Atria Evergreen Valley

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced required annual inspection and met with Executive Director/Administrator (ED/ADM) Maddalena Chavez to explain the purpose of the visit. The facility serves adults aged 60 and over. It is a three story building approved for 134 non-ambulatory residents and is equipped with delayed egress. The facility has an approved hospice waiver for 13 residents. LPA toured the interior of the facility, including the entryway, lobby, resident hallways, common areas, dining room, kitchen, laundry room, emergency food and water supply storage, medication room, activity areas, six Assisted Living (AL) resident rooms, and two private Memory Care (MC) rooms. Resident rooms and bathrooms were inspected. Emergency exits were observed free of obstruction and tripping hazards. The facility has a staffed reception lobby where visitors sign in and out. The main dining room, located on the ground floor, also serves as an activity area. Monthly activities for August were posted conspicuously throughout the building, including hallways, the dining area, and the elevator. Residents in AL received individual copies of the monthly calendar. LPA observed resident participation in activities during the visit in both AL and MC areas. The MC unit is equipped with delayed egress doors and functioning audible alarms. In the MC dining area, LPA observed that no utensils were left on tables, and all dining utensils were stored in a locked cabinet. The facility kitchen is equipped with commercial-grade walk-in refrigerator and freezer. Kitchen doors remained locked when not in use and were not accessible to residents. LPA observed sufficient emergency drinking water, a seven day supply of non-perishable food, and easy-to-prepare emergency meals. Snack stations were available in activity areas. The kitchen was found sanitary and organized. The freezer contained sufficient perishable food for at least two days. The refrigerator temperature was measured at 38°F and the freezer at 0°F. The dishwashing area and kitchen hot water were measured above 125°F, and required warning signage was posted. Kitchen staff were observed cleaning and preparing the area for the next meal. Dining room floors were clean, and residents were present during inspection. During inspection of MC and AL resident rooms, LPA observed storage for resident's personal-belonging that is sufficient and within the regulation requirement. Hot water temperatures measured using a digital thermometer ranged between 108.8°F and 115.1°F. LPA reviewed 10 staff files for background clearance, required training, personnel documentation, and current certifications. Ten resident files were reviewed for individual care plans, physician reports (LIC 602), personal rights documentation, admission agreements, emergency information, and consent forms. Medication records and the medication room were reviewed and records are current. The Resident Services Supervisor (RSS) stated medication audit procedures occur three times daily—one per shift. LPA verified that the facility conducts required training per Health and Safety Code (HSC) 1569.626. Fire and disaster drills are completed monthly across different shifts. Disaster drills occurred on 01/13/26, 02/19/26, 03/10/26, 04/07/26, 05/19/26, 06/23/26, and 07/21/26. Annual inspection of the fire alarm system is conducted by Johnson Controls, covering the entire building including stairwells, resident rooms, exterior areas, kitchen, and all floors. Fire extinguishers are placed strategically on each floor and inspected monthly. The facility maintains a fire alarm panel connected to local fire services, a manual wet standpipe, and operational sprinkler systems. No deficiencies were cited during today’s annual required inspection. An exit interview was conducted with Executive Director/Administrator (ED/ADM) Maddalena Chavez. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 19, 2026

Allegation investigated: Facility calling 9-1-1 for a lift assistance even if there is no need for emergency services

Licensing Program Analyst (LPA) Mita Partoza conducted an unannounced visit to deliver the findings of the complaint investigation. LPA met with Executive Director/ Administrator (ED/ADM) Maddalena Chavez and stated the purpose of the visit. On 01/21/2026, the Department received a complaint alleging the facility contacted 911 multiple times per day for lift assists that did not constitute medical emergencies. LPA conducted interviews with the reporting party, witnesses, staff, residents, and reviewed the facility’s 911 call logs and incident reports for the period of 08/01/2025 up to 01/31/2026. page 1 of 3 Substantiated Witnesses 1 and 2 (W1 and W2) from the local emergency response agencies reported receiving calls from the facility that did not meet medical emergency criteria, including multiple calls per day during early January. One witness stated residents were left on the floor for responders to lift, and that these calls were categorized as public service rather than medical emergencies. On 01/23/2026 at approximately 1:35 p.m., LPA Partoza received a phone call from Executive Director/Administrator (S1) regarding the above allegation. During the phone conversation LPA inquired if S1 is aware of the Provider Information Notification (PIN) 25-06-ASC. S1 stated that he/she is unaware of the PIN. LPA proceeded to read PIN 25-06-ASC to S1 and discussed the PIN with S1. LPA provided technical assistance to S1 with accessing the CCLD website PIN portal. LPA interviewed the following staff (S1 to S8) on the following dates, 01/23/2026, 02/06/26, 02/27/2026 and 03/26/2026. S1 to S8 stated that the facility is non-medical, has no 24/7 nurse, and does not maintain lift equipment. S1 to S8 stated, staff provide one person assistance and are not authorized or trained to take vital signs. Staff S1, S3 to S7 stated that staff calls 911 for unwitnessed falls, head strikes, new pain, and when residents were unable to bear weight or assist with transfers. Staff S1, S3 to S8 stated that 911 was contacted for lift assistance in non-injury situations due to size, weight or gender disparities between staff and residents and the absence of lift equipment. S1 to S8 stated that the facility does not have lift equipment and provides one person assistance. On 02/27/2026, LPA Partoza interviewed four residents (R1–R4). R1 and R4 declined to be interviewed. R2 and R3 stated they required lift assistance in the past and could not be lifted by staff. R3 stated he/she began using personal lift equipment to avoid 911 calls. Based on the documents reviewed, eleven 911 calls were made between 01/04/2026 and 01/31/2026. On 01/10/2026, two calls were made, one of the calls had no corresponding documentation. On 01/11/2026, two calls were made for two residents, followed by a third call on 01/12/2026 for one of the residents at the physician’s request. page 2 of 3 On 12/27/2025, two calls were made to 911 and both residents were transported to the emergency room. Additional documented 911 calls identified as lift assists occurred on 08/09/2025, 10/31/2025, 11/15/2025, and 12/23/2025, that was documented by staff on the incident report as unwitnessed falls and residents had no injury, declined hospital transport, or were unable to stand without assistance. Based on the Provider’s Information Notification (PIN) 25-06-ASC issued on 06/24/2025, it states, “For circumstances that do not constitute an imminent threat, as outlined in California Code of Regulations (CCR) Title 22, Section 87465 (g), Incidental Medical and Dental Care Services, as a best practice, licensees may consider alternative options for obtaining medical attention. Evaluation by an on site appropriately skilled professional or other licensed healthcare professional, Program of All-inclusive Care for the Elderly (PACE) provider, hospice care to name a few (pg. 2). “Lift Assists” occurs when a resident needs help with mobility or transferring from one position to another, but there are no signs of injury or medical concern. Licensees are responsible for ensuring that sufficient staff are available to meet resident’s needs and staff are adequately trained and equipped to assist residents with lift assistance, mobility and transfers safely, and without the need for emergency services, as long as the resident is not injured or experiencing health concerns…Thus, calling 911 solely for lift assist is not appropriate if it has been determined that the resident has not sustained any injury (pg. 4).” Based on document review and interviews, the facility contacted 911 for lift assistance in non emergency situations on the following dates 08/09/2025, 10/31/2025, 11/15/2025, and 12/23/2025. Staff reported that 911 was contacted when residents could not assist with transfers due to the absence of lift equipment and the facility’s one person assist staffing. PIN 25-06-ASC (06/24/2025) states that 911 should not be contacted solely for lift assist when no injury is present and that licensees are responsible for ensuring staff are trained and equipped to perform non-injury lift assists. Based on LPAs observations, interviews which conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22 87465 (g) is being cited on the attached LIC 9099D. An exit interview was conducted with Executive Director/Administrator (ED/ADM) Maddalena Chavez, a copy of the report and appeals rights were provided. page 3 of 3 end of reportthe state’s words, verbatim · CDSS document, Apr 8, 2026 · control 26-AS-20260121163506

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Apr 9, 2026

87465 Incidental Medical and Dental Care (g)The licensee shall immediately telephone 9-1-1 if an injury ... resulted in an imminent threat to a resident’s health..an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by: Based on interview, document reviews, licensee did not ensure that staff are available to meet resident’s needs and staff are adequately trained and equipped to assist residents with lift assistance when it has been determined that the resident has not sustained any injury. Which pose/posesthe state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: ED/ADM stated he/she will submit a written plan of correction for staff training on PIN 25-06-ASC, review alternative options based on the PIN. ED/ADM stated written plan of correction will be submitted to LPA by end of POC due date of 04/09/2026. an immediate, health, safety and personal rigths risk to persons in care.

Allegation investigated: Facility Administrator is not consistently present to supervise and direct the facility's daily operations. Facility staff did not have direct supervision for 3 months causing delays in medication administration.

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to deliver the findings of the complaint investigation. LPA met with Executive Director/Administrator Maddalena Chavez and stated the purpose of the visit. On 09/05/25, the Department received a complaint with the above allegations. On 09/11/25, 09/18/25, and 10/07/25, the Department continued with the investigation, conducted interviews and observations. LPA conducted a phone interview with Witness 1 (W1), who stated that the facility does not have an administrator, at least 80% of the time. W1stated that he/she met the Regional Vice President (RVP); however, RVP is not at the facility every day and staff did not have direct supervision for 3 months when the facility administrator and Resident Service Director (RSD) left early July of 2025. W1 stated that R1 was given a medication that belongs to another resident. W1 stated that the trainee no longer works at the facility after the incident. Page 1 of 4 see LIC 9099C Unfounded LPA interviewed the Regional Vice President/Administrator (RVP/ADM), stated that former ED/ADM and RSD resigned, RVP took over the daily operation of the facility the day after ADM vacated the position. RVP stated there was no gap of supervision for 3 months. When RVP is attending to other duties and responsibilities, he/she assigns directors and managers to supervise and manage facility operation. LPA observed RVP to be present at the facility during unannounced investigation visits on 09/05/25, 09/11/25, 09/18/25 and 10/07/25. LPA observed that a manager of the day is posted at the front desk. LPA interviewed 8 staff (S2 to S9). 8 out 8 staff stated that RVP/ADM is at the facility 3 to 5 days in a week and comes in at random times, in addition 8 out of 8 staff stated an interim RSD was assigned and an RSS was hired to fill in the position expeditiously. 8 out of 8 staff stated there was no gap for 3 months that staff were not supervised. This agency has investigated the complaint allegations that facility Administrator is not consistently present to supervise and direct the facility's daily operations and facility staff did not have direct supervision for 3 months causing delays in medication administration. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Executive Director/ Administrator (ED/ADM) Maddalena Chavez. A copy of the report was provided. page 2 of 4 According to responsible party (RP), R1s medication was put on hold on 03/22/25 when the medication technician (MT1) trainee inadvertently administered the incorrect medication. A senior medication technician (MT2) was with MT1 while in training. R1 was observed for 24 hours for possible adverse reaction. MT2 reported the incident to R1s medical team, and responsible party (RP), former ADM, RSD and CCLD expeditiously according to the policy and procedure of the facility. RP stated that there was no adverse effect on R1, and the error was correctly handled. Based on document review and interviews that facility staff did not administer resident’s medication correctly due to lack of supervision while in training may have happened or is valid, there is not a preponderance of evidence to prove the allegation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with Executive Director/Administrator (ED/ADM) Maddalena Chavez and a copy of the report was provided. page 4 of 4 end of reportthe state’s words, verbatim · CDSS document, Dec 22, 2025 · control 26-AS-20250905092711

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted and unannounced Required 1-year inspection. LPA was met by Shay Arias Community Business Director and Beth Jennings - Life Guidance Director. Administrator Kris Waluszko was not present due to prior commitment at the time of the visit. The facility serves adults age 60 and over, 134 non-ambulatory, and delayed egress and hospice waiver for 13. LPA toured the interior of the facility, including entryway, common room, dining room, kitchen and food storage, laundry room, resident bedrooms, bathrooms, medicine room, and activities room, Assisted Living and Memory Care area of the facility. All emergency exits are clear from obstruction. Facility has activities scheduled posted for the whole month. LPA observed residents participating during activity time. The water temperature measured from 105 to 120 degree F. Memory Care exits are equipped with delayed egress and working audible alarms. The kitchen is equipped with commercial grade refrigerator and freezer and doors to the kitchen have locks when not in used and are not accessible to residents. The facility has emergency drinking water supply, 2 days of perishable food and 7 days for non-perishable food. The facility has snack bars in the activity areas. The facility is equipped with fire alarm and carbon monoxide alarm system that alerts the fire department. The residents room have sufficient and ample storage for the assisted living. Rooms in the assisted living were observed to be sanitary and organized. page 1 of 2 see LIC 809-C The facility has fire and disaster drill training that was administered on 7/17/2025. Fire extinguishers strategically placed in each floor and the kitchen. The facility is equipped with smoke alarm and water sprinklers. The fire extinguishers were consistently checked and maintained. The medication room is locked are accessed by authorized employees, the room is not accessible to residents and unauthorized staff. Medications records are updated, reports are made in a timely manner. Residents were observed engaging in activities in the game room, some are outside walking and resting outdoor by the courtyard and some of the residents joined the group for an outing. The memory care unit has 2 residents that were tested positive for Covid 19, LPA was not able to tour the Memory Care Area of the facility. LPA reviewed 5 resident records and 5 staff record. LPA was able to verify that 5 Out of 5 Resident records are complete and updated. 5 Out of 5 staff record, have current First Aid/CPR certificates and have are background and fingerprint cleared by the Department. Staff training were updated according to their current positions. LPA requested the following for updated information: Admission Agreement, Dementia Care Plan, Liability Insurance, LIC 500 (personnel report), LIC 400, Surety Bond and LIC 308 and submitted to LPA by 09/09/2025. No deficiency was cited during today's annual required visit. An exit interview was conducted with Life Guidance Director (LGD) Beth Jennings and a copy of the report was provided. Page 2 of 2 End of Reportthe state’s words, verbatim · CDSS document, Sep 5, 2025

Allegation investigated: Staff unlawfully evicted a resident.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Business Director Shay Arias (BD). On 05/12/2025, the Department received a complaint with the allegation that staff unlawfully evicted a resident. On 05/13/2025, the Department conducted an initial investigation visit. LPA interviewed previous Executive Director (PED) and previous Resident Service Director (PRSD). LPA requested resident R1's physician report, appraisal needs and service plan , and R1's resident notes. Continue on LIC9099-C. Page 1 of 4. Unfounded On 05/13/2025, LPA interviewed previous Executive Director (PED). PED stated resident R1's urologist notified local public health department regarding R1's Lab test result of an infection of resistant to broad spectrum antibiotics. PED stated local public health department asked if the facility has skilled nursing unit. PED stated the facility replied to public health department that the facility has no skilled nursing unit. PED stated public health department asked if the facility has Enhanced Barrier Protection, and the facility replied no. PED stated public health department stated R1 needed to sent to hospital if the facility had no skilled nursing unit and no Enhanced Barrier Protection. PED stated the facility contacted R1's family member (FM) to send R1 to hospital but FM stated he/she was unable to send R1 to hospital at that time. PED stated the facility called non emergency ambulance service and R1 was sent to hospital on 5/9/2025, around 8:00PM. PED stated on 5/9/2025, around 11:30PM, R1 was discharged from hospital and was sent back to the facility. PED stated the facility told ambulance staff that the facility did not receive public health department's approval to accept R1. PED stated R1 was sent back to the hospital. PED stated the facility explained to another family member of R1 that R1 needs to have a clearance of blood test and to notify public health department. PED stated the facility will accept R1 back to the facility when public health department notifies the facility that R1 is clear. PED stated the facility also explained to the hospital staff why the facility cannot accept R1 back to the facility. PED stated on 5/12/2025, Monday, around 11:00AM - 11:30AM, the facility confirmed with the hospital manger that he/she understood why the facility cannot accept R1 back to the facility at that time. PED stated the facility also explained to R1's family member (FM), POA, why the facility cannot accept R1 back to the facility at that time. PED stated until 5/13/2025, the facility did not receive any response from public health department. LPA interviewed previous Resident Service Director (PRSD). PRSD stated resident R1's urologist notified the public health department regarding R1's lab test result. PRSD stated the facility received notice from public health department that R1 needs to be sent to hospital or to live in skilled nursing facility because the facility cannot provide the needed care service to R1. PRSD stated he/she consulted with Atria regional center office and they provided the advice to send R1 to hospital. S1 stated the facility contacted R1's family member (FM) but FM was unable to send R1 to hospital at that time. PRSD stated R1 was sent to hospital via ambulance on 5/9/2025 evening. PRSD stated after R1's treatment and clearance then R1 can return to the facility. Continue on LIC9099-C. Page 2 of 4. PRSD stated he/she communicated with the hospital's case worker and the manager of the hospital why the facility cannot accept R1 back to the facility at that time. PRSD stated he/she also communicate with R1's family why the facility cannot accept R1 back to the facility at that time. PRSD stated on 5/13/2025, R1 still in the hospital. On 8/6/2025, LPA interviewed Regional Vice President (RVP) Kris Waluszko. RVP stated he/she is aware of resident R1's case. RVP stated R1 lives in the facility assist living unit now. RVP provided R1's resident notes. LPA interviewed staff S1. S1 stated R1 lives in the assist living unit now. S1 stated The hospital sent R1 to a skilled nursing facility. Then R1 was moved to another residential facility on 5/31/2025. S1 stated R1 returned to the facility on 6/25/2025. S1 stated R1 is fine in the facility now. LPA interviewed R1's family member (FM), POA, in R1's room and R1 was on site in the room. FM stated R1 had UTI before and the Lab sent the test result to R1's urologist and public health department. FM stated on 5/9/2025, previous Resident Service Director (PRSD) notified him/her to send R1 to hospital. FM stated he/she was unable to send R1 to the hospital at that time. FM stated he/she asked the facility to call non emergency ambulance to send R1 to hospital. FM stated On 5/9/2025 night the hospital discharged R1 and sent R1 back to the facility. FM stated the facility did not accept R1 at that time and R1 was sent back to the hospital. FM stated R1 stayed at the hospital until 5/16/2025. FM stated on 5/16/2025, R1 was sent to a skilled nursing facility until 6/3/2025. FM stated R1 was moved a residential facility on 6/3/2025. FM stated R1 wanted to move back to the facility because R1's friends were here. FM stated R1 moved back to the facility on 6/25/2025. FM stated the facility explained to him/her why the facility was unable to accept R1 at that time. FM was with LPA and R1, and called the hospital manager (HM). HM confirmed he/she understood R1's situation at that time. HM stated the facility explained to him/her why the facility cannot accept R1 at that time. HM stated the hospital did not recommend to send R1 to skilled nursing facility. HM stated the hospital sent R1 to skilled nursing home because no residential facility accepted R1 at that time. Continue On LIC9099-C. Page 3 of 4. FM stated there might be a gap and confusion at that time. FM stated the LAB sent the test result to public health department but no one sent R1's clearance report to public health department until the skilled nursing facility sent it. FM stated R1 is fine at the facility now. Based on the review of R1's resident note and the email log between public health department and previous resident service director (PRSD), public health department and the facility were discussing R1's test result and the status of R1. The Department has investigated the above allegations. Based on the investigation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. Exit interview conducted with BD. This report was provided to review and for signature. A copy of this report was provided to BD. Page 4 of 4.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 26-AS-20250512094949

Allegation investigated: Facility took medications away from a resident

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Felicia Barkley, Administrator (ADM). On 04/13/2023, the department received a complaint with the above allegation. On 04/19/2023, LPA David Marrufo conducted an initial complaint investigation visit. On 09/04/2024, LPA Mita Partoza conducted an additional complaint investigation visit. On 04/12/2023, the facility submitted two Unusual Injury/Incident Reports (IRs) to the department. The IRs reported an incident involving two residents, resident R1 and resident R2. The incident occurred on 04/12/2023. The IRs state that a facility staff found a pill of medication M1 in R2’s living unit. The IRs state that R2 told the staff that R2 had a headache and R1 gave two pills of M1 to R2. R2 stated to have consumed one of the pills. Facility staff confiscated the other pill of M1. The IRs state that R1 stated that R2 complained of a headache and R1 gave R2 two tablets of M1. See LIC9099-C page for more information. Page 1 of 2. Unfounded LPA Marrufo obtained a copy of R1’s Physician’s Report, dated 07/12/2022. R1’s Physician’s Report states R1 is not able to administer own prescription medications, not able to administer own PRN medications, and not able to store own medications. LPA Marrufo obtained a copy of R2’s Physician’s Report, dated 07/05/2022. R2’s Physician’s Report states R2 is not able to administer own prescription medications and is able to administer own PRN medications. R2’s Physician’s Report states R2 is not able to store own medications. There is a handwritten note stating, “please manage prescription medication. PRN medications – OK with patient.” During interview on 04/19/2023, R1 stated to have given R2 a tablet of M1. R1 stated that R2 visited R1 in R1’s living unit and gave R2 a tablet of M1 from a bottle that R1 had stored in one of R1’s cabinets. R1 stated to have had the bottle of M1 since August but does not remember how he/she got the bottle. During interview on 04/19/2023, staff S1 stated to have observed a pill of M1 in R2’s sink. S1 stated R2 stated to S1 that R1 gave R2 two pills of M1, and R2 had already consumed one of the pills of M1 and was waiting 8 hours to consume the other pill of M1. S1 stated to have visited R1 to see if R1 had any more medications. S1 stated R1 gave S1 the bottle of M1 and more medications in a zip lock bag. S1 stated the bottle of M1 did not have a prescription label. S1 stated that M1 is listed as a PRN in R1’s Medication Administration Record (MAR). LPA Marrufo obtained a copy of R1’s MAR, which lists M1 as a PRN. This agency has investigated the complaint allegation listed. Based on interviews, and review of records, the CCLD has found that the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This report was reviewed with Life Guidance DIrector Beth Jennings and a copy of this report was provided. Page 2 of 2. END REPORT S1 stated R1 gave S1 the bottle of M1 and more medications in a zip lock bag. S1 stated the bottle of M1 did not have a prescription label. S1 stated that M1 is listed as a PRN in R1’s Medication Administration Record (MAR). Based on records review and interviews, there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegation is substantiated. See 9099-D for a deficiency cited per the California Code of Regulations, Title 22. This report was reviewed with Life Guidance Director Beth Jennings and a copy of this report and appeal rights were provided. Page 2 of 2. END REPORT During visit, ADM stated that the licensee does not have any facilities in Puerto Rico. Based on information from interviews conducted with staff, and records reviewed, although the allegation listed above 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. No Deficiencies were cited under California Code of Regulations Title 22. This report was reviewed with Life Guidance Director Beth Jennings and a copy of this report was provided. Page 2 of 2. END REPORTthe state’s words, verbatim · CDSS document, May 30, 2025 · control 26-AS-20230413113300

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(1)(B) · Plan of correction due date: May 31, 2025

87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement was not met as evidenced by: Licensee did not ensure that medications that were determined by the physician to be hazardous if kept in R1’s personal possession were centrally stored and not in the possession of R1 in R1’s living unit, which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: Licensee agrees to submit a Plan of Correction by PoC due date to the department stating how the licensee agrees to conduct an in-service training with staff on ensuring that medications are centrally stored, including by inspecting resident living units for unsecured medications. Once training is complete, the licensee will submit copies of training logs with names of staff trained, dates of training, training topics, and names and qualifications of trainers.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator (ADM) Felicia Barkely. The purpose of the visit was to cite the facility for a deficiency found as part of a complaint investigation for a complaint received by the department on 04/13/2023. During visit, LPA Marrufo reviewed R1's facility file and observed that it did not have a Safeguard for Property and Valuables form. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. This report was reviewed with Life Guidance Director Beth Jennings and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 30, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(16) · Plan of correction due date: Jun 6, 2025

87506 Resident Records (b) Each resident’s record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. This requirement was not met as evidenced by: Licensee did not ensure that resident R1's resident record contained a Safeguard for Personal Property and Valuables form, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: Licensee agrees to submit a copy of R1's Safeguard for Personal Property and Valuables form to CCL by Plan of Correction date.

Allegation investigated: Staff changed the resident's service plan without the consent of the resident's authorized person.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Executive Director (ED) Felicia Barkley . On 2/15/2024, the Department received a complaint that staff changed the resident's service plan without the consent of resident's authorized person. On 2/22/2024, the Department conducted an initial investigation visit. LPA interviewed 2 staff and 4 residents. LPA requested residents Appraisal Needs and Service Plan, physician report, pre-admission assessment, communication log, and incident reports. Continue on LIC9099-C. Page 1 of 3. Unsubstantiated Staff changed the resident's service plan without the consent of the resident's authorized person: The allegation is that resident R1's family member (FM) does not agree with the request from the facility to hire 24x7 1:1 private caregiver for R1. On 2/22/2024, LPA interviewed previous Executive Director (PED). PED stated he/she communicated with resident R1's family member (FM) and explained to FM the reasons why R1 needs 24x7 1:1 caregiver immediately. PED stated he/she sent a letter to FM to notify FM that R1 needs 24x7 1:1 caregiver. LPA interviewed a staff S1. S1 stated resident R1 needed 1:1 caregiver due to his/her aggressive behavior. LPA interviewed a staff S2. S2 stated resident R1 needed 1:1 caregiver because he/she continued to have aggressive behavior to others. S2 stated before LPA visit, R1 was just sent to hospital due to aggressive behavior. On 2/23/2024, LPA received an email from PED which describing the incidents regarding R1. PED stated on 1/242024, R1 was confusion and with aggressive behavior to staff. On 1/25/2024, PED called R1's family member (FM) for requesting 1:1 private caregiver for R1 because R1's aggressive behavior. The reason for 1:1 private caregiver is for the safety for resident R1 and other residents in the facility. The formal letter to request 1:1 private caregiver was emailed to FM on 1/25/2024. On 1/26/2024, R1 started to have 1:1 caregiver for 10 hours daily because FM did not agree 24 hours x 7 days and wanted to limit to 10 hours daily. PED stated he/she communicated with FM and R1's another family member (FM1) that R1 needs 24x7 1:1 caregiver. PED stated FM and FM1 understood the requirement of 24 hours x 7 days 1:1 caregiver for R1. On 2/5/2024, The facility staff had a meeting with FM and FM1 to discuss R1's continuos aggressive behavior. Continue on LIC9099-C. Page 2 of 3. Based on the review of the letter that the facility sent to FM regarding the requirements of 24 x 7 1:1 private caregiver for R1, the reasons are that R1 had a change in physical and mental condition, R1 engaged in conduct that was recognized as a wander risk, and R1 engaged in aggressive behavior which poses a potential threat to R1 and other residents' safety. Based on the review of R1's incident reports, on 1/31/2024 R1 was observed walking to the exit. R1 conducted aggressive behavior to staff while staff was redirecting R1. On 2/16/2024, around 8:45PM, R1 was found yelling at R1's family member in R1's room and hitting R1's family member. R1 was then sent to hospital. On 2/22/2024, R1 was found screaming inside his/her room and R1's room doorway was found blocked, and R1's private caregiver stated it was blocked to not let R1 get out of the room to wander. R1 was then sent to hospital. Based on the interview, records reviewed, R1's had condition change, R1 had wandering behavior and aggressive behavior. The facility notified FM and discussed with FM regarding R1's issues. The facility suggested R1 to have 24x7 1:1 private caregiver for R1's safety.. Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No citations noted for today’s visit. Exit interview was conducted with ED. A copy of this report was provided to ED. Page 3 of 3.the state’s words, verbatim · CDSS document, Nov 15, 2024 · control 26-AS-20240215155626

Allegation investigated: Facility staff are verbally abusing resident. Facility staff pushed resident to the toilet seat Staff wrapped resident's undergarment too tightly which caused constriction of blood circulation Facility staff physically abusing resident by splashing water on resident's face.

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to deliver a complaint investigation findings and met with administrator Felicia Barkley. On 12/28/2023 The Department received a complaint alleging the facility staff are verbally abusing resident, facility staff pushed resident to the toilet seat. Staff wrapped resident's undergarment too tightly which caused constriction of blood circulation, facility staff physically abusing resident by splashing water on resident's face. On 1/2/2024 - LPAs Simi Rai and Maria (Mita) Partoza, conducted interviews of staff (S1 to S6) inspected 5 resident bedroom, interview 5 residents in the memory care and requested physician's report, resident roster, staff roster and staff schedule. page 1 of 4 see LIC 9099C Unsubstantiated This agency has investigated the complaint alleging shower temperature is not within the standard. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiency were cited during today's visit based on California Code of Regulation (CCR) Title 22. An exit interview was conducted with current executive director/administrator (ED/ADM2) Felicia Barkley. A copy of the report was provided. page 2 of 2 end of report Facility staff are verbally abusing resident. On 12/13/2023 - staff 11 (S11) reported to staff 12 (S12) regarding what he/she witnessed while in training. On 12/14/23, S12 escalated the incident to former executive director/administrator 1 (ED/ADM 1). On 12/16/23, S3 was coached regarding his/her approach with memory care (MC) residents. On 1/2/2024 - LPAs Simi Rai and Mita Partoza, conducted interviews with staff 1 to 6 (S1 to S6). S1 to S6 and stated they have not seen, or heard a staff be verbally abusive to resident in MC. On 1/3/2024 - LPA conducted an interview with S11. S11 stated while shadowing he/she witnessed S3 to be mean and verbally abusive towards the resident. S11 stated "S3 did everything wrong." S11 stated, R2 and R3 are roommates and have witnessed S3 be verbally abusive to R2. S11 stated he/she reported what was witnessed to S12. On 1/18/2024 - The facility conducted an interview with 4 staff (S14 to S17). 3 out of 4 stated that S3 was loud. 1 out of 4 stated S3 comes out as abrasive and blunt. 2 out of 4 stated they did not see or hear S3 to be verbally or physically abusive to residents. On 4/27/2024, LPA Partoza interviewed ED/ADM 2 and stated S3 was placed on suspension and subsequently S3 was terminated. ED/ADM 2 stated the facility management investigated S3 regarding S3's approach with memory care residents and it did not align with the company policy. On 9/4/2024 - LPA Mita Partoza, conducted additional staff interviews with 4 staff (S7 to s10). 1 out of 4 stated S3 was loud, lots of energy, 2 out of 4 stated S3 has a foul mouth and overheard S3 say to a resident that their private part is stinky, but does not remember the resident's name and when it happened. 4 out of 4 stated they did not see S3 to be physically abusive to resident. page 2 of 4 Facility staff pushed resident to the toilet seat On 1/2/2024, LPAs Simi Rai and Mita Partoza, conducted an interview with S1 to S6, who stated they did not see or witness a staff push a resident to the toilet seat. On 1/3/2024, LPA Partoza conducted an interview with S11 who stated while shadowing he/she witnessed S3 pushed R2 to the toilet seat while being verbally abusive to R2. Staff wrapped resident's undergarment too tightly which caused constriction of blood circulation. Based of interviews conducted by LPAs on 1/2/2024 of 6 staff (S1 to S6) stated they did not see or witness a resident's undergarment wrapped too tightly. Based on interview conducted on 1/3/2024, S11 stated while shadowing S3, he/she witnessed S3 being abusive to R1 by wrapping resident's undergarment too tightly and double diapered R1. Based on interview conducted by ED/ADM 1 on 1/18/2024, 4 staff (S14 to S17), they did not witness a resident's undergarment wrapped too tightly. Facility staff physically abusing resident by splashing water on resident's face. On 1/2/2024, LPAs Simi Rai and Mita Partoza, conducted an interview of 6 staff, S1 to S6. Based on the interview 6 out of 6 stated they did not witness any staff to be physically abusive to resident, by splashing water on resident's face. On 1/3/2024 S11 stated on an email that he/she "observed a caregiver splash water on resident's face and was too rough with the resident." Based on document review, S11 reported the incident to S12. S12 escalated the incident to ED/ADM 1 and an internal investigation was conducted. page 3 of 4, See LIC 9099C Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiency was cited during today' visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with current executive director / administrator (ED/ADM 2) Felicia Barkley. A copy of the report was provided. page 4 of 4 End of Reportthe state’s words, verbatim · CDSS document, Oct 2, 2024 · control 26-AS-20231228164703

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Staff did not respond to residents’ requests for assistance in a timely manner

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced visit to deliver the finding of the complaint investigation received by the department. LPA with executive director/administrator Felicia Barkley and stated the purpose of the visit. On 4/16/2024 - The Department received a complaint allegiing that staff did not respond to residents’ requests for assistance in a timely manner. On 4/23/2024 - LPA Partoza, conducted the initial investigation and requested pendant call logs and Physician's Report (LIC 602) of residents and interviewed ED/ADM and the Facility Maintenance Director (FMD). page 1 of 3, see LIC 9099C Unsubstantiated The posters are located at the ground floor near the mail boxes and the parlor. Opposite the posters are other facility information required and issued by the city, county, state and federal agencies. This agency has investigated the complaint alleging Licensee did not ensure complaint information was posted in facility as required. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with executive director/administrator Felicia Barkley and a copy of the report was provided. Page 2 of 2 End of Report On 4/22/2024 at 10:08 a.m. LPA interviewed resident 1 (R1). R1 stated that the residents have pendant call buttons but are only allowed to use the pendant for an emergency. R1 stated on 4/10/2024 before lunch, R1 needed assistance to go to the restroom. R1 stated he/she followed the instruction called the receptionist and was told that a staff will be with R1 within 10 minutes. After 10 minutes RP stated that no one came and R1 called the reception area once again, but this time there was no answer and voicemail says the "voice mailbox is full and could not take any messages" and then the line went dead. On 4/23/2024 at 2:55 pm. - LPA conducted an interview with Facility Maintenance Director (FMD). FMD stated "in terms of priority who ever pushed the pendant first will have the priority. FMD stated that the residents are encourage to call the reception area first for non immediate emergency and is not a life and death situation and does not require the facility to call 911. On 8/29/2024 and 9/4/2024, LPA interviewed staff 1 to 3 (S1 to S3), 3 out of 3 stated the facility uses a pager and it alerts staff who needs assistance. 1 out 3 stated that the pager has a 2 to 3 minute delay, 2 out of 3 stated there's no delay. 3 out of 3 stated they respond within 10 minutes and 3 out of 3 stated sometimes there's a delay due to unavoidable circumstances such as a resident needing more time with assistance and at times staff is at the other end of the building causing delays. On 9/4/2024, LPA interviewed 2 residents, in AL. 2 out of 2 stated they rarely use the pendant. The staff are pretty good at checking their needs. 1 out of 2 stated that staff response could be better but usually it's within 10, but it can go over 10 minutes. 1 out of 2 stated, the staff tries their best to be on time. Based on document review, LPA observed that delays were for open windows, the loading dock door was open. Care staff are able to respond within 10 minutes once pendant is pressed by the resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Residents can use the pendant for incontinence assistance. No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with ED/ADM Felicia Barkley and a copy of the report was provided. page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Oct 2, 2024 · control 26-AS-20240416110730

Allegation investigated: Facility did not identify resident's need prior to admission that resulted to eviction.

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to deliver the complaint findings and met with executive director/administrator (ED/ADM) Felicia Barkley and stated the purpose of the visit. On 8/27/2024, the Department received a complaint alleging the facility did not identify resident's need prior to admission that resulted to eviction. On 8/29/2024, LPA Partoza, conducted an initial investigation, interviewed staff, residents and requested for documents. Page 1 of 2, see LIC 9099C Unsubstantiated On 9/4/2024, LPA Partoza, interviewed resident 1 (R1). R1 stated prior to moving in to the facility. R1 was assessed and the facility was aware that R1 uses an assistive device to transfer and does not require a two person assist when transferring. On 8/29/24 and 9/4/2024, LPA interviewed 3 staff, 3 out of 3 staff stated that R1 did not need a two person assist. Based on review of the facility's pre-admission assessment dated 12/31/2023, and reappraisal assessment dated 01/31/2024, the facility is able to meet the need of the resident. On 7/12/2024, based on record review, R1 was re-assessed by the Resident Services Director (RSD), and stated on the report that R1 required extensive assistance with dressing, continence, and transfer ability. Based on document reviews, R1's level of care has changed from the date the resident moved in to the facility to the date R1 was re-assessed. Based on the assessment the Community can no longer meet the need of the resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies are being cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Executive Director/Administrator (ED/ADM) Felicia Barkley. A copy of the report was provided. page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Oct 2, 2024 · control 26-AS-20240827103323

Allegation investigated: Facilty staff did not provide a resident a bathe for at least two months. Faclity hired a private caregiver for a resident without resident's DPOA's consent.

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to deliver complaint findings. LPA Met with Executive Director/Administartor (ED/ADM) Felicia Barkley. On 4/23/2024 - The department received a complaint alleging the facility staff did not provide a resident a bathe for at least two months and facility hired a private caregiver for a resident without the resident's DPOAs consent. On 4/23/2024, LPA Partoza conducted an initial complaint investigation and requested for documents from the facility such as but not limited to physician's report and admission agreement. A complaint was filed on 2/15/2024 for the 2nd allegation complaint #26-AS-20240215155626. page 1 of 2, See LIC 9099C Unsubstantiated Facility staff did not provide a resident a bathe for at least two months. On 5/14/2024, RP sent a written statement stating that "the facility administration knowingly did not bathe R1 from January 10, 2024 through March 6, 2024." Based on RP's written statement the Resident Services Director (RSD) specifically told his/her sibling that he/she was aware that R1 had not been bathed according to R1s level of care. Based on document review R1 refused to bathe for 8 weeks. On 9/4/2024 and 9/20/2024 LPA interviewed staff 1 to 6 (S1 to S6). 6 Out of 6 staff stated that they cannot force a resident if they refuse to bathe. 6 Out of 6 stated that they will try and ask 3 times to convince resident to bathe. Facility hired a private caregiver for a resident without resident's DPOA's consent. On 4/24/2024, LPA interviewed ED/ADM who stated that the third party vendor "The Key" is the provider for the 1:1 care. The Key is a separate entity from the facility. ED/ADM stated on 10/2/2024 the facility refunded RP for the amount of $3,462.00 for the remaining balance. On 4/28/2024, LPA interviewed responsible party (RP) and stated that former ED/ADM informed RP that R1 requires 1:1 care and have 24 hours to respond and make a decision. RP stated his/her sibling opted for the 1:1 care for R1 for one week and signed the electronic contract with "The Key" on 1/26/2024. RP stated they were able to speak with a representative from "The Key" and is able to change R1s care from 24/7 to 8 hrs a day. Based on review of RPs written statement, RP stated "I was able to obtain back $3,462 from the facility." Based on review of the facility's admission agreement, "if residents become a safety risk to self and others during their residency, the facility have the right at their sole determination, at the resident's expense, private duty personnel to provide supervision or assistance...The facility will communicate the decision on behalf of the resident to the respective responsible party and will occur in advance, if reasonably possible..." Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are unsubstantiated. No deficiencies were during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with executive director/administrator Felicia Barkley and a copy of the report was provided. page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Oct 2, 2024 · control 26-AS-20240423154553

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Maria Partoza and Santino Fortes conducted an unannounced annual inspection with Administrator Felicia Barkley (ADM). ADM informed that facility has 18 memory care and 71 assisted living residents. LPAs toured the facility inside and out including: kitchen, dining room, and 3 memory care resident rooms and 5 Assisted living rooms. Restrooms observed to have non-skid flooring. LPAs observed perishable food supply of at least two days and non-perishable food supply of at least seven days. Refrigerator temperature was observed at 38 degrees F and Freezer temperature was 0 Degrees F. The front yard and back of the facility was also inspected. LPA observed that walkway leading from the back has no fencing and opens to the parking lot. There was no obstructions blocking the outdoor exits. LPA observed Facility License and Resident Personal rights were posted in public view. LPA observed the medication storage area with first aid kit, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. Room temperature was at 73 degree F, and hot water temperature was measured from resident bathroom at 105.8 degrees F. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors functioned properly when tested. Fire extinguishers were last serviced on 9/5/2024. The facility conducts their fire drills quarterly. LPA reviewed facility records for 6 staff and 10 clients. LPA reviewed 5 clients medications and centrally stored medication records and were found to be updated.. No deficiencies were cited during today's visit as per California Code of Regulations Title 22. Exit interview was conducted with ADM. ADM reviewed the report and a copy was provided to ADM for signature.the state’s words, verbatim · CDSS document, Sep 20, 2024

Allegation investigated: Staff cut resident hair without consent. Staff provided a massage to a resident, which caused the resident neck pain. Staff are retaliating against residents

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced visit to continue the investigation of the above allegation and met with current Executive Director Felicia Barkley. On 10/31/2023, the Department received a complaint stating that the staff cut the resident hair without consent, staff massage the resident which caused neck pain and staff are retaliating against the resident. On 11/09/2023 - LPA conducted a complaint investigation, requested for documents to be reviewed and conducted interviews with staff and resident. page 1 of 4 see LIC9099C Unfounded On 11/9/2023 LPA, Monter interviewed R1 and stated that a facility staff (S1) gave him/her a massage by the hallway because of a sprained neck and was very rough. R1 stated he/she does not remember when the massage took place. R1 stated S2 and S3 witnessed S1 give him/her a massage R1 stated he/she complained and reported S1 to the former executive director (ED) and S1 retaliated against him/her by cutting his/her hair while in a deep sleep. Staff cut resident's hair without consent. On 11/09/2023 LPA Monter interviewed staff 3 (S3). S3 stated he/she did not see R1s hair was cut. S3 stated R1 sees people who are not there. On 11/09/2023 LPA Monter interviewed staff 4 (S4), S4 stated R1 is very confused and would say someone is chasing him/her and trying to hurt him/her. On 4/27/2024 LPA Partoza, continued with the investigation and interviewed former Executive Director (ED) by phone. Former ED stated staff do not carry scissors and does not go in the resident's room without knocking first and getting a consent to come in. ED stated that R1 experience confusion and hallucination. R1 is diagnosed with alopecia that causes hair loss. Former ED stated, the next day (10/20/2023) he/she visited R1 and asked R1 if he/she recognized the staff that cut his/her hair, R1 stated to ED that he/she does not know what former ED is talking about. On 5/18/2024 LPA Partoza interviewed staff 2 (S2) by phone. S2 stated that on 10/19/2023, after 10:00 p.m. R1 called S2 to report that a staff, while in deep sleep cut R1s hair. R1 indicated to S2 that S1 was the one who cut his/her hair. S2 stated he/she did not see any cut hair on the floor or the bed, S2 stated that R1 has medication for his/her head/hair irritation. On 8/28/2024 LPA Partoza, interviewed staff 1(S1) by phone and stated that he/she does not go inside a resident room without permission. S1 stated as staff he/she is not allowed to carry scissors and no scissors are allowed inside the resident's apartment. page 2 of 4 see LIC 9099C Staff provided a massage to a resident, which caused the resident neck pain. On 11/09/2023, LPA Monter interviewed R1 and stated that S1 gave him/her a massage without permission and was very rough and caused neck pain. It was witnessed by two other staff (S2 and S3). R1 stated he/she does not remember when the massage took place and only remember that it was in the afternoon. On 11/09/2023, LPA Monter interviewed S3, S3 stated he/she did not see S1 give R1 a massage. S3 stated that he/she heard, that S1 massaged R1 because her neck was hurting. S3 stated that R1 suffers from confusion and sees people who are not there. On 11/09/2023, LPA Monter interviewed S4, S4 stated he/she works in the AM shift and did not witness S1 giving R1 a massage. S4 stated R1 has never asked S4 for a massage. On 11/09/2023 LPA Monter, interviewed former ED. Former ED stated R1 came by the office and told ED S1 gave him/her a massage and it still hurt and asked R1 for details. Former ED met with S1 and S1 stated R1 complained of a neck pain and asked if R1 wanted a massage and R1 stated yes. On 4/27/2024, LPA Partoza, continued with the investigation and interviewed former ED and stated S1 asked R1 and R1 consented to the massage. After the massage, R1 complained to former ED of a neck pain and stated the pain did not go away. The following day R1 stated to former ED that his/her neck no longer hurts and the massage felt good. On 5/18/2024 , LPA Partoza, interviewed S2 and stated on the day of the incident (10/19/2023), R1 went to S2 for pain medication and stated that his/her neck was in a lot of pain. S2 stated R1 came back and asking for more pain medication for neck pain. S2 stated the following day, S2 observed R1 was fine and no more neck pain. On 8/28/2024, LPA Partoza, interviewed S1, by phone and stated he/she did not give massage or neck rub to R1. R1 complained he/she was in pain. S1 gave R1 a side hug and was really careful because R1 was in pain. S1 stated R1 is confused most of the time. page 3 of 4 see LIC 9099C Staff are retaliating against residents On 11/9/2023, LPA Monter interviewed S3 who stated "I don’t work with S1 at all" and only sees S1 during shift change which lasts 5 minutes. On 11/09/23, LPA Monter interviewed S4 who stated he/she worked with R1. S4 stated R1 sees things that are not there. S4 stated R1 would say someone is chasing him/her and trying to hurt him/her. On 4/27/2024 LPA Partoza, interviewed by phone former ED who stated S1 did not retaliate against R1. Former ED stated R1 have episodes of confusion. On 5/18/2024, LPA Partoza, interviewed S2 by phone who stated stated after the incident S1 stayed away from R1 and was fearful of R1. S2 stated R1 is confused and was not sure if it was S1 or another person who retaliated against him/her. On 8/28/2024, LPA Partoza interviewed S1 by phone and stated he/she does not retaliate at anyone. S1 stated R1 made him/her uncomfortable because R1 followed him/her around while working. S1 stated after that he/she stayed away from R1. Based on document reviews and interviews, R1 is diagnosed with mental disorder that contributed to R1s behavior. R1 is diagnose with head/hair irritation. This agency has investigated the complaint alleging staff cut resident hair without consent, staff provided a massage to a resident which caused the resident pain, and staff are retaliating against resident. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No citations were issued during today's visit based on the California Code of Regulations Title 22. An exit interview was conducted with current Executive Director/Administrator Felicia Barkley. A copy of the report was provided. Page 4 of 4 End of Reportthe state’s words, verbatim · CDSS document, Sep 4, 2024 · control 26-AS-20231031153118

Allegation investigated: Facility is overcharging resident for services

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced visit to continue the investigation of the above allegation and met with current Executive Director Felicia Barkley. On 10/13/2023, the Department received a complaint that the facility is overcharging the resident (R1) for services. On 5/12/2023, resident (R1) was admitted to the facility with a level 2 care for his/her neurocognitive disorder. On 7/1/2023, R1 was found at the parking lot and was looking for his/her car placing himself/herself in danger, 911 was called and prompted the facility to make a determination to increase R1s level of care. page 1 of 2 see LIC 9099C Unsubstantiated Based on responsible party's (RP) statement and interview, RP visited the facility and was informed that R1 walked out of the facility unassisted and later received an email that the facility is hiring a company to provide a 1 on 1 care for R1. Based on a written statement by RP, on 7/3/2023 RP set a meeting with the facility to discuss options for the 1 on 1 care services for R1. On 7/5/2023 RP met with former Memory Care Director (MCD) and was given two option, either to move R1 to a memory care which will cost $5500 per month or a 1 on 1 care in the assisted living unit and will cost $33,000 a month or $1,100 per day, 24/7. RP agreed to transfer R1 to memory care on 7/6/2023 and signed the room change addendum for R1 on 7/5/2023. RP stated he/she assumed that 1 on 1 care service will be stopped by MCD for R1 once R1 transfers to memory care. RP stated, the facility is charging the RPs $19,000 for R1's 1 on 1 care from 7/1/2023 to 7/18/2023. RP stated he/she did not agree for the 1 on 1 to continue after 7/6/2023. RP stated he/she were not notified that 1 on 1 care service continued for R1 up to 7/18/2023. RP stated former ED/ADM called and explained why R1 needs a 1 on 1 care even though R1s moved to memory care unit. On 10/19/2023, LPA Rai interviewed the former Executive Director/Administrator (ED). Former ED stated that R1 has 1 on 1 care service that started on 7/4/2023 and ended on 7/18/2023. ED stated the 1 on 1 continued up to 7/18/2023 because R1 continues to have agitation even in the memory care unit. Former ED stated the facility determines the need for 1 on 1 service if the resident continues to have a behavior. On 10/19/2023, LPA Rai interviewed the Community Business Director (CBD) and stated that 1 on 1 care services is through a third party and not provided by the facility. CBD stated because R1 was initially admitted with his/her spouse, the charges are billed under one account. CBD stated that all services are itemized and listed on the invoice including the 1 on 1 care. On 4/27/2024, LPA Partoza continued with the investigation and, interviewed former ED, who stated the family was in agreement with the 1 on 1 care for R1, which was provided by a third party, The Key. The contract is with the third party and not with the facility. Former ED stated when RP received the invoice from their business center the 1 on 1 care service amounted to $19,000. Former ED stated the facility met with RP and settled on sharing the cost. Former ED stated the facility paid $9,000 and $10,000 was left for RP to pay. page 2 of 3 See LIC 9099C On 8/22/2024, LPA Partoza, interviewed RP. RP stated they had a meeting the week after 7/18/2023 with former ED. The $19,000 1 on 1 care service payment was settled between the facility and RP. RP stated the family settled their portion of the balance. On 8/29/2024 LPA Partoza, interviewed current Executive Director/Administrator (ED2), and stated the meeting between the facility and the RP to settle the bill occurred on 3/2/2024 and the amount was settled middle of March 2024. Based on the review of admission agreement "if residents become a safety risk to self and others during their residency, the facility have the right at their sole determination, at the resident's expense, private duty personnel to provide supervision or assistance...The facility will communicate the decision on behalf of the resident to the respective responsible party and will occur in advance, if reasonably possible..." Based on document review and interview the facility's business center listed the services based on the admission agreement according to the level of care for R1 and his/her spouse. The 1 on 1 care service charges were adjusted and resolved. Based on document review, interviews and admission agreement, the facility provided the basic services of R1. As stipulated on the admission agreement optional services may be purchased by residents. If the level of care provided by the facility no longer is appropriate for the resident's needs, the facility will implement a change in the level of care and will consult the change with the resident or their responsible parties. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited during today's visit based on California Code of Regulations Title 22. An exit interview was conducted with current ED/ADM Felicia Barkley and a copy of the report was provided. page 3 of 3 END OF REPORTthe state’s words, verbatim · CDSS document, Sep 4, 2024 · control 26-AS-20231013103238

Type of visit: Case Management - Incident

On 7/24/2024, Licensing Program Analysts (LPAs) Maria (Mita) Partoza and Marcela Yanez, conducted an unannounced case management for incident report regarding elder abuse. LPAs met with Executive Director/Administrator (ED/ADM) Felicia Barkley and stated the purpose of the visit. The facility serves adults 60 years old and over and is a Residential Care Facility for the Elderly (RCFE) the facility is approved for 134 non-ambulatory and delayed egress. Hospice waiver for 13. LPAs requested the following documents from ED/ADM; LIC 500, LIC 602 , LIC 625, resident roster, staff contact information, responsible party (RP) for resident (R1) and training log for S1 and S2. ED/ADM provided the Police Department Case number. Other documents requested will be emailed to LPA such as training logs, statement of S1 and S2 pre-appraisal and appraisal needs and services plan for R1. Based on interview, ED/ADM stated that S2 heard R1 scream and came to see what was happening. ED/ADM stated that S2 witnessed S1 holding down R1 and forcing R1 to seat down. ED/ADM stated this happened around 6:00 p.m. of 7/20/2024 inside the common area/activity room. ED/ADM stated an internal investigation was conducted on 7/22/2024 and ED/ADM interviewed S1 and S2. S1 and S2 both gave statement to ED/ADM. ED/ADM stated that, S1 was suspended until internal investigation findings are finalized. ED/ADM stated that S2 reported the incident on 7/21/2024 by calling ED/ADM. Based on the following information gathered during the investigation, this case management will remain open for further investigation. No deficiencies were cited during today's visit. An exit interview was conducted with ED/ADM Felicia Barkley and a copy of the report was provided. page 1 of 1 End of reportthe state’s words, verbatim · CDSS document, Jul 24, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management for incident reported on 4/15/2024. This incident occurred on 4/14/2024 for medication error. LPA met with Executive Director (ED) Felicia Barkley. The report stated that facility Medication Technician (MT) gave resident (R1) the wrong medication on April 14, 2024 that happened in the morning during breakfast. R1s physician and family were notified. There was no side effects or adverse reactions reported or observed. Facility staff monitored R1 for any changes in condition after the incident. The frequency of monitoring by staff was every two hours. During today's visit, LPA Partoza interviewed ED. ED stated she was notified by the Resident Service director who was notified by the staff regarding the medication error and upon investigation it was discovered that the medication error was caused by a human error. ED stated that MT was given a final warning. ED will email LPA Partoza the requested documents from ED a copy of S1s training records and the length of observation for R1. This case management will be kept open pending investigation. Exit interview conducted with ED Felicia Barkley and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 27, 2024

Allegation investigated: Staff did not resolve noise disturbance from another resident.

Licensing Program (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Maintenance Director (MD) JR Gracia. On 11/29/23, the Department received an allegation that the facility did not resolve a resident's concern regarding a noise from another resident's bedroom which prevent residented (referred to as R1) from resting and/or sleeping. On 12/06/2023, the Department conducted an initial investigation visit. LPAs interviewed Executive Director/administrator (ED/ADM), 4 staff, and 2 residents. LPAs toured the 2nd floor and visited the resident apartments, and other possible sources of noise, like the activity area, and the medication Continue on LIC9099-C. Page 1 of 2. Unfounded During the visit, LPAs interviewed Executive Director/Administrator (ED/ADM), residents (R1 and R2), and staff (S1 to S4). ED/ADM stated that R1 did complain about the loud TV volume coming from R2's bedroom. ED/ADM stated R1's was complaint about R2's TV volume was addressed, a memo was sent to all residents stating the quiet time so everyone can rest, the memo states “To ensure that this environment is maintained, we request that all residents monitor the volume of their televisions and radios…TVs must be turned to lower volume around 10:00 p.m. or turned off around bedtime.” In addition to the memo, ED/ADM installed acoustic panels on both sides of shared walls and suggested to R1 if he/she is willing to move to another apartment, but R1 refused. ED/ADM asked R2 to lower down the TV volume and made suggestions to R2 to use a headset. R2 refused to utilize a headset. ED/ADM asked R2’s if instead R2 is willing to move the TV to a different area in R2s apartment. R2 stated “yes.” ED/ADM instructed R1 to alert staff if R2's TV volume becomes loud during sleeping hours if needed. Interviews with staff stated that after installation of the acoustic insulation panels on both walls, they could not hear noise from R2's bedroom but R1 continued to complain that a noise can still be heard from R2's apartment. Staff stated that none of the residents complained about loud TV noise from R2's bedroom. Staff check on R2's bedroom when R1 alerts them about loud noise from R2's bedroom but when checked either R2 was not in his/her bedroom or TV was not in use, or volume level was at 20. Based on observation and interviews, the facility made efforts to eliminate every possibility of noise reduction from R2's bedroom to R1's bedroom. No other residents complained of noise from R2's bedroom. The Department has investigated the above allegations. Based on the interviews conducted with residents and staff, observations and documents reviewed, the allegations were UNFOUNDED. Meaning that the allegations were false, could not have happened and/or are without reasonable basis. No deficiencies cited. This report was reviewed with MD and a copy of this report was provided MD. Page 2 of 2.the state’s words, verbatim · CDSS document, Feb 12, 2024 · control 26-AS-20231129142215

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Monter conducted an unannounced case management visit regarding an incident report. LPA met with (ADM) administrator Flavio Silva & explained the purpose of the visit. On October 27, 2023, the Department received an in incident report stating resident, R1 had consumed a cleaning solution. R1 reported that his/her throat was sore, and facility staff called 911. R1 was transported to a hospital. R1 returned the same day with no change of orders. On October 30, 2023, LPA interviewed resident R1 in the Assisted Living Unit. R1 stated he/she was feeling better. With R1’s permission, LPA conducted an inspection of R1’s apartment. LPA did not find cleaning solutions and other items that could pose hazard to R1. LPA interviewed ADM. ADM stated R1 moved into the facility on May 15, 2023. ADM stated R1 resides in assisted living unit and requires minimal assistance when it comes to ADL's. ADM stated R1 manages his/her own medications. ADM stated R1 has not shown any signs of a change of condition in the past 5 months. R1's responsible party was informed about incident. A 2-hour check on the resident was in place as of 10/27/2023. LPA recommend to ADM to maintain the monitoring of every two hours is log and documented by staff, in every shift, and to report if there’s any change on R1’s health and medical condition. R1 is schedule to be seen by his/her PCP. LPA interviewed 2 staff (S1 and S2). S1 and S2 stated R1 has not had a change in condition and has not shown any signs confusion. LPA requested staff schedule for the week ending 10/27 and R1's facility files such as but not limited to Physician’s report, Appraisal Needs and Services Plan and Medical Records. LPA requested and reviewed R1's Appraisal Needs and Services Plan LIC625 dated July 9, 2023. ADM stated did not update LIC625 after R1’s incident on 10/26/23. Although the facility implemented increase monitoring on R1 of every two hours and facility removed all cleaning solutions and other toxic materials from R1's apartment unit. Furthermore, ADM or Resident Services Director did not update LIC625. ADM stated that R1 will be seen by his/her PCP on 10/31/23. In addition, LPA interviewed staff who stated that every 2 hour checks is being done. LPA interviewed Resident services director (RSD). RSD stated he/she was not able to update needs and services plan. RSD stated he/she did request R1's physician for an updated physicians report. RSD stated, R1 was given 2 hours status checks but the entire care plan itself was not updated. Deficiency was cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with Administrator Flavio Silva and a copy of the report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Oct 30, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a) · Plan of correction due date: Oct 31, 2023

(a) The pre-admission appraisal shall be updated... to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement was not met as evidence by: Based on document review and investigation, R1 was not reassessed after R1 consumed cleaning solution on 10/26/23. R1’s Reappraisal was not updated for the facility to develop the care plan to meet resident’s needs. This poses an immediate risk to the health of the resident.the state’s words, verbatim · CDSS document, Oct 30, 2023

Plan of correction: Licensee agrees to send plan of action in how the facility will ensure care and supervision are provided to residents whose conditions have changed or observations with updated care plans and submit the plan of action to CCL by POC date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit. This case management visit was regarding an incident which occurred on 9/25/2023. LPA Rai met with Administrator (ADM) Flavio Silva and stated the purpose of the visit. Per report, facility medication technician (S4) did not administer medication to resident (R1) resulting in missing a dose of medication prescribed by R1's physician. The R1's responsible party was contacted right away and R1's primary care physician was notified. Facility staff was advised to monitor R1 for any change of condition. During today's visit, LPA Rai interview with ADM, who was notified by another staff member of the medication error and upon investigation it was discovered the medication error did occur based on electronic Medication Administration Record (eMAR) and ADM observed the missed dose still within the medication package. S4 was suspended and later terminated. ADM stated R1 was okay after the reported incident. LPA Rai interviewed S1-S3. LPA Rai obtained a copy of S2-S3's most recent completed training course and resident roster. ADM will email LPA Rai copy of S2-S4's training records and updated LIC 500. This case management will be kept open pending investigation. Exit interview conducted with Administrator (ADM) Flavio Silva and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 19, 2023