Almond Heights

Allegation investigated: Staff do not ensure the facility is kept free of scabies due to neglect.

On 7/28/26, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to do complaint investigation into the allegations listed above and met with Lori Spencer, Regional Director Of Sales & Operations. LPA investigated the allegation of “ Staff do not ensure the facility is kept free of scabies due to neglect ". LPA reviewed resident and facility records , conducted facility tour and interviewed 3 staff regarding the outbreak. LPA interviewed administrator in which they stated there has not been a scabies outbreak within the facility. Staff interviews indicated that there were cases of scabies in the past months but they were cleared and there are no cases of scabies for any staff or residents at the facility at this time. LPA conducted facility tour during today's visit and did not observe any issues with this matter. Based on interviews conducted, a review of staff and resident records, and the documentation that residents were examined and there was no diagnosis of scabies at the facility, this allegation is UNFOUNDED, meaning the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Jul 28, 2026 · control 59-AS-20260724082611

Allegation investigated: Staff did not follow infection control protocols. Staff did not ensure that facility is free of pests. Staff are not meeting residents' needs. Staff did not seek medical attention for residents.

On March 23, 2026, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Director of Health Services Eva Bowlin. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unfounded Allegation- Staff did not follow infection control protocols.-UNFOUNDED Based on observation, record review, and statement reviewed, the facility was following universal precautions. As a precaution, during the first sign of a rash, facility puts out PPE outside the resident room, notifies staff of the potential of scabies, and an in-service to staff is reviewed on proper handwashing and universal precautions. Facility encouraged residents to stay in their rooms during the episode. It was observed facility had required PPE outside the residents rooms; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Allegation- Staff did not ensure that facility is free of pests. UNFOUNDED Based on documents obtained and statements reviewed, the department determined that there was insufficient evidence that the facility is not kept free of pests. The facility representative stated that the pest control company comes in monthly, and more often as needed. The department reviewed Pest Control dates for the monthly visits for 2025, 2026 which did not indicate any concerns. The pest control company is continuing to monitor any pest activity. Four (4) staff and four (4) residents were interviewed and stated they have not seen any pests at the facility. During the department visits, the facility was toured and there were no concerns that were noted about this area. Therefore, the above allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Allegation- Staff are not meeting residents' needs. Staff did not seek medical attention for residents. UNFOUNDED Based on interviews with four (4) staff and four (4) residents, the Department determined that there are enough staff present to meet the needs of the residents in care and that staff seek timely medical attention. Staff stated they know the protocol on how to address any medical intervention, and residents had no concerns with timely medical attention. Therefore, the allegations are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Mar 23, 2026 · control 59-AS-20260205091546

Allegation investigated: Staff are not properly addressing scabies outbreak. Staff not ensuring proper hygiene of resident. Staff did not provide privacy for resident in care.

On March 23, 2026, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Director of Health Services Eva Bowlin. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unfounded Allegation- Staff are not properly addressing scabies outbreak. UNFOUNDED Based on observation, record review, and statement reviewed, the facility was following universal precautions. As a precaution, during the first sign of a rash, facility puts out PPE outside the resident room, notifies staff of the potential of scabies, and an in-service to staff is reviewed on proper handwashing and universal precautions. Facility encouraged residents to stay in their rooms during the episode. It was observed facility had required PPE outside the residents rooms. Furthermore, facility notified all required agencies and followed local health department guidelines to address this matter, therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Allegation- Staff not ensuring proper hygiene of resident. Staff did not provide privacy for resident in care. UNFOUNDED Based on staff interviews, resident interviews, and department observation, the department observed the facility to be clean and sanitary. During department visits on several occasions, including on 3/23/26, the department did not observe any issues regarding facility and was not following regarding proper hygiene of residents. The facility did not observe to be unsanitary including resident rooms, common areas and restrooms. Residents stated the caregivers clean the facility and take out the trash frequently. Residents stated that their hygiene, toileting, and laundering needs are being met and that housekeeping, and the staff, do a great job. Staff interviews indicated that the facility is kept clean and sanitary without any concern. Residents and staff interviews indicated that staff treat residents with respect and dignity and there were no concerns; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Mar 23, 2026 · control 59-AS-20260311110951

Type of visit: Required - 1 Year

On 3/23/26, Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived unannounced to conduct the annual inspection. LPAs met with Director of Health Services, Eva Bowlin and explained the purpose of the visit. LPAs toured facility with to ensure the health and safety of residents in care. LPAs toured residents rooms, medication room, bathrooms, kitchen, dining room, common areas and activity areas. LPAs observed residents in common areas participating in activities and in the dining room having lunch. The facility was found to be clean, safe, sanitary and in good condition. LPAs observed the facility to have the mandated posters posted. Fire extinguishers are maintained and ready for emergency use. Facility has required food supplies. There are appropriate staff present to meet the needs of residents. Inside temperature was 72-74 degree F. Hot water measured between 113-117 in three different areas at facility was in required range 105-120 degree F. Facility was conducting fire and disaster drills per requirement. LPAs reviewed eight (8) residents files and five (5) staff files. Staff records reviewed indicated training completed and other required paperwork. Residents files found to have required documentation. LPAs observed that medications were secured and were inaccessible to residents. LPAs completed the full care tool and no deficiencies were observed or cited per Title 22 Regulations. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Mar 23, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 11/25/25 to conduct a case management inspection to follow up on a choking incident on 11/10/25 and 11/12/25 for resident, R1 at the facility. LPA met with Staff, LVN Eva Bowlin and explained the purpose of the visit. Facility submitted incident report (LIC624) to department on 11/17/25 about resident, R1 who had choking incident on 11/10/25 during outing (1st incident ) and 11/12/25 (2nd incident) in the main dining room around 10.00am. On 11/10/25, R1 choked on candy while in store and facility staff called emergency services (9-1-1) for R1 when R1 returned from outing and R1 was sent to local hospital to get medical assistance. On 11/12/25, R1 choked at facility in the dining room. Facility staff took appropriate measures and performed Heimlich Maneuver on R1. Medical assistance was offered but declined by R1 due to this incident on 11/12/25. R1 was back to their baseline after this incident. Facility notified R1s family, physician and other required agencies as required. During today visit, LPA interviewed R1 and staff. After reviewing the incidents reports and information gathered, it has been determined that facility took appropriate measures to address R1s choking incidents . No citations were observed or cited per Title 22 Regulations. Exit interview conducted and copy of the report has been provided.the state’s words, verbatim · CDSS document, Nov 25, 2025

Type of visit: Case Management - Incident

On 10/06/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred around 09/16/25. LPA met with Administrator Stephen Macdonald and staff LVN, Eva Bowlin and explained reason for visit. Incident Report (LIC 624) submitted by facility on 09/26/25 to CCL stated that resident, R1 did not receive their prescribed medication Carbamazepine ER 400mg tab 8am, 8pm dose on 09/17/25 and 09/18/25 as facility ran out for this medication for R1 per their physician’s order. Record review and staff interviews indicated that staff did not notice till 09/15/25 morning that R1 has no medication to administer and contacted R1s pharmacy to refill the medication. Facility notified R1s physician and responsible party regarding this matter. Based on incident report, staff interviews and medication record review from the facility, It was determined that facility did not administer prescribed medication to R1 which poses a immediate health and safety risks to residents in care. Based on gathered information, deficiencies are cited per pursuit to California Code of Regulations, Title 22, Section 87465(a)(4) and documented on the attached LIC809D. Civil penalties may be assessed if facility does not comply with POC requirements which were issued today. The report was reviewed, appeal rights and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 7, 2025

87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on incident report and staff interview the facility did not provide resident, R1 their medications as prescribed which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2025

Plan of correction: Administrator shall letter of understanding of this regulation by 10/07/25. Administrator shall conduct staff training for medication management and to send into CCL a copy of the training and date the training was provided by 10/13/25. Furthermore, facility will train staff regarding written policy of refill medications for residents and shall send a copy to CCL.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 09/23/25 to conduct a case management inspection to follow up on a recent AWOL for R1 at the facility. LPA met with Administrator Stephen MacDonald and explained the purpose of the visit. R1’s AWOL Incident- The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 09/15/25 regarding resident (R1) leaving the facility unattended on 09/12/25 , at approximately 1430. Per incident report, R1 was brought back to the facility uninjured by neighbor. Facility notified R1s doctor and family regarding this AWOL incident. R1's physician's report dated 01/14/25 indicates that resident has diagnosis of Mild Cognitive Impairment (MCI) and cannot leave the facility unassisted. Although no injuries resulted from R1s AWOL incident, R1s LIC602 indicated they were unable to leave the facility unassisted. Facility staff did not provide care and supervision for R1 resulting in R1 leaving the facility unassisted. Based on gathered information, violations are cited today per California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies issued are noted on the LIC809D. Exit interview conducted. Copy of report, appeal rights have been provided .the state’s words, verbatim · CDSS document, Sep 23, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411 · Plan of correction due date: Sep 23, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by; Based on record review and interviews, it was concluded that resident, R1 was able to AWOL from the facility, unassisted on 09/12/25 , which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Sep 23, 2025

Plan of correction: Administrator shall conduct staff training, regarding AWOL risk for residents and will send training documents to CCL. POC due date is 09/23/25. LPA cleared the POC as record review indicated that facility conducted staff training regarding AWOL risks residents on 09/12/25 and 09/13/25.

Type of visit: Case Management - Incident

On 09/23/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct case management visit follow up regarding an incident that occurred on 09/16/25 as facility reported on 09/17/2025. LPA met with Administrator Stephen MacDonald and explained the purpose of the visit. The visit was in response to a report from the facility regarding an incident that occurred on 09/16/25. According to the report, on 09/16/2025, at around 9:00PM, staff went to resident, R1s room to give their medication but found R1 to be unresponsive. The facility contacted local law enforcement and emergency services, but R1 was pronounced deceased approximately 09:38 PM by emergency staff. The facility notified all relevant parties involved regarding R1 passing. During the visit, LPA is requesting relevant documents related to the incident. All these requested documents shall by submitted via email to LPA Bains by 09/24/25 by 5PM. At this time, this incident is under review and the department will do follow up if warranted. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Sep 23, 2025

Type of visit: Case Management - Other

On May 14, 2025, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains conducted an unannounced case management visit . This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. LPAs met with Administrator Stephen MacDonald and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective May 14, 2025 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.the state’s words, verbatim · CDSS document, May 14, 2025

Allegation investigated: Resident sustained an injury while in care.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 04/22/25 to deliver complaint findings for above allegation. LPA met with administrator Stephen Macdonald and explained the purpose of the visit. Allegation- Resident sustained an injury while in care. - Unsubstantiated The department conducted record review, interviewed residents and staff to investigate this allegation. Record review indicated that R1 sustained a foot injury on 04/09/25 around 1pm when R1 was sitting in the common area and table lamp fell on their foot causing a cut on their foot. Staff immediately offered help to R1 and sent them to hospital to get medical care. R1 returned the same day after getting the necessary treatment. Four staff interviewed reflected that this incident was accidental, and staff offered appropriate help to R1. It has been evaluated that even though R1 got injury, but it was not due to lack and care from staff. Based on gathered information, this allegation was found to be Unsubstantiated. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit meeting conducted. A copy of this report has been provided to facility. Unsubstantiated ***Report continued from 9099-A.... Allegation- Staff are not ensuring that resident is properly fed.-Unfounded The department conducted facility observations, interviews with four residents and four staff to investigate this allegation. Staff interviews reflected that staff were assisting residents who require assistance with their meals and there were no issues. Residents’ interviews indicated that staff were assisting them with their dietary needs and there were no concerns. During department visit on 04/15/25, it was noted that staff were attentive to residents who require help with their meals and there were no concerns. Based on gathered information, this allegation was found to be Unfounded. Allegation- Staff left resident in dirty clothing for a long period of time.-Unfounded The department conducted facility observations, interviews with four residents and four staff to investigate this allegation. Staff interviews reflected that staff were changing residents’ clothes daily and as needed, not leaving residents in dirty clothes and there were no issues to address. Residents’ interviews indicated that staff were assisting them with their care needs and there were no concerns. During department visit on 04/15/25, it was noted that residents were well groomed and in good care and there were no concerns. Based on gathered information, this allegation was found to be Unfounded. Allegation- Staff did not pick resident up from the hospital in a timely manner. - Unfounded The department conducted interviews with four staff to investigate this allegation. Staff interviews reflected that facility was not arranging any transportation services for any residents once they were ready to return to facility after ER or hospital visit, and it is arranged by ER/Hospital staff. Record review for resident R1 did not indicate any incident, where staff did not pick R1 from hospital in timely manner. Based on this information, this allegation was found to be Unfounded. Allegation- Staff did not clean resident's room. -Unfounded The department conducted facility observations, interviews with four residents and four staff to investigate this allegation. Staff interviews reflected that staff were providing laundry and housekeeping service as agreed in residents’ admission agreements and there were no issues to address. Residents’ interviews indicated that staff were assisting them with laundry and housekeeping tasks in timely manner and there were no concerns. During department visit on 04/15/25, it was noted that facility was clean and odor free and there were no concerns. Based on gathered information, this allegation was found to be Unfounded. ***report continued...... ***Report continued from 9099-A.... Allegation- Staff are over medicating a resident in care. -Unfounded The department conducted record review, interviewed residents and staff to investigate this allegation. Four residents’ interviews indicated that staff were giving them medications per their physician’s orders. Four staff interviews reflected that staff were following resident’s physician’s orders and not mismanaging residents’ medications. Record review for R1s medications indicated that staff were administering R1s medications per their physician’s orders and there were no issues identified. Based on gathered information, this allegation was found to be Unfounded. Allegation- Staff did not safeguard resident's personal belongings. -Unfounded The department conducted interviews with four residents and four staff to investigate this allegation. Staff interviews reflected that staff were safeguarding residents’ belongings per facility protocol and there were no issues to address. Residents’ interviews indicated that staff were safeguarding their personal items, assisting them to locate any missing items as needed, and there were no concerns. During department visit on 04/15/25, it was noted all personal belongings for R1 was labeled and secured in R1s room. Based on gathered information, this allegation was found to be Unfounded. A finding that the allegations are Unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 59-AS-20250410161623

Allegation investigated: Staff wrongfully evicted resident. Staff has not issued responsible party a refund.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 04/22/25 to deliver complaint findings for above allegations. LPA met with administrator, Stephen Macdonald and explained the purpose of the visit. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unsubstantiated **Report continued from 9099.... Allegation- Staff wrongfully evicted resident.-UNSUBSTANTIATED The department conducted record review, interview with staff and with witness to investigate this allegation. It was learned that resident, R1 was hospitalized due to change in condition from March 4, 2025 until time of move out. Interviews with staff and witnesses reflected that R1s was scheduled for discharge from hospital around March 11, 2025. Facility staff contacted R1 and R1s family to discuss the discharge plan on March 11, 2025 and March 18, 2025 but was inconclusive. It was learned that facility had planned to visit R1 for reassessment on March 21, 2025 but was notified by R1s family on March 20, 2025 that R1 and family decided to move R1 to another facility and will not return to Almond Heights. it was also learned that facility did not issue any eviction notice to R1. Based on gathered information, this allegation was found to be UNSUBSTANTIATED. Allegation- Staff has not issued responsible party a refund.-UNSUBSTANTIATED The department conducted record review, interview with staff and with witness to investigate this allegation. Record review indicated that resident, R1 signed admission agreement, dated April 23, 2023, which indicated that facility require 30 days’ notice if resident want to move out. During the investigation, it was found out that R1 was in hospital from March 04, 2025 until March 20, 2025 but moved out to another facility and did not provide 30 days move out notice as agreed per admission agreement. Based on facility ledger, for the Month of April, R1 was charged $7410. A credit of $1410 for care for April and credit of $1228 for care in March was issued while R1 was in the hospital. Record review and staff interviews indicated that R1’s end balance was $4,771.94. Based on this information, this allegation was found to be UNSUBSTANTIATED. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit meeting conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 59-AS-20250326131505

Type of visit: Required - 1 Year

On 02/12/25 , Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived unannounced to conduct the annual inspection. LPAs met with administrator, Stephen MacDonald and explained the purpose of the visit. LPAs toured facility with to ensure the health and safety of residents in care. LPAs toured residents rooms, medication room, bathrooms, kitchen, dining room, common areas and activity areas. LPAs observed residents in common areas participating in activities and in the dining room having lunch. The facility was found to be clean, safe, sanitary and in good condition. LPAs observed the facility to have the mandated posters posted. Fire extinguishers are maintained and ready for emergency use. Facility has required food supplies. There are appropriate staff present to meet the needs of residents. Inside temperature was 72-74 degree F. Hot water measured between 110-114 in three different areas at facility was in required range 105-120 degree F. Facility was conducting fire and disaster drills per requirement. LPAs reviewed ten (10) residents files and ten (10) staff files. Staff records reviewed indicated training completed and other required paperwork. Residents files found to have required documentation. LPAs reviewed two (2) residents medications comparing with current physician orders and found it to be correct. LPA checked the current narcotic medications log with staff and found no errors. LPAs observed that medications were secured and were inaccessible to residents. LPAs completed the full care tool and no deficiencies were observed or cited per Title 22 Regulations. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Feb 12, 2025

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced on 02/12/25 to do case management visit . LPAs met with Administrator , Stephen Macdonald and explained the purpose of the visit. Incident for Resident, R1- Department followed up on SOC 341 sent by facility on 02/07/25 stating that resident, R1 and family reported to staff that $360 in cash was missing on two separate time frames. Family noticed in December of 2024 that $200 was missing and also in mid January that another $160 was missing from R1's room. R1's family has initiated search of the room for the missing funds and facility also initiated search of the room. Facility notified LTCO and responsible party regarding this matter. Department conducted interviews with 1 residents and 3 staff during today's visit. At this time, this incident is under review and department will do follow up if warranted. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Feb 12, 2025

Type of visit: Office

A virtual meeting was conduct on 10/07/24 with the facility to discuss a situation at the facility regarding resident, R1. Facility Executive Director (ED) , Stephen MacDonald, Facility’s representatives and CCL staff, Regional Manager, Alycia Rayner , Licensing Program Analyst Talwinder Bains, and Licensing Program Manager, Anthony Perez were present. Also in attendance today are representatives from the Long-Term Care Ombudsman (LTCO), Byron Toliver. Department has been made aware that R1 was not paying their share of cost for monthly charges and was given 1st written notice by the facility on 07/12/2024 which indicated the amount of $5464.80. R1 did not take any action on 1st notice, so facility issued a 2nd written notice to R1 on 08/20/2024 per admission agreement and facility’s policy. R1 was non complaint with facility’s payment policy, therefore, facility issued a 30- day Eviction Notice to R1 on 09/26/2024. LPA spoke to R1 regarding this matter in August and September 2024, by thyself and with Long Term Care Ombudsman, Byron Toliver and each time the conversation went for 30-45 minutes. During these interactions with R1, R1 acknowledged the issues with their pending payments with facility and were aware that it can lead to possible eviction if not being addressed in timely way. Record review and gathered information indicated that R1 was not taking necessary steps to resolve this matter despite being provided with different resources and assistance by LPA, LTCO and Facility Staff. At this point , it appeared that R1 might have a undiagnosed health condition which is causing them a delay not to take required actions to take care of their health and financial needs which can effect their well being and possible eviction. During this meeting, it was discussed that the facility will send a request to Sacramento County for possible appointment of legal conservator for R1 to ensure their health and safety needs. No citations were issued per Title 22 Regulations. Exit interview is conducted with ED via phone. Copy of the report was sent via email and ED will sign and send it back to LPA via email by 10/08/24 by 5pm.the state’s words, verbatim · CDSS document, Oct 7, 2024

Allegation investigated: Staff mistreated the resident in care. Ilegal Eviction.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 10/02/24 to deliver complaint findings for above allegations. LPA met with administrator Stephen Macdonald and explained the purpose of the visit. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unfounded ***Report continued from 9099..... Allegation- Staff mistreated the resident in care. Unfounded The Department conducted record review, interviews with staff and residents to investigate the allegation. From record review, it was learnt that resident, R1 was behind with their co-payment with facility and first reminder notice regarding that was given to R1 on 07/12/24 which indicated that R1’s pending balance was $5464.80 . Furthermore, facility staff followed up with R1 on 08/16/24 regarding this matter and R1 was given verbal reminder only and written second notice regarding pending payment was given to R1 on 08/20/24. Four (4) staff interviews indicated that staff was only discussing R1s pending payment issue with R1 on 08/16/24 in a professional manner and did not mistreat R1 in any manner. During resident, R1’S interview, R1 indicated that they were upset during payment issue discussion which occurred on 08/16/24 and took that meeting in negative manner but realized later that facility staff were doing their job and did not mistreat R1 and were fine at the facility. Based on gathered information, this allegation was found to be UNFOUNDED. Allegation- Illegal Eviction. Unfounded The Department conducted record review , interviews with staff and residents to investigate the allegation. From record review, it was learnt that resident, R1 was behind with their co-payment with facility and first reminder notice regarding that was given to R1 on 07/12/24 which indicated that R1’s pending balance was $5464.80 . Furthermore, facility staff followed up with R1 on 08/16/24 regarding this matter and R1 was given verbal reminder only and written second notice regarding pending payment was given to R1 on 08/20/24. Four (4) staff interviews indicated that staff was only discussing R1s pending payment issue with R1 on 08/16/24 and there was no Eviction Notice issued to R1. During resident, R1’S interview, R1 indicated that they have received two notices from facility regarding their pending co-payment balance , first one on 07/12/24 and second one on 08/20/24 but facility did not issue any Eviction Notice to them, Based on gathered information this allegation was found to be UNFOUNDED. A finding that the allegations are Unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Oct 2, 2024 · control 59-AS-20240819153957

Type of visit: Case Management - Incident

On 10/02/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 09/19/24. LPA met with Administrator, Stephen Macdonald and explained reason for visit. Special Incident Report (LIC 624) submitted by facility on 09/20/24 to CCL stated that R1 was send to hospital on 09/19/24 around 6PM, after R1 was given wrong medications by staff. Incident report indicated that R1 was given medications, Calcium Citrate 250mg- 2 tablets, Simvastatin 20mg-1 tablet and Memantine 10 mg- 1 tablet which were NOT prescribed by R1s physician during evening med pass on 09/19/24 around 6PM. Staff notified immediately facility’s management regarding the medication error and facility send out R1 to hospital to seek medical care. R1 came back to the facility on 09/23/24. Facility notified R1s physician and responsible party on 09/19/24 regarding medication error. LPA was notified by administrator that facility took appropriate action with staff regarding this incident per facility policy who was associated with this incident . Based on incident report, staff interviews and medication record review from the facility, R1 was given medications, Calcium Citrate 250mg- 2 tablets, Simvastatin 20mg-1 tablet and Memantine 10 mg- 1 tablet by mistake. It was determined that facility administered wrong medications to R1 which poses a immediate heath and safety risks to residents in care. Deficiencies are cited on LIC809D, pursuant to California Code of Regulations, Title 22, Section 80075(b)(5)(B) and documented on the attached LIC809D. Civil penalties may be assessed if facility does not comply with POC requirements which were issued today. The report was reviewed, appeal rights and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 2, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80075(b)(5)(B) · Plan of correction due date: Oct 3, 2024

80075 -Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions.... This requirement was not met as evidenced by: Based on record review from the facility, it was observed that on 09/19/24, resident, R1 was given medications, Calcium Citrate 250mg- 2 tablets, Simvastatin 20mg-1 tablet and Memantine 10 mg- 1 tablet by mistake from staff and these medications were not ordered by R1s physician which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: Administrator agreed to submit a self certification for this regulation and will do training for all staff regarding medication administration and submit proof to LPA by POC date- 10/03/24. Additionally, facility shall conduct monthly staff training for medications administration till December 2024 will send monthly training proofs to Department.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 08/05/24 to do case management visit . LPA met with Administrator , Stephen Macdonald and explained the purpose of the visit. Incident for Resident, R1- Department followed up on Incident Report and SOC 341 sent by facility on 07/19/24 stating that resident, R1 reported to staff on 07/18/24 around 8AM that staff, S1 was rough with them while providing care to R1 on 07/18/24 during morning shift care. Facility notified law enforcement regarding this incident and there were no findings. Facility also notified R1s physician, LTCO and responsible party regarding this incident. Facility Nurse checked R1 for any injurers and none were present. Incident for Residents, R2 and R3 - Department followed up on Incident Report and SOC 341 sent by facility on 07/22/24 regarding an incident which happened between 2 residents (R2,R3) during dinner time around 6pm on 07/21/24. Incident report stated that R2 was at dining room table, when R3 walked up and began to move the cups around. R2 began to yell at R3 to get away from the table. R3 was observed throwing a cup at R2 and it hit R2 above their lip, causing a small cut. R3 was redirected to another area. Med tech was notified, and the cut was cleaned and covered for R2. Facility notified R2s and R3s physician, LTCO and responsible party regarding this incident. Department conducted interviews with 3 residents during today's visit and requested documents from staff,S1s file and facility shall send all requested documents to LPA via email by 08/06/24 by 5pm. At this time, these incidents are under review and department will do follow up if warranted. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Aug 5, 2024

Allegation investigated: Staff do not respond to resident's call for assistance in a timely manner.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/29/24 to deliver complaint findings for above allegation. LPA met with administrator Stephen Macdonald and explained the purpose of the visit. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unsubstantiated ***Report continued from 9099....... Allegation- Staff do not respond to resident's call for assistance in a timely manner.-Unsubstantiated The Department conducted interviews with six (6) residents and five (5) staff members regarding the allegation cited above. Residents’ interviews indicated that staff were assisting with their care needs and responding to the call lights in timely way however there were some delay times if staff were assisting other residents. Staff interviews indicated that staff were trying their best to respond to resident’s call light in the best possible way and tried to prioritize their response per resident’s needs. Record review conducted for call light log March 2024 revealed some dates and times with extended response time without any definite reason. Although record review revealed there were some dates and time with long call response, California Code of Regulation, Title 22, does not specify a time frame of when facility is to assist to a non-emergency call. Additionally based on interviews with staff, it revealed that facility staff has the tendency to "forget to reset the system at the conclusion of the service they are doing". Therefore, the allegation cited above is Unsubstantiated. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit meeting conducted. A copy of this report has been provided to facility. **Report continued from 9099-A..... Allegation- Staff are caring for residents without adequate training. Staff do not transfer residents that require 2 person assistance in a safe manner. -Unfounded The Department conducted interviews with five (5) staff members and reviewed record regarding the allegations cited above. Staff interviews revealed that staff have adequate training (on boarding and ongoing) regarding residents safe transfers techniques and there were no issues. Staff interviews also reflected that they were feeling safe regarding any residents who required 2 persons assist with transfers. Six (6) residents interview indicated that staff were properly trained, and residents felt safe with staff’s care without any problems. Record review indicated that facility has all required documentation regarding staff’s training's regarding Residents Transfers Techniques and other Care Provision per Requirement, therefore these allegations were found to be Unfounded. Allegation- Staff do not rotate residents as required to prevent pressure injuries.- Unfounded The Department conducted interviews with six (6) residents and five (5) staff members regarding the allegation cited above. Residents interview indicated that staff were providing care per their care needs and there were on issues including those residents who required staff to turn and reposition. Staff interviews revealed that staff were aware which residents needs turning and repositioning per their care needs and were providing that care and documenting it timely. Based on information gathered, this allegation was found to be Unfounded. Allegation -Untrained staff dispensing medications to residents. -Unfounded The Department conducted interviews with five (5) staff members and reviewed record regarding the allegations cited above. Staff interviews revealed that facility has trained staff who were managing residents’ medications and has access to medication room. Staff interviews denied that any unauthorized person was dispensing residents’ medications. There were some staff who were cross trained to do other duties and those staff also fill-in to do Med Tech job as needed per facility’s staffing needs. Record review indicated that facility has proper documentation of resident’s medication administration and there were no discrepancies. Based on information gathered, this allegation was found to be Unfounded. A finding that the allegations are Unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis.No citations were issued. Exit interview conducted.A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, May 29, 2024 · control 59-AS-20240404105609

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/29/24 to do case management visit . LPA met with Administrator, Stephen Macdonald and explained the purpose of the visit. Department followed up on SOC 341 sent by facility on 05/24/24 for date -05/20/24 regarding resident, R1 where R1 alleged that R1 fell into the bed on 05/20/24 around 10.30pm when staff S1 and S2 were assisting them. Facility notified R1s responsible party, law enforcement and long term care ombudsman (LTCO) regarding this incident. Per facility records, there were no visible injuries to R1 after this incident. Per facility’s staffing records, S1 was not working on 05/20/24. LPA conducted interview with resident, R1 regarding this incident during today’s visit. LPA attempted to interview S2 but found out that S2 was not working today. LPA requested documents related to this incident and facility will submit all documents by 05/31/24 by 5pm. At this time, this case in under review and department will do follow up as needed. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, May 29, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/23/24 to do case management visit for Residents, R1 and R2 . LPA met with administrator Stephen Macdonald and explained the purpose of the visit. Incident for R1- Department followed up on Incident Report and SOC 341 sent by facility on 04/19/24 for an incident that occurred on 04/18/24 regarding resident, R1. Department conducted record review and interviews regarding this incident which occurred on 04/18/24 around 10.30 pm. Based on information gathered, it has been concluded that R1 advised staff they were not ready to lay down to go to bed however staff assisted R1 to their bed without R1’s consent which was a violation of Resident’s Rights per CCR, Title 22 Regulation, therefore Citation-A has been issued during this visit. Incident for R2- The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 05/09/24 regarding resident (R2) leaving the facility (AWOL) unattended on 05/08/24 at approximately 07:30 pm. Per incident report, it was discovered that R2 exited from main lobby door and was outside for approximately 3 minutes. IR indicated that R2 was wearing a wander guard at time of incident which alerted staff that R2 left the premises. R2 was brought back to the facility by staff uninjured. Facility notified R2’s doctor and family regarding this AWOL incident. R2's physician's report (LIC602) dated 04/26/24 indicates that resident has diagnosis of dementia and cannot leave the facility unassisted. Although no injuries resulted from R2’s AWOL, R2 was unable to leave the facility unassisted. Facility staff did not provide care and supervision to R2 resulting in R2 leaving the facility unassisted. Immediate Civil penalties of $250.00 were assessed on LIC421FC today due to repeat violations of the same regulations within 12 months for Regulation 87411. Deficiencies issued are noted on the LIC809D per Title 22 Regulations. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted. Appeal rights were provided and copy of the report was provided.the state’s words, verbatim · CDSS document, May 23, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 24, 2024

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:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidence by; Record review and interviews conducted indicated that staff assisted R1 to their bed on 04/18/24 without their consent which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, May 23, 2024

Plan of correction: Administrator shall submit letter of understanding regarding Regulation-87468 and shall conduct all staff training to go over Residents Personal Rights and send all these documents to CCL by POC date-05/24/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411 · Plan of correction due date: May 24, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by; Based on records of the incidents for R2, it was concluded that R2 was able AWOL from the facility unassisted on 05/08/24 which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, May 23, 2024

Plan of correction: Administrator shall conduct staff training regarding AWOL risk residents twice a month till July 2024 and will send training documents to CCL. Outline of training shall be send to CCL by 05/24/24.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced on 04/24/24 to do case management visit . LPAs met with administrator Stephen Macdonald and explained the purpose of the visit. Department followed up on Incident Report and SOC 341 sent by facility on 04/19/24 for date -04/18/24 regarding resident, R1. Facility notified law enforcement and long term care ombudsman (LTCO) regarding this incident. Department conducted interview with resident, R1 regarding this incident during today’s visit. LPAs requested documents related to this incident and facility will submit all documents by 04/25/24 by 5pm. At this time, this case in under review and department will do follow up as needed. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Apr 24, 2024

Type of visit: POC

On 04/15/24, LPA Talwinder Bains conducted a plan of correction (POC) visit to follow-up on citations issued on 03/20/24. LPA met with administrator, Stephen MacDonald and explained the purpose of the visit. Although the facility submitted documentation to clear the citations issued on 03/21/24, the Department will not be accepting the staff training sign-in sheets due to discrepancies with the date, time and attendance of staff at the training. As of this date, the plan of correction for the citations issued on 03/20/24 are outstanding. Should the facility fail to provide adequate documentation to satisfy the plan of corrections as agreed by 04/18/24, COB, the Department may assess civil penalties for failure to correct deficiencies. Exit interview conducted and copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 15, 2024

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced on 04/10/24 to do case management visit . LPAs met with administrator Stephen Macdonald and explained the purpose of the visit. Department followed up on Incident Report and SOC 341 sent by facility on 03/20/24 stating that resident, R1 reported to staff on 03/19/24 around 4pm that staff, S1 hit R1 with hard towel on their face while providing care to R1 on 03/18/24 during night shift. Facility notified law enforcement regarding this incident and there were no findings. Facility Nurse checked R1 for any injurers and none were present. Department conducted interviews with 3 residents and 3 staff members regarding this allegation. At this time, this case in under review and department will do follow up as needed. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Apr 10, 2024

Type of visit: Office

An Non-Compliance conference was conducted on 04/04/24 at Sacramento North Regional Office, located at 9835 Goethe Road, Suite 100. Present in the meeting were facility’s representatives- Stephen MacDonald-Executive Director, Courtney Lane- Regional Director of Operations, Dan Williams-Regional Director of Health, Denise Munoz- Corporate Director of Administration, Joel Goldman- MBK Counsel and CCLD staff, Regional Manager (RM), Alycia Berryman, Licensing Program Manager (LPM), Laura Munoz, and Licensing Program Analyst (LPA), Talwinder Bains. This Non-Compliance conference has been scheduled today as the Department has identified some substantial compliance issues with the facility. It is the goal of today’s meeting to discuss the noncompliance and develop a plan in assisting to get the facility back into compliance. This conference does not in any manner excuse past problems or resolve the Department’s case against the licensee if the problems are not corrected. The Non-Compliance Conference may be the last step prior to initiating administrative action following unsuccessful attempts by the Department to gain compliance. The following topics were discussed during today's meeting: · Staffing · Record keeping · Reporting responsibilities · Lack of Care and supervision (falls and AWOLs) · The facility has had 4 residents AWOL from the facility. · Severity of the falls (multiple falls reports) · Staff aware of care plans · Medication administration · Overall leadership and accountability · Internal audits and quality assurance **Report continued on 809-C.... The facility has stated they will do the following to achieve continued and substantial compliance: · The facility shall send in monthly staff schedules to the Department for 6 months to ensure the facility is meeting staffing requirements. · The facility shall develop and implement a quality assurance plan to ensure resident and facility staff records are complete and updated. The plan shall be sent to the Department for approval. · The facility shall develop and implement a plan on how the facility will ensure staff that care for residents are knowledgeable of the resident’s needs and limitations. The plan shall be sent to the Department for approval. Once approved, the facility shall train staff in plan and document training. · The facility shall develop and implement training for staff who administer medications that include but not limited to ensuring correct medications are dispensed to the correct resident and documenting any medication errors. Training shall be conducted quarterly and documented. · Facility shall develop and implement a plan addressing facility’s reporting requirement responsibility. The facility shall designate a member of staff whose responsibility it is to ensure all reportable items are reported to the Department based on Title 22 regulations. · Facility will develop and implement a plan on how facility staff will assist residents who are documented fall risks and how staff will mitigate falls for residents in care. The facility shall obtain an outside agency to train all facility staff on fall mitigation. · Facility shall train staff on recognizing if a resident AWOLs the facility who is unable to leave unassisted. Facility leadership shall have a communication process developed for staff to report resident AWOLs. The Compliance Plan is a demonstration of the licensee’s intention to make a good faith effort to comply and remain in substantial compliance with licensing regulations and statutes. If the licensee fails to maintain compliance with the conditions established in the plan, revocation action may be pursued. A follow up meeting will be scheduled between facility and department. The Department may increase monitoring at your facility. In an effort to assist you with coming into compliance, the Department would like to request the above documents by 05/04/24. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 4, 2024

Type of visit: Office

A virtual meeting was conduct on 04/03/24 with the facility to discuss a situation at the facility regarding resident, R1. Facility Executive Director (ED) , Stephen MacDonald, Facility’s representatives and CCL staff, Regional Manager, Alycia Berryman, Licensing Program Analyst Talwinder Bains, and Licensing Program Manager, Laura Munoz were present. Also in attendance today are representatives from the Long-Term Care Ombudsman (LTCO) , Sacramento County Adult Protective Services (APS), and Department of Justice (DOJ) . Prior to this meeting, the facility notified the Department that R1’s responsible party has not paid R1’s board and care rate since September 2023 till date. Facility also notified that R1 was admitted to facility in July 2023 and R1s responsible party paid the board and care for July and August 2023. The facility has indicated they have attempted to contact R1’s responsible party but have been unsuccessful. Adult Protective Services and the Long-Term Care Ombudsman has been involved in that it is believed that there is financial misuse of R1’s finances by R1’s responsible party. Facility has issued 30 days eviction notice to R1 due to nonpayment. During this meeting, it was discussed that APS and CCL will work together to enroll R1 to Assisted Living Waiver (ALW) program so R1 can move to another facility as current facility does not accept residents with the ALW program. It was also discussed that R1 will stay at the facility until appropriate placement is found for R1 per their care needs. No citations were issued per Title 22 Regulations. Exit interview is conducted with ED via phone. Copy of the report was sent via email and ED will sign and send it back to LPA via email by 04/03/24 by 5pm.the state’s words, verbatim · CDSS document, Apr 3, 2024

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced on 03/20/24 to conduct a case management inspection to follow up on a recent AWOL for residents, R1 and R2 at the facility. LPAs met with Executive Director (ED), Stephan Mcdonald and explained the purpose of the visit. R1’s AWOL Incident (1) - The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 03/05/24 regarding resident (R1) for date 02/26/24. Facility indicated R1 was at Winco around 3pm when R1 had change in condition which resulted in Winco staff calling EMS services. R1 was transferred to a local hospital and received medical care. R1 returned to the facility on the same day with no change. It is noted that Winco is 0.2 miles from the facility and is located across a busy street. The incident report and LIC602 (dated-07/19/21) were reviewed for R1 and it was discovered R1 has diagnosis of dementia and cannot leave the facility unassisted. The incident report submitted to the Department did not indicate that R1 was AWOL, only that EMS services were sought while R1 was out of the community. R2’s AWOL Incident (1)- Based on information provided by the facility, it was learned that R2 was at Winco with R1 on 02/26/2024. A review of R2’s physician report (LIC602, dated- 11/07/23 stated R2 has a diagnosed of dementia and cannot leave facility unassisted as well. The facility did not submit an incident report for R2’s AWOL. Although no injuries resulted from R1 and R2s AWOL incident on 02/26/24, R1 and R2s LIC602s indicate they were unable to leave the facility unassisted. Facility staff did not provide care and supervision to R1 and R2 resulting in R1and R2 leaving the facility unassisted. It has been determined that the facility did not report R1 and R2s AWOL on 02/26/24 therefore did not meet mandatory reporting requirements. In addition, record review indicated that facility does not has updated medical assessment for R1, who has a diagnosis of dementia. R1’s last LIC602 was dated 07/19/21. Based on Title 22 regulations, a resident with a diagnosis of Dementia shall have an updated medical assessment at least annually. Violations are cited today per California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies issued are noted on the LIC809D. Immediate Civil penalties of $250.00 were assessed on LIC421FC today due to repeat violations of the same regulations within 12 months for Regulation 87411 and Regulation 87211. Exit interview conducted. Copy of report, appeal rights has been provided to ED.the state’s words, verbatim · CDSS document, Mar 20, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411 · Plan of correction due date: Mar 21, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by; Based on information of the incident for R1 and R2, R1 and R2, AWOL from the facility on 02/26/24. This poses a immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Licensee/administrator will send statement of understating of regulation 87411 and will do staff training regarding providing care and supervision to residents per their needs and service plan. All these documents shall be submitted to department by POC date-03/21/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(D) · Plan of correction due date: Apr 5, 2024

87211-Reporting Requirements(a) (D)- (a) Each licensee shall furnish to the licensing agency such reports as the Department….(D) Any incident which threatens the welfare, safety or health of any resident,…… unexplained absence of any resident…..This requirement is not met as evidenced by; Based on records review,it has been observed that facility did not report R1 and R2s AWOL incident for 02/26/24 to department as required which poses potential health and safety risks for residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Licensee/administrator will send statement of understating of regulation 87211 and will do staff training regarding reporting requirements as required by this regulation. All these documents shall be submitted to department by POC date-04/05/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Apr 5, 2024

87705-Care of Persons with Dementia- (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually.. this requirement is not met as evidence by; Record review and gathered information indicated that facility does not have updated Medical Assesment (LIC602) and Re-appriasal completed for R1 as required which poses a potenial risk to health and safety for residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Licensee/administartor shall complete medical assesment (LIC602) and re-appraisal for resident R1 as required and will send proof to department once completed. All POC documents are due by 04/05/24.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced on 03/20/24 to conduct a case management inspection to follow up on a choking incident on 03/11/24 for resident, R1 at the facility. LPAs met with Executive Director (ED), Stephan McDonald and explained the purpose of the visit. Facility submitted incident report to department on 03/18/24 about resident, R1 who had choking incident on 03/11/24 in the main dining room around 10.30am. Facility staff took appropriate measures and performed Heimlick Manuever on R1. R1 was back to their baseline after this incident. Facility notified R1s family, hospice agency, physician and other required agencies as required. After reviewing the incident report and information gathered, it has been determined that facility took appropriate measures to address R1s choking incident on 03/11/24. No citations were observed or cited per Title 22 Regulations. Exit interview conducted and copy of the report has been provided.the state’s words, verbatim · CDSS document, Mar 20, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived on 3/20/24 to conduct the annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed resident (10) and staff (10) files. All residents (10) files contained the required paperwork. Medications reviewed. LPAs and Administrator Stephen MacDonald toured the facility together to ensure the health and safety of residents in care. The areas toured included, kitchen, hallways, apartments, dining room/kitchen, and common areas. Food is within compliance. Fire drills and disaster drills reviewed. Fire extinguisher ready to be used. Smoke detector and carbon monoxide detectors are operational. Deficiencies were observed and cited per Title 22, CCR Regulations as listed on 809-D. Exit interview conducted. Copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 20, 2024

Allegation investigated: Staff did not properly supervise resident resulting in resident being sexually assaulted while in care.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 03/07/24 to deliver complaint findings for above allegation. LPA met with administrator Stephen Macdonald and explained the purpose of the visit. LPA was screened upon entry. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unsubstantiated ***Report continued from 9099..... Allegation- Staff did not properly supervise resident resulting in resident being sexually assaulted while in care. The department investigated the allegation listed above. On 01/24/24, it was reported that R1 was raped by an unknown male in the facility. Facility notified R1’s responsible party, physician, CCLD, LTCO, Law enforcement and other agencies as required. R1 was taken to the local hospital for a Sexual Assault Evidentiary Exam, and the results were found to be inconclusive. Medical exam indicated that there were no signs of sexual assault on R1. Department conducted interviews with staff and witnesses which indicated that there is no information that a sexual assault for R1 occurred at the facility on 1/24/24. As a result of this investigation, the department finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited per Title 22, CCR Regulations. Report reviewed with administrator and copy of report provided.the state’s words, verbatim · CDSS document, Mar 7, 2024 · control 59-AS-20240125145224

Allegation investigated: Licensee is not ensuring that resident(s) receive services as agreed to in the Admissions Agreement.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 12/19/23 to do complaint investigation and to deliver complaint findings for above allegation. LPA met with administrator Stephen Macdonald and explained the purpose of the visit. LPA was screened upon entry. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unsubstantiated **Report continued from 9099........ Allegation- Licensee is not ensuring that resident(s) receive services as agreed to in the Admissions Agreement.- UNSUBSTANTIATED LPA conducted residents and staff interviews and reviewed records to investigate this allegation. LPA observed laundry being done during facility visit on 11/20/2023 and on 12/19/23 .LPA interviewed 4 residents and all, but 1 stated their linens get cleaned in timely manner. Record review indicated that the facility has documentation about residents’ schedule for laundry and housekeeping on a weekly basis, however schedule day can change to another day due to facility’s staffing needs. Based on interviews conducted, 3 residents stated that all laundry services are conducted by facility staff and staff wash resident’s sheets/linens at least once a week. 3 Residents interviewed stated that staff have never had any issues changing and washing their bed sheets more than once a week. Staff interviews indicated that there’s a schedule for laundry services for residents; however, staff would provide laundry services for those who need it and that is not scheduled. Based on this information, this allegation was found to be UNSUBSTANTIATED. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit meeting conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Dec 19, 2023 · control 59-AS-20231116093520

Type of visit: Case Management - Incident

Licensing Program Manager (LPM), Laura Munoz and Licensing Program Analysts (LPAs) Talwinder Bains and Cheyenne Ratajczak arrived at the facility unannounced on 11/28/23 to conduct a case management inspection to follow up on a recent AWOL for R1 at the facility. LPAs and LPM met with Executive Director (ED), Stephan McDonald and explained the purpose of the visit. R1’s AWOL Incident (1) - The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 10/20/23 regarding resident (R1) leaving the facility unattended on 10/12/23, at approximately 3pm. Per incident report, it was discovered R1 was missing from community on 10/12/23 around 1.30pm. Interviews indicated staff looked around for the resident but were unable to locate R1. Around 3pm, the police called the community stating they had located R1. R1 was found at their old house after R1s neighbors called the police. R1 was brought back to the facility uninjured by Executive Director, Stephan McDonald. LPA followed up with facility after this incident and gathered information for R1 including R1’s LIC602. Facility notified R1s doctor and family regarding this AWOL incident. R1's physician's report, LIC602, dated 09/07/23 and R1s Needs and Service plan by facility, dated 09/23/23 indicates that resident has diagnosis of bipolar disorder and cannot leave the facility unassisted. R1’s AWOL Incident (2)- During record review, LPA observed that R1s charting notes by facility staff indicated that R1 had another AWOL incident on 11/01/23 where R1 went to local grocery shop by themselves on 11/01/23 around 1pm. Staff did not notice R1 was missing until R1 came back to the facility. This AWOL incident was not reported to the department as required. Although the facility has implemented safety precautions for R1 after their AWOL incident on 10/12/23, those measures were not effective since R1 left again unassisted on 11/01/23 which is a safety risk for R1. Although no injuries resulted from R1’s AWOL, R1 was unable to leave the facility unassisted. Facility staff did not provide care and supervision to R1 resulting in R1 leaving the facility unassisted. In addition, the facility did not report R1’s AWOL on 11/01/2023 therefore not meeting reporting requirements. Violations are cited today per California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies issued are noted on the LIC809D. Exit interview conducted. Copy of report, appeal rights has been provided to ED.the state’s words, verbatim · CDSS document, Nov 28, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411 · Plan of correction due date: Nov 29, 2023

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by; Based on records of the incidents for R1, R1 AWOL from the facility on 10/12/23 and on 11/01/23. This poses a immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Nov 28, 2023

Plan of correction: Licensee/administrator will send statement of understating of regulation 87411 and will do staff training regarding providing care and supervision to residents per their needs and service plan. All these documents shall be submitted to department by POC date-11/29/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(D) · Plan of correction due date: Dec 12, 2023

87211-Reporting Requirements(a) (D)- (a) Each licensee shall furnish to the licensing agency such reports as the Department….(D) Any incident which threatens the welfare, safety or health of any resident,…… unexplained absence of any resident…..This requirement is not met as evidenced by; Based on records review,it has been observed that facility did not report R1s AWOL incident for 11/01/23 to department as required which poses potential health and safety risks for residents in care.the state’s words, verbatim · CDSS document, Nov 28, 2023

Plan of correction: Licensee/administrator will send statement of understating of regulation 87211 and will do staff training regarding reporting requirements as required by this regulation. All these documents shall be submitted to department by POC date-12/12/23.

Type of visit: Case Management - Incident

On 11/01/23, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 10/12/23.LPA met with Executive Director (ED) , Stephen MacDonald and explained reason for visit. On 10/20/23, the facility notified the Department via LIC624 (Incident Report) that R1 eloped from the facility on 10/12/23 and had returned after being located by law enforcement on 10/12/23. On 10/23/23, LPA Bains requested R1 facility records via email. On 10/25/23, LPA Bains followed up with the facility via email regarding the requested documents. On 10/25/23, Executive Director, Stephen MacDonald, advised the Department that records would be sent over by close of business. On 10/30/23, LPA Bains sent another follow up request for R1’s documents. As of this date, the Department has not received documents for R1 which were requested on 10/23/23, therefore citations are being issued pursuant to Title 22 and notated on the 809-D page attached herewith. Failure to submit Proof of Correction (POC) by Plan of Correction date may result in civil penalties. Exit interview was conducted with ED and the report was reviewed. Appeal rights and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 1, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(d) · Plan of correction due date: Nov 2, 2023

87506-Resident Records- (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours…this requirement is not met as evidenced by; Facility did not provide requested documents to department related to resident, R1s elopement incident which were requested on 10/23/23,10/25/23 and 10/30/23 which poses a potential health and safety risks for residents in care.the state’s words, verbatim · CDSS document, Nov 1, 2023

Plan of correction: Facility shall provide all requested documents for resident, R1 to the department by POC date, 11/02/23 by 5pm via E-FAX/E-MAIL. result in civil penalties. Failure to submit Proof of Correction (POC) by Plan of Correction date may result in civil penalties.

Allegation investigated: Staff are not following a licensed physician's order for a resident.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 10/17/23 to deliver complaint findings for above allegation. LPA met with administrator Stephen Macdonald and explained the purpose of the visit. LPA was screened by facility staff upon entry. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unsubstantiated **Report continued from 9099..... Allegation- Staff are not following a licensed physician's order for a resident. Unsubstantiated. The department conducted interviews with staff, record review and facility observations to investigate this allegation. From record review and interviews, it has been found out that R1 had unwitnessed fall on 09/24/23 and facility sent out R1 to hospital to seek medical treatment after that fall incident. R1 sustained a neck fracture due to the fall and came back to the facility on 09/29/23 and had order to put neck brace on however there were no specific instructions as to how many hours per day the R1 must wear neck brace. Based on interviews conducted, it was learned that R1 did not like the neck brace and did not want to wear it. R1 was seen by occupational therapy (OT) on 10/02/23 who advised facility staff that R1 needs to wear their neck brace at all times, even during meals however staff can loosen it or can leave paper towel in between so R1 can enjoy the meals. Facility staff reported that R1 has poor food intake due to neck brace and R1 not wanting to wear neck brace. Additionally, facility clarified with R1s doctor and therapy regarding this issue and following the doctor’s orders for R1. Based on all this information, this allegation is Unsubstantiated. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit meeting conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 59-AS-20231003154710

Allegation investigated: Staff do not ensure that resident is adminstered their medications according to physician's instructions. Staff are mismanaging resident's medical documentation. Staff do not respond to resident's requests for assistance in a timely manner.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 10/17/23 to deliver complaint findings for above allegations. LPA met with administrator Stephen Macdonald and explained the purpose of the visit. LPA was screened by facility staff upon entry. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unsubstantiated **Report continued from 9099A..... Allegation- Staff do not address resident being harassed by other resident while in care - Unfounded During interviews with staff and residents regarding the allegation listed above. It has been determined that two residents who reside in the facility do not get along however based on interviews conducted, staff ensure that the facility provides a healthy and safe environment to all residents and there was no indication of harassment. Based on the information, the preponderance of evidence standard has not been met, therefore this allegation is unfounded. Allegation- Food services are inadequate. Staff do not adhere to resident's special diet - Unfounded. During the course of this investigation, LPA interviewed residents and staff, toured the facility, inspected the nonperishable and perishable food supply, and reviewed facility records. LPA finds staff provide adequate food service for residents in care. LPA reviewed weekly menus, food supply, and grocery receipts, confirming staff provide a well-balanced diet with fresh fruits and vegetables daily. Residents and staff interviews indicated that facility provides food to resident’s who require specialized diet orders. Residents and staff interviews indicated that they could report any dietary issues to management as needed however there are no issues with food services at this time. Based on this information, this allegation is unfounded. Allegation- Staff do not accord dignity to resident in care. Staff do not accord privacy to resident in care. .-Unfounded. LPA Bains interviewed 4 staff and 4 residents during complaint investigation on 09/12/23. The department conducted the investigation for the stated allegation from this complaint. The department conducted a tour of the facility on 09/12/23 and conducted interviews with residents and staff. Interviews did not indicate any residents, staff and/or witness observed that staff are not providing privacy to residents in care. Department observed during facility tour on 09/12/23 that facility staff appeared to be attentive to resident’s needs and providing them privacy while taking care of them and during resident’s personal time with families and visitors. During residents’ interviews, residents stated that facility staff are meeting their care needs and did not express any concerns with privacy or dignity. Residents’ interviews indicated that staff were treating all residents with dignity and respect and did not express any issues. Based on facility tour, interviews and observation, the department found this allegation is to be UNFOUNDED. Due to this information the department finds all above allegations to be UNFOUNDED - A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and copy of the report left at facility. **Report continued from 9099........ Allegation- Staff do not ensure that resident is administered their medications according to physician's instructions. - Unsubstantiated Based on the information provided, the investigation conducted by the department involved facility observations, record review, and interviews with staff and residents to investigate the complaint allegation. During these interviews, it was revealed that the facility dispensed all residents' medications on time and administered them as scheduled. Furthermore, a review of the records for the months of August and September 2023 indicated that the facility maintained a proper logs for all medications in the centrally stored medication log, following physician's orders, and documenting them in the Medication Administration Record (MAR) without any errors. Based on these findings, this allegation is considered unsubstantiated. Allegation- Staff are mismanaging resident's medical documentation. .-Unsubstantiated Based on the information provided, the investigation conducted by the department involved facility observations, record review, and interviews with staff and residents to investigate the complaint allegation. During the record review, it was revealed that the facility is properly documenting medical records for residents per Title 22 regulations. Residents and staff interviews indicated that the facility conducts medical documentation and assessment of residents in a timely manner. Based on this, this allegation is unsubstantiated. Allegation- Staff do not respond to resident's requests for assistance in a timely manner. .-Unsubstantiated The department conducted staff and residents' interviews, reviewed records to investigate the allegation. During residents’ interviews, residents stated that staff respond to resident’s in a timely manner, however sometimes there is a delay in response due to staff assisting other resident’s needs. Interviews and record review indicated that resident’s ADL’s, which include, residents showering, incontinence and care needs are met as required and documented accordingly. Residents’ interviews indicated that staff were providing care in a professional manner and did not express any concerns. During interviews with facility staff and residents, it has been revealed that the facility is providing care to residents according to resident’s needs and service plans, therefore this allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit meeting conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 59-AS-20230908162502