Aroha Memory Care

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to conduct a Case Management. LPA met with Rajesh Kalra, licensee. Facility currently has five (5) doors with delayed egress: main entrance, two (2)side door exits, and two (2) side gate exits. The facility perimeter itself is open; facility does not have perimeter fence at this time. However, as part of the licensee's application for licensure, applicant submitted a “secured perimeter request." LPA met with licensee to address this request. At this time, licensee does not have any plans to install a locked exterior perimeter fence. Licensee is entertaining putting a small gate just outside the front entrance door; however, it would not be locked. LPA advised should licensee want to install a locked perimeter fence/gate, facility would first need approval from Fire Department, then facility would need to request a waiver request from CCL. If approved, CCL will note the locked perimeter waiver in the license comments on licensee's license. Today, LPA confirmed timing of egress is 15 seconds maximum as required per Health and Safety Code (HSC)1569.699. Within 30 days, licensee will add signs to each egress location that is complaint with HSC1569.699(a)(7)(A) which states: a sign shall be provided on the door located above and within 12 inches (305mm) of the panic bar or other door-latching hardware reading: KEEP PUSHING. THIS DOOR WILL OPEN IN (15) SECONDS. ALARM WILL SOUND. Additionally, licensee will ensure sign itself is complaint with HSC 1569.699(a)(7)(B) which states sign letter shall be at least one inch (25mm) in height and shall have a stroke of not less than one-eighth inch (3.3mm). Continued on 809C... Continued from 809... During this visit, LPA also addressed Incident report submitted to CCL on 5/14/26. LPA discussed with licensee incident that occurred on 5/5/25. Per Incident report, resident (R1) attempted to elope. R1 was presenting as agitated and ultimately assaulted staff by punching them in the stomach, R1 later attempted to hit and bite other staff. EMS was called and R1 was taken to the hospital. Licensee coreferenced with R1's responsible party and hospital care team. Licensee indicated that R1 is presenting a significant escalation in exit-seeking behavior and aggression. These escalations present a change of condition for R1. Discussion concluded that R1 will remain hospitalized at this time. Facility will continue to work with R1's responsible party and hospital care team in order to determine next steps in order to provide R1 with a higher level of care. As of today, R1 is no longer a resident. LPA discussed with licensee regulation 87705(e)(4) which states that (e) Licensees that use delayed egress devices on exterior doors and perimeter fence gates shall meet the following initial and continuing requirements: (4) Residents who continue to indicate a desire to leave the facility following redirection shall be permitted to do so with staff supervision. LPA advised to staff facility such that if an occasion arises such as described in 87705(e)(4), facility has staff available to remain compliant. No deficiencies cited during this visit. Exit interview conducted with licensee and a copy of this report given.the state’s words, verbatim · CDSS document, May 29, 2026

Allegation investigated: Staff did not administer medication to a resident in care.

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings for the above allegation. LPA met with Executive Director Joe Hansen. Licensee was available by phone. Complaint alleges staff did not administer medication to a resident in care. Complainant states that a resident (R1), is on hospice but is not receiving their pain medication as necessary. Complainant reported that the licensee is not leaving the keys for the med cart and the staff are unable to access the medications to administer to the resident. During investigation, LPA interviewed licensee. Per licensee, he had a conversation with R1 focused on explaining that they have two PRN pain medication options available. We reviewed the purpose of each medication, along with the risks and benefits, in an understandable way, so R1 could make an informed Continued on 9099C... Unsubstantiated Continued from 9099... choice when requesting pain relief. When R1 reports pain, the staff process is as follows: · Staff assess and acknowledge R1’s report of pain. · Staff review the PRN medications that are currently ordered and available to R1. · Staff ask R1 which medication they would prefer. · Staff administer the medication R1 chooses according to physician orders and document the administration and response on a PRN MAR. During investigation, LPA reviewed PRN MAR and Authorization letter for R1. PRN MAR incomplete as dates present for February but nothing for January. Resident moved in January 2026. Per licensee, the lack of MAR entries were due to the fact that facility was on boarding their e-MAR system ALICE, which also has other functionalities such as appraisals. However, LPA reviewed R1’s PRN Authorization letter and found that their physician marked that R1 “can determine and clearly communicate his/her need for prescription and non-prescription medication on a PRN basis. Therefore, there a PRN MAR was not required for R1. During investigation, LPA conducted staff interviews. Two [2] out of three [3] staff denied not being able access to the medication cart. So, 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. Exit interview conducted with Executive Director and copy of this report given.the state’s words, verbatim · CDSS document, Apr 3, 2026 · control 21-AS-20260209102652

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to conduct a Case Management. LPA met with Executive Director (ED), Joe Hansen. Licensee was available by phone. On 3/9/26 CCL received an Incident Report from facility indicating a medication error had occurred for residents (R1, R2, R3, and R4). On 3/2/26 the scheduled medications for R1, R2, R3, and R4 were not administered (deficiency cited, see 809D). The Health and Wellness Director (HWD) was the staff member responsible on shift to administer medications. However, the HWD became ill during working hours and was unable to complete the medication pass that shift. Unfortunately, HWD did not communicate to upper management that they were not able to complete the medication pass for that shift. As a result, the evening medications for R1, R2, R3, and R4 were missed. According to the Incident Report submitted by licensee, none of the four [4] residents experienced any injuries, adverse reactions, or negative behaviors as a result of the missed medication pass. Due to this medication error, licensee conducted an audit of medication and medication records. The audit revealed another error pertaining to resident (R4). R4 was prescribed 5mg of Apixaban to be administered twice daily. However, medication records show that R4 only received the 5mg of Apixaban once daily. The Apixaban was prescribed on 2/18/26 and the correct milligram dose began being administered 3/4/26. Per licensee, all affected residents (R1, R2, R3, and R4) of medication errors were reviewed and monitored for any potential adverse effects. Licensee reported no injuries or negative outcomes were observed or noted. During visit, LPA reviewed charting notes of R1, R2, R3, and R4. Charting notes identify daily activity Continued on 809C... Continued from 809... and help with ADLs, but did not specifically note staff checking for adverse reactions. However, LPA did not observe any negative outcomes or side effects noted pertaining to ADLs. Per licensee, resident families were all notified as well as primary care physicians. LPA reviewed charting notes in ALICE noting primary care physician and responsible parties being notified but ED could not produce an email or fax showing notification occurred. LPA and ED discussed the importance of ensuring the notifications are documented in such a way as to produce a written record. As a result of the errors and review of the audit, licensee terminated the employment of the HWD. Additionally, a staff meeting was held to discuss medication management and administration with all staff responsible for medication administration. LPA reviewed proof of training for all staff responsible for medication administration. LPA found all required documentation present. LPA and ED discussed developing a shift change-over acknowledgment/notes sheet. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with ED and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 3, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 6, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility…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 LPA record review, the licensee did not comply with the section cited above in that R1, R2, R3, and R4 did not receive their medication which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: Facility to submit plan to conduct training on medication management including ordering, checking-in medications, and maintaining inventory by plan of correction due date. Recognizing medications changes will also be covered. Facility to conduct training by no later than 4/17/26. Training to be conducted with all staff administering medication

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Post Licensing visit. LPA met with and was greeted by Rajesh Kalra, licensee. Facility currently has seven (7) residents in care one (1) of which is currently on hospice. LPA and licensee toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Some food was found open and unsealed or missing date of opening. LPA discussed with kitchen staff and licensee ensuring all foods, especially sugar and other staples to be properly sealed. LPA observed kitchen cabinet under sink to contain disinfectants and cleaning supplies. Cabinet has locking mechanism. LPA discussed with licensee ensuring that all disinfectants remain locked at all times. LPA discussed with licensee and kitchen staff importance of maintaining accurate and up to date temperature logs on the both the refrigerator and freezer. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Resident bathrooms had required bath mats and grab bars. LPA observed pull cords present in toured rooms and bathrooms. LPA tested pull cord and observed caregivers notification alert. As of now, residents do not have pendants. LPA discussed regulation 87303 which states: Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each Continued on 809C... Continued form 809... resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. Water temperature in sinks measured at 107.8 degrees F in the kitchen and 105.4 in the community bathroom, and 114.7 degrees F in room #111, all of which are within the allowable range of 105 to 120 degrees F. Facility has another room designated staff break room. LPA conducted a review staff records. Staff mostly have training completed. Per licensee, staff that have not completed training are on not active on the floor yet. LPA discussed with licensee ensuring all training is conducted per Health and Safety Code (HSC) 1569.625 and 1569.69. LPA also discussed with licensee that First Aid is required of all staff and that at least one staff member per shift has CPR certification. However, it may be beneficial to have all staff complete CPR/First Aid in case of scheduling changes, etc. LPA discussed with licensee importance of having all staff complete a Health Screen with TB clearance before working with residents. LPA conducted a review of resident files. LPA discussed with licensee ensuring all orders for half rails are on file. LPA and licensee conducted a spot check of medication and medication records. Medication is centrally stored in a locked cart. LPA discussed with licensee and Health and Wellness Director (HWD) the requirement of PRN MARs, having current signed doctor's orders on file, and the maintenance of Centrally Stored Medication Log (CSML). All current doctors orders, including those orders from hospice, and PRNs must be on the CSML. Additionally, if a medication is discontinued a discontinuation order must be maintained in the resident's file. No deficiencies cited during this inspection. Exit interview conducted with licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Feb 19, 2026

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Christi Coppoi arrived unannounced to conduct a Pre-Licensing Inspection and met with Applicant, Rajesh Kalra. LPA and applicant initiated a tour of the facility at approximately 9:30am and made the following observations: Facility is a one story residence with twenty-two (22) single resident bedrooms, each resident room has its own private shower, some rooms have a tub/shower combo. Each bath/shower has grab bars and pull cord present. LPA and applicant discussed adding non-skid strips or mats to each bath. Facility will use SafelyYou, a fall detection and prevention technology for Memory Care communities. Each resident room therefore has a SafelyYou camera in the corner of the room, bathrooms excluded. Applicant advised LPA that disclosure of SafelyYou will be included in each resident's Admission Agreement. At this time, facility will also utilize SafelyYou in common areas. LPA advised that if video cameras are used in common areas the audio must be disabled as audio is not allowed. All camera surveillance must disclosed. Passageways were free from obstruction. All resident rooms were furnished with a small armoire wardrobe. LPA discussed regulation 87307(a)(3) and ensuring that if the resident does not provide their own items listed in 87307(a)(3) then the facility must provide it for them. Water temperature in tested bathrooms read at 105.9 degrees F in room #201 and 105.8 in room #108 which are both within the allowable range of 105 to 120 degrees F. Facility has sufficient items used for cooking. Non-perishable foods were present; per applicant, as residents move-in facility will stock perishable food. Facility has an industrial kitchen with a locking door such that it only opens with a code. Kitchen has temperature regulated freezer and two (2) refrigerators. LPA and applicant discussed regulation 87309(a)(1) requiring that disinfectants and cleaning solutions must be stored separately from food. LPA and Continued on 809C... Continued from 809... applicant discussed storing those cleaning products needed in the kitchen under or next to the eye wash station, housed in a closing cabinet or drawer. Facility has a kitchen area located in the common area (the "country kitchen") that will have snacks and beverages freely accessible to residents in care. Facility received an approved fire clearance dated November 5,2025 that allows for 27 non-ambulatory residents. LPA discussed with applicant that facility does not have bedridden fire clearance. LPA discussed with Admin the definition of bedridden per Health and Safety Code Section 1569.72(b)(1)…'bedridden' means either requiring assistance in turning and repositioning in bed, or being unable to independently transfer to and from bed being such that a resident cannot reposition themselves on their own. LPA discussed notification requirements of facility for the retention of bedridden residents per regulation 87606. Fire extinguishers were last serviced October 21, 2025. Smoke/Carbon monoxide detectors and sprinklers are hardwired and serviced by a vendor; last date of service was November 7, 2025. Facility has lighting in hallways, lighting has dimming feature that will remain on at all times. LPA advised should hallway lighting turn off, night lights will need to be implemented, per regulation 87307(d)(5). LPA confirmed that contents of the facility's First Aid Kit were sufficient, facility will purchase tweezers, and that facility has emergency lighting in case of a power outage via back up generator. Facility also has supply of flashlights. Emergency food and water supplies are stored in the industrial kitchen. LPA advised facility must maintain emergency water and food for each resident, enough for at least 72 hours per Health and Safety Code 1569.695. Before residents are admitted, facility will ensure 72 hour emergency food and water supply are on hand. Facility has three egress doors: entrance door, outdoor exit on left side of facility, and outdoor exit on right side of facility, LPA observed egress to sound appropriately. Facility has large area for outdoor activities. Outdoor areas free from obstruction. LPA discussed with applicant regulation 87219(h)(2) requiring an outdoor shaded area. Applicant showed LPA proof of purgola purchase at pre-licensing visit. LPA observed required postings including the CCL Complaint Poster, Long Term Care Ombudsman Poster, Resident's Rights, and the rights to Resident and Family Councils. Continued on 809(C(2)... Continued from 809C... Medications will be secured in a locked cabinet in the Wellness room. LPA and applicant discussed adding a lock to the Wellness room door. LPA advised Applicant to sign up for the Guardian and Provider Information Notices (PINs) that the Department sends out. Component III review conducted with applicant. LPA reviewed with applicant Health and Safety Code 1569.625 as well as 1569.69 in depth and printed for applicant. LPA discussed using approved vendor for training and the choice to conduct training on their own using materials that are current within the decade. LPA advised that using an approved vendor is not required but if they choose to conduct their own training documentation of said training must include: date, hour of duration, subject matter, instructor, and staff name/initials. No physical plant corrections required. LPA will submit facility's application for approval. Exit interview conducted with applicant. No deficiencies cited during this inspectionthe state’s words, verbatim · CDSS document, Dec 8, 2025

Type of visit: Office

COMP II by CAB successfully completed Method: Phone Call at CAB Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Nov 6, 2025