIC9099C*** Substantiated During this visit, S1 reported to LPA Brown that their Legal Department sent Resident #1 (R1) records to R1’s authorized representative on 06/21/2024. Per documents review and interviews conducted, R1’s authorized representative requested R1’s records on 06/06/2024 and the facility did not make the documents available to R1's authorized representative as required per Title 22 Division 6 Chapter 8 Article 8 Resident Assessments, Fundamental Services and Right 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(19). Based on LPA Brown’s observations and records review, the preponderance of evidence standard has been met, and therefore the above allegation of Staff did not provide resident's records to authorized representative is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC9099D. An exit interview was conducted where this report, LIC9099, LIC9099D, and Appeal Rights were discussed and provided to Executive Director (ED) Patricia Gustin.the state’s words, verbatim · CDSS document, Jun 27, 2024 · control 56-AS-20240621151145

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Jul 8, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) 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.. (19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed... This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by not providing Resident #1 (R1) records to R1 representative as required as evidenced of the facility provided R1's records to R1's Representative on 06/21/2024 which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 27, 2024

Plan of correction: Licensee stated to train all staff on CCR 87468.2(a)(19) and submit proof of all staff training log to LPA Brown on Plan of Correction (POC) due date.

Allegation investigated: Resident sustained an unexplained injury while in care Staff did not provide adequate care and supervision to a resident

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Patricia Gustin and explained the elements of the complaint. Regarding the allegation that resident sustained an unexplained injury while in care; Staff #1 (S1) interview reveal that resident #1 (R1), in question, was dressed in the AM and did not observe any injuries to R1 during S1's shift. Interview with staff #2 (S2) revealed the R1 is on blood thinners and is susceptible to bruising, but S2 did not observe any injuries to R1. R1 resided at the facility for approximately 31 hours and was not available for interview or observation for any injuries or the care received at the facility. ***continued on LIC 9099C*** Unsubstantiated Interview with staff #3 (S3) states that hourly checks were conducted with R1 as all new resident are. S3 stated that R1 was assisted by S3 with eating. S3 stated that R1 had no injuries throughout the day, but did observe a small bruise on R1's leg when 911 was called to attend to R1 on an unrelated medical matter. S3 stated bruise was not on R1's person throughout the day. Regarding the allegation that staff did not provide adequate care and supervision to a resident; Staff interviews reveal the R1 was dressed by two (2) staff members, assisted with feeding and seen by the med tech staff in the short time R1 resided at the facility. Staff called 911 services for R1 and medical staff were present at that facility to address R1's needs right away. Based on the information obtained there is not enough evidence that resident sustained an unexplained injury while in care and staff did not provide adequate care and supervision to a resident . Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Gustin and a copy was left with the facility.the state’s words, verbatim · CDSS document, Jun 10, 2024 · control 56-AS-20240606103223

Allegation investigated: Facility Staff did not respond to resident's pendant in a timely manner. Staff left resident in soiled diapers for an extended period of time. Staff do not provide adequate food service to residents in care. Staff did not ensure that facility dishes were properly sanitized.

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Allara Senior Living Residential Care Facility for the Elderly to initiate a complaint investigation into the allegations listed above. LPA introduced self and stated purpose of the visit. LPA met with Patricia Gustin, Executive Director. Today's visit consisted of staff and resident interviews, a walk through of the facility and collection of pertinent documents. It is alleged that facility staff did not respond to resident's call pendant in a timely manner. Observations of the facility call light system revealed that when resident's trigger their call lights, caregivers and medication technicians are notified via pager system and respond by going to the residents room. Executive Director reports that the facility is fully staffed at this time. Also, frequently works with Resident Care Director to address all staffing. During interviews residents revealed that call lights are answered within a reasonable time frame. According to Building Services Director, Mark Cunningham all personal pendants for residents and their rooms are in good condition and working order. Unsubstantiated It is alleged that staff left resident in soiled diapers for an extended period of time. LPA walked through the facility and did not make observation of residents being left in soiled depends. LPA did not observed lingering odors that would indicate soiled linens or depends are left unattended. Staff deny that residents are left in soiled linens and/or depends for long periods of time. Residents deny that staff leave them in soiled linens and/or depends. Residents report that all of their incontinence needs are addressed when needed. It is alleged that staff do not provide adequate food service to residents in care. Residents report that the food services provided are adequate and meet their needs. Residents report entering the dining room, being waited on and served happen within 10 to 15 minutes of their arrival. During walk through of the dining room and kitchen, LPA observed a variety of beverages, fruits, breads, and snacks available and accessible to residents to pick up and take along with them. The dining room contained adequate amounts of seating and space for the residents in care. LPA found that the kitchen contained a sufficient amount of food for the number residents in care. LPA also observed well maintained storage spaces to house the food and food services department. Dishes, utensils and cook ware were also observed to be in good condition with proper storage. Staff denied that residents are waiting for long periods of time for assistance with eating their meals. It is alleged that staff do not ensure the facility dishes were properly sanitized. All kitchen staff deny that they were ever advised to wash/sanitize dishware, utensils, and cook ware without proper supplies or materials to sanitize the equipment. Staff report that they have always had all supplies required to properly sanitize dishes, utensils and equipment used in food preparations. According to Building Services Director, the kitchen's dishwasher is in functional condition. All staff denied that the dishwasher was ever in disrepair. LPA observed the facility kitchen during the visit and observed kitchen equipment in working condition and adequate amounts of cleaning supplies. Based on observations, interviews and record reviews, the above listed allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted. This report was reviewed and discussed with facility representative; then provided.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 56-AS-20231121172525

Type of visit: Case Management - Deficiencies

Licensing Program Analyst, Amber Coleman, (LPA) made an unannounced complaint visit for complaint 56-AS-20231121172525. It was during this visit, LPA’s observed deficiencies not related to the complaint allegations. LPA reviewed resident records and observed that three resident records contained Physician's Reports (LIC602) that were outdated. Staff interviews revealed that the facility had not had the resident's Physician's Reports completed with in the regulated time frame. LPA and staff worked together to coordinate getting the residents Physician's Reports completed. Resident Care Director agreed to work with the residents, their families and primary care physician's to have the Physician's Report completed. Based on record reviews, a deficiency is being cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Facility Representative; signature acknowledges understanding and receipt of report and attachments.the state’s words, verbatim · CDSS document, Nov 30, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80069(1)(a) · Plan of correction due date: Dec 15, 2023

80069 Client Medical Assessment The assessment shall be performed by a licensed physician or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained. This requirement is not met as evidenced by: Based on a review of records, Administrator did not ensure 3 resident's files contained current (annual) Physician's Peports within the regulated timeframe which poses a potential Health, Safety, and/or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 30, 2023

Plan of correction: Administrator agrees to work with the residents, their families and primary care physicians to obtain a current medical assessment. Administrator agrees to submit verification that the Physician's Reports were completed to the Community Care Licensing Office within the following 14 business days.

Type of visit: Case Management - Incident

Licensing Program Analyst, Amber Coleman, (LPA) arrived at Allara Senior Living Facility, Residential Care Facility for the Elderly to conduct a Health and Safety Case Management Visit. This Case Management visit is in response to a Special/Unusual Incident Report, (SIR) called into the Community Care Licensing Office by voicemail on 10/26/23. LPA met with Business Office Manager, Helen Jaquez, introduced self and stated purpose of the visit; which is to gather more information about the incident and surrounding events. The incident reported occurred 10/26/23 at approximately 5:30pm, R1 departed the facility through an unlocked door of the Memory Care Unit. R1 walked to the main street (19th Street) was witnessed by a bystander who contacted the Police. The Police transported R1 to the station, contacted the facility to confirm, and returned the resident back to the facility. Today's visit consisted of a walk through of the Memory Care Unit, observation of the door and route R1 used to depart facility, staff interviews and record reviews. According to staff interviews, on 10/26/23 during the 2pm to 10pm shift; there were 4 staff members assigned to the floor. At approximately 5:30pm, 2 staff left the floor for break. Leaving 2 staff members on the floor. There were no witnesses to the resident's departure. LPA was informed that the memory care unit is a secure unit. When the door is opened an alarm is supposed to sound, but the door alarm failed. Its unknown how often the doors and alarms are checked. At this time, parts have been purchased to fix the alarm and staff is in the process of contacting the alarm company to schedule an appointment. Until the door, lock and alarm can be fixed, a staff member has been stationed to the door. Resident checks have been increased to provide rounds or checks every 30 minutes. R1 was assessed upon the return to the facility. According to staff, R1 had no apparent injuries to her person. Please see LIC809-C At approximately 2:30pm LPA was provided a copy of R1's Physician's Report. LPA observed that the document was missing a signature of the R1's representative. The report indicates R1 cannot leave the facility unassisted. Mental condition includes wandering. Based on observations, record reviews and staff interviews deficiencies will be cited to address the above mentioned concerns.the state’s words, verbatim · CDSS document, Oct 27, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80078(a) · Plan of correction due date: Oct 30, 2023

80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by: Based on interviews and record reviews, the Administrator failed to ensure the resident had assistance/supervision before leaving the facility on 10/26/23. Additionally, not ensuring the unit was secure to prevent R1 from departing facility; which posed an immediate Health, Safety and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: During the visit, Vortex staff was dispatched to fix the door before the end of the day. Staff. Caregivers/Staff has been increase from 2 caregivers to 3 caregivers to provide additonal support for the memory care unit on going. Administrator agrees complete a statement of understanding by way of a LIC9098 and submit this LIC9098 to the Community Care Licensing Office by 10/30/23

Type of visit: Case Management - Other

Licensing Program Analyst, Amber Coleman, (LPA) made an unannounced case management visit to obtain signatures for an amended report. LPA met with staff, introduced self and stated purpose of the visit. LPA obtained signatures and completed report. An exit interview was conducted where this report was discussed and provided to facility representative.the state’s words, verbatim · CDSS document, Oct 5, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Facility Executive Leadership Ted Burgess and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (120) current census (69). LPA was accompanied by Facility Executive Leadership, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected residents bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be at 119.8 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inside Med-Room inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed four (5) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. PNI funds were counted for and matched with the ledger. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Executive Leadership Ted Burgess.the state’s words, verbatim · CDSS document, Oct 2, 2023