Atria Newport Beach

Allegation investigated: Staff did not dispense medication to resident as prescribed by physician Staff did not return medication to resident upon termination of services Staff made inappropriate comments to resident

On March 26, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility continue to the investigation into the allegations listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Brian Keys was present and assisted on today's visit. During the course of the investigation, the Department interviewed residents, interviewed staff, reviewed and collected pertinent documents for this complaint. Regarding the allegation, staff did not dispense medication to resident as prescribed by physician, the following has been concluded: It was alleged that staff did not dispense Resident #1 (R1) Buprenorphine 10MG patch and Seroquel 25MG tablets as prescribed by her physician. The Department reviewed R1's medication and medication administration records. The Department observed that R1 was being provided all of her medications, including her Buprenorphine 10MG patch and Seroquel 25MG tablets, as prescribed according to regulations. CONTINUED ON LIC9099-C Unsubstantiated The Department was unable to conduct an interview with R1 for this complaint, due to R1 moving out of the facility on January 31, 2025. The Department conducted an additional six resident interviews. Five out of the six residents interviewed denied the allegation and stated that they have not had any issues with receiving their medication from staff. However, one out of the six residents stated that they have received the wrong dosage of their medication by staff on two previous occasions. The Department conducted five staff interviews. Five out of the five staff interviewed denied the allegation and stated that R1 was given all of her medications according to orders prescribed by her physician. Regarding the allegation, staff did not return medication to resident upon termination of services, the following has been concluded: It was alleged that staff did not return medication to R1 upon termination of services. The Department was unable to conduct an interview with R1 for this complaint, due to R1 moving out of the facility on January 31, 2025. The Department reviewed R1's medication release form, which describes the medications that were released for R1 upon her termination from the facility. The Department observed that all of R1's prescribed medications were released to an authorized representative on January 31, 2025. The Department conducted five staff interviews. Five out of the five staff interviewed denied the allegation and stated that all medications were released for R1 to an authorized representative when she moved out of the facility. However, one staff stated that one medication was not initially provided to the authorized representative for R1. The staff stated that when they realized this issue, R1's responsible party was contacted and that they picked up the missing medication the same day. The staff stated that the medication release form for R1 was later updated to reflect the additional medication release. Regarding the allegation, staff made inappropriate comments to resident, the following has been concluded: It was alleged that staff made inappropriate comments to R1. The Department was unable to conduct an interview with R1 for this complaint, due to R1 moving out of the facility on January 31, 2025. The Department conducted six resident interviews. Six out of the six residents interviewed denied the allegation and stated that staff have never made any inappropriate comments to them. The Department conducted five staff interviews. Five out of the five staff interviewed denied the allegation and stated that they have never observed, or heard of any staff making any inappropriate comments to R1, or any other resident. CONTINUED ON LIC9099-C Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the three allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Assistant Executive Director Sofiane Lahouasnia and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 26, 2026 · control 22-AS-20250210104442

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct a case management visit. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Brian Keys and discussed the purpose of the visit. During the course of the investigation for complaint control number #22-AS-20250902095612 it was revealed by 2 of 5 staff that emergency personnel were not given necessary documentation for Resident #1 (R1) until they were leaving the facility to transport R1 to the hospital. Based on today's visit California Code of Regulations are being cited on the attached LIC9099D. An exit interview was conducted and a copy of this report, clearance letter, LIC9099D and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Mar 18, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87469(c)(1) · Plan of correction due date: Mar 25, 2026

87469(c)(1)Advanced Directives and Requests Regarding Resuscitative Measures(1) Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel... This requirement is not met as evidence by: 2 of 5 staff confirmed that emergency services were not given necessary documentation until they were leaving the facility with R1. This poses a potential health, safety, or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: Executive Director stated they will do an audit of all residents to check for POLST documentation, put in emergency folders for emergency personnel, and give an in service to staff by POC due date. Proof of POC was given to LPA and deficiency was cleared at the time of the visit.

Type of visit: Required - 1 Year

On January 12, 2026, Licensing Program Analysts (LPAs) Brandon Lopez and William Vanegas made an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Brian Keys was present and assisted on today's visit. LPAs observed that Brian Keys has a valid Administrator certificate which expires on February 18, 2027. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for one hundred and ninety five residents, all of which can be non-ambulatory, ten can be bedridden, and has a hospice waiver for eight. The facility consist of two buildings, both of which are two stories. Each building consist of resident apartments, with bathrooms located in suite, a commercial kitchen, a dining room, a wellness center, a salon, laundry rooms, medication rooms, activity rooms, and storage rooms. LPAs, accompanied by the ED, conducted a tour of the interior portions of the facility. LPAs observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPAs inspected a total of sixteen resident apartments, including both buildings. LPAs observed resident apartments to be free of hazards. LPAs observed resident apartments to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPAs observed resident beds to have clean linens and blankets. LPAs tested the call buttons in resident apartments and they tested operational. LPAs inspected the resident bathrooms in the apartments inspected and observed them to be clean. LPA observed resident bathrooms to be equipped with grab bars and nonskid floor mats. Faucets and toilets were operational. Hot water temperature measured between 111.9 and 116.7 degrees Fahrenheit. LPAs inspected the facility commercial kitchen area and observed it be clean. CONTINUED ON 809-C LPAs observed the facility to have a minimum two day perishable and seven day non-perishable food supply on hand. LPAs observed the facility has a three day emergency food and water supply kept in a storage room. LPAs observed multiple fire extinguishers in both buildings to be mounted on the walls. All fire extinguishers were observed to be charged and up to date on service. LPAs observed that the facility had their most recent fire inspection conducted on July 9, 2025. LPAs observed that the facility fire sprinklers and smoke detectors tested operational during the inspection. LPAs observed the facility conducted their last emergency disaster drill on December 12, 2025. LPAs observed the centrally stored medication to be kept in locked medicine carts located in the medication room, in their respective buildings. LPAs observed first aid kits to be stored in each of the medication rooms and they had all the required components. LPAs observed all the facility's chemicals and toxins to be stored in a locked storage room. LPAs observed other common areas such as the dining rooms, staff offices, and activity areas to be clear of any hazards. LPAs, accompanied by the ED, conducted a tour of the exterior portions of the facility. LPAs observed that each buildings has their respective outdoor seating areas. LPAs observed shaded outdoor seating areas with furniture for resident use. LPAs observed the exterior to be free of obstructions and hazards. LPAs tested the delay egress doors located on the exterior portions which tested operational. There are no bodies of water on the premises. LPA reviewed the sixteen resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed residents' medication and medication administration records. LPAs reviewed sixteen staff files. All staff are background cleared and associated to the facility. Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with Executive Director Brian Keys and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 12, 2026

Allegation investigated: Staff were unaware of residents Portable Medical Orders

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility for the purpose of investigating the above mentioned allegation. LPA was greeted and granted entry by staff. LPA met with Executive Director (ED) Brian Keys and discussed the purpose of the visit. The investigation into the allegation Staff were unaware of residents Portable Medical Orders revealed the following: Resident #1(R1) was admitted to the facility on December 14, 2023. LPA observed R1s physicians report dated January 6, 2025, stating that there is an advanced directive and Physicians Orders for Life-Sustaining Treatment (POLST) in place for R1. LPA observed R1s functional needs and services plan dated January 16, 2024, stating that there is a POLST on file and that R1s code status is Do Not Resuscitate (DNR). LPA observed R1s face sheet that has emergency contacts and code status as DNR. LPA observed a POLST dated December 12, 2023 that was marked as DNR. LPA observed the POLST to be signed by a physician. Continue on LIC9099-C Substantiated LPA observed a Directive to Physicians dated March 19, 2008, signed by R1 stating that if R1 at any time is in a terminal condition or should have an incurable and irreversible condition that, without the administration of life-sustaining treatment, will in the opinion of R1s attending physician withhold or withdraw treatment that only prolongs the process of dying and is not necessary for R1s comfort or to alleviate pain. During interviews it was revealed that staff called emergency services twice on August 24, 2025, for R1 due to changes in condition. It was revealed that 3 of 5 staff were present at the time of the incidents. 2 of 5 staff informed LPA that staff were delayed in giving emergency personnel all necessary documentation due to the printer being down. 2 of 5 staff informed LPA that emergency services were given all of the necessary documentation as they were exiting the facility with R1. Staff #3 (S3) informed LPA that emergency services were called again in the evening due to R1 being unresponsive. S3 informed LPA that they started chest compressions until emergency personnel arrived to the facility. S3 informed LPA that emergency personnel informed them that there was a POLST and DNR in place for R1 and S3 stopped compressions once they were made aware of the directives in place. 2 of 5 staff informed LPA that it is the facility policy to provide emergency personnel with necessary documentation upon their arrival and to follow the DNR and POLST directives that are in place. 4 of 5 staff informed LPA that when giving emergency personnel documentation they give the face sheet, insurance documentation, and medication list. Witness #1(W1) informed the Department that they saw staff conducting chest compressions on R1. W1 informed the Department that there was a delay with facility staff giving the necessary documentation upon emergency personnel’s arrival. Based on observation, interviews, record review and information gathered during the investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 are being cited on the attached LIC 9099D. An exit interview was conducted with ED Brian Keys and a copy of this report, LIC9099-D and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Sep 9, 2025 · control 22-AS-20250902095612

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87469(c)(1) · Plan of correction due date: Oct 7, 2025

87469(c)(1)Advanced Directives and Requests Regarding Resuscitative Measures(1) Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel... This requirement is not met as evidence by: 2 of 5 staff confirmed that emergency services were not given necessary documentation until they were leaving the facility with R1. This poses a potential health, safety, or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 9, 2025

Plan of correction: Executive Director stated they will do an audit of all residents to check for POLST documentation, put in emergency folders for emergency personnel, and give an in service to staff by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(b)(8) · Plan of correction due date: Oct 7, 2025

87468.1(b)(8) Personal Rights of Residents in All Facilities (8) ... Provide medical or nonmedical care to the resident in a manner that... unduly demeans the resident’s dignity... This requirement is not met as evidence by: 1 of 5 staff performing chest compressions when R1 had a DNR in place and did not stop until emergency personnel informed them of the DNR. This poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 9, 2025

Plan of correction: Executive director stated they will do an in service for staff regarding DNR status of residents and place a DNR list in the medication room for staff access.

Allegation investigated: Staff did not prevent resident from exiting facility alone.

Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Hanna Gough conduct an unannounced initial visit and to deliver findings on the above allegation received on January 22, 2025. LPAs were greeted and granted entry into the facility and met with Executive Director (ED) Brian Keys. LPAs explained the reason for the visit. This Department has investigated the complaint alleging that staff did not prevent resident from exiting facility alone. Resident 1 (R1) was admitted to the facility on November 22, 2024. Documents reviewed included the Physician Report (LIC602) dated July 05, 2024, for R1. Per Physician report R1’s diagnosis is Alzheimer’s dementia. Regarding the allegation that staff did not prevent resident from exiting facility alone, the following was revealed: During the investigation LPA reviewed documents including the Physician Report for R1. Per Physician Report for R1 under Mental Condition it states that R1 has wandering behavior. LPA reviewed documents including the Unusual Incident/Injury Report (UIIR) dated December 10, 2024, for R1. CONTINUED ON LIC9099-C... Substantiated Per UIIR Report on December 10, 2024, R1 exited the building, resident was found at a local elementary school and resident was returned to the building. During the investigation LPA reviewed documents including the Preplacement Appraisal Information dated November 20, 2024, for R1. Per Preplacement Appraisal Information R1 is not mentally and physically able to follow signals and instructions for evacuation. During the course of the interviews with Staff, Staff 1 (S1) reported that one of the team members left the door open and stated that R1 exited behind the staff member. Per S1, staff noticed that R1 was missing approximately 20 minutes after. S1 reported that the local Police Department was called and stated that R1 was found within 45 minutes. An immediately $500 Civil Penalty was issued today. Based on observations and the interviews which were conducted, the preponderance of evidence standard has been met, therefore the following allegation: staff did not prevent resident from exiting facility alone is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with ED Keys and a copy of this report along with the Appeal Rights were provided at the time of this visit. Per Atria Newport Beach Resident Functional Needs Assessment R1 requires status checks every two hours for up to 14 hours per day. During the course of the interviews with Staff, Staff 1 (S1) reported that R1 was never issued an Eviction and stated that R1 needs a 1:1 caregiver for their safety. Therefore, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. LPAs conducted an exit interview with ED Keys, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 31, 2025 · control 22-AS-20250122114459

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 3, 2025

Basic Services: Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: Based on interviews and records reviewed R1 exited the Memory Care through a delayed egress door, left the facility unassisted and was found at a local Elementary School. This poses an immediately health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 31, 2025

Plan of correction: Licensee to submit a Plan on Action on how facility will prevent Residents from Eloping from Memory Care. Licensee to provide an in-service training on Elopement prevention. Licensee to submit Plan of Corection (POC) by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Joseph Alejandre, Hanna Gough and Fred Arias made an unannounced visit to conduct the required annual inspection. LPAs met with Executive Director (ED) Brian Keys and explained the reason for the visit. Facility consists of two buildings, one is for Assisted Living (AL) and the other for Memory Care (MC). The capacity is 195 non-ambulatory of which ten can be bedridden and a hospice waiver for eight. Brian Keys' Administrator's Certificate expires on February 18, 2025. LPAs observed the PUB 475 poster (See Something, Say Something Poster) posted in the main entry way is 11 1/2 by 17 1/2. The PUB 475 poster posted by the mailboxes is 20" X 26." LPAs and ED Keys toured the facility. LPAs observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. LPAs observed an emergency food and water supply stored in a storage room. LPAs observed that the refrigerator and the freezer had a temperature log posted in the kitchen. The refrigerators and freezers are at the required temperature. LPAs and ED toured resident rooms on the first and second floors in AL. LPAs and ED toured the resident rooms in the MC building. LPAs inspected 15 resident rooms. All resident rooms had the required furnishings. All resident bathrooms were clean and operational. The hot water in the fifteen resident rooms inspected measured 107.2 degrees Fahrenheit to 115.5 degrees Fahrenheit. There is a fitness room and activity room for AL residents. There is a movie theater, music room and activity room from MC residents in the MC building. There is an outdoor courtyard in both buildings for residents to sit outside. There are fire extinguishers on every floor and all fire extinguishers are fully charged. LPAs observed emergency evacuation chairs in each stairwell. The last emergency fire drill was conducted on January 4, 2025. The delayed egress tested operational in the MC Building. The fire alarm and life safety system was inspected and tested operational on July 5, 2024. LPAs observed medications are kept secured in a medication cart that is locked in a medication room. LPAs observed that the First Aid Kit in the medication room has all the required elements. LPAs interviewed staff and residents. LPAs reviewed 5 staff files with no discrepancies observed. All staff files reviewed had current training and CPR/First Aid training. LPAs observed the resident library has a computer with internet access for resident use. LPAs tested the call system in both buildings, the average response time was 4 minutes. LPAs reviewed 16 resident files with no discrepancies observed. LPAs inspected medication and medication administration records. No discrepancies observed. All resident files had the required documents. No obstacles or hazards were noted inside or outside of the facility. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Jan 27, 2025

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

Type of visit: Case Management - Incident

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on an incident report submitted by the facility on December 10, 2024. Per the incident report submitted and reviewed, resident R1 left the community unassisted on December 10, 2024 at approximately 11:58am. R1's absence was noticed at approximately 12:25pm. 911 was called and a search performed which resulted in the resident being located and brought back unharmed to the facility. During the present visit, LPA requested R1's physician report and individual needs assessment which confirmed R1 resides in the Memory Care unit of the facility and is assessed to not be able to leave the facility unsupervised after following an unspecified staff member out of the secure perimeter of the memory care unit. Based on the incident report and records reviewed, it is thus confirmed that no supervision was provided temporarily until the resident was found approximately two and a half hours later. Since the incident, R1 has been provided with 72-hours of private caregiver supervision. All facility staff has received an updated in-service training on elopement prevention, documentation of which was obtained during the visit. Based on the evidence gathered during today's visit, a type A deficiency is being cited. An exit interview was conducted and a copy of the present report along with appeal rights was provided to a facility representative.the state’s words, verbatim · CDSS document, Dec 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80078(a) · Plan of correction due date: Dec 13, 2024

Per CCR Section 80078(a) regarding the Responsibility for Providing Care and Supervision: "(a) The licensee shall provide care and supervision as necessary to meet the client's needs". This requirement was not met as evidenced by: Based on interviews and records reviewed, resident R1 was assessed to be unable to leave the premises unassisted and was unsupervised for approximately 2.5 hours outside the facility. This constitutes an immediate rsisk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: Since the incident, resident R1 has been receiving 72 hours of private caregiver supervision. Additionally, a facility-wide in-service training on Elopement prevention has been conducyed on December 11, 2024.

Allegation investigated: Facility did not ensure resident's safety

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit regarding the complaint allegation above. LPA Haley was granted entry and explained the reason for the visit upon entry. During the visit LPA Haley was lead on a tour of the Assisted Living portion of the facility and made observations, conducted interviews with facility staff, one resident, and one witness during the complaint investigation. Regarding the allegation: Facility did not ensure resident's safety. Regarding the safety of Resident 1 (R1), 6 of 7 individuals interviewed were unable to corroborate the complaint allegation as reported. During the investigation it was discovered R1 was served two glasses of wine at the bar before being assessed and eventually sent out to the hospital. According to Staff 1 (S1), R1 is a very talkative person and was nowhere near that baseline before being sent to the hospital. Staff 4 (S4) stated before 911 was called, R1 was yelling at other residents and talking nonsense so S4 went to assess R1 and eventually called 911. Continued on LIC9099C Unsubstantiated When 911 was called they decided to transport R1 for intoxication. R1 returned to the facility a few hours later and had a private care companion for the remainder of the night. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegation is deemed Unsubstantiated.the state’s words, verbatim · CDSS document, Jul 22, 2024 · control 22-AS-20240718151623

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Joseph Alejandre, Faith La, Michael Tea and Rose Ruppert made an unannounced visit to conduct the required annual inspection. LPAs met with Executive Director (ED) Brian Keys and explained the reason for the visit. Facility consists of two buildings in which one is for Assisted Living (AL) and the other for Memory Care (MC). The capacity is 195 non-ambulatory of which ten can be bedridden and a hospice waiver for eight. Brian Keys' Administrator's Certificate expires on February 18, 2025. LPAs observed the PUB 475 poster (See Something, Say Something Poster) posted next to the mailboxes and not in the main entrance of the facility. The PUB 475 poster posted is 20" X 26." LPAs and ED Keys toured the facility. LPAs observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. LPAs observed that the refrigerator and the freezer had a temperature log posted in the kitchen. LPAs and ED toured resident rooms on the first and second floors in AL. LPAs and ED toured the resident rooms in the MC building. LPAs inspected ten resident rooms. All resident rooms had the required furnishings. All resident bathrooms were clean and operational. The hot water in the ten resident rooms inspected measured 111.5 degrees Fahrenheit to 119.3 degrees Fahrenheit. LPAs observed residents participating in yoga in the yoga room. There is a fitness room and activity room for AL residents. There is a movie theater, music room and activity room from MC residents in the MC building. There is an outdoor courtyard in both buildings for residents to sit outside. There are fire extinguishers on every floor and all fire extinguishers are fully charged. LPAs observed emergency evacuation chairs in each stairwell. The last emergency fire drill was conducted on March 29, 2024. The delayed egress tested operational in the MC Building. The fire alarm and life safety system was inspected and tested operational on July 7, 2023. LPAs observed medications are kept secured in a medication cart that is locked in a medication room. LPAs observed that the First Aid Kit did not contain a current edition First Aid Manual but had a pocket First Aid booklet. LPAs interviewed staff and residents. LPAs reviewed ten staff files with no discrepancies observed. All staff files reviewed had current CPR/First Aid training. All direct care staff files reviewed met training requirements. LPAs reviewed twelve resident files with no discrepancies observed. LPAs inspected medication and medication administration records (MAR) for six residents. No discrepancies observed. All resident files had the required documents. No obstacles or hazards were noted inside or outside of the facility. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Apr 23, 2024

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff not properly trained on caregiver duties

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to the facility to deliver findings on the above allegation. LPA Lyman was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as staff training records. Regarding the allegation that staff not properly trained on caregiver duties, the investigation revealed the following: Review of staff training records indicated one out of three staff did not have required training. Staff 1 (S1) has 12.5 out of 20 hours of annual training and 4 out of 8 hours of Dementia training. Based on Records reviewed, the preponderance of evidence standard has been met. Therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights. Substantiated Staff 1 (S1) does not have required annual training. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights. *This is an amended report to be deleted in the system. The continuation page was formatted onto one page at delivery and this page did not delete due to a system error. any knowledge of missing medications. Five out of five staff indicate R1's responsible party would refuse staff entry into the resident's room. Facility utilizes electronic scanning to enter a resident's room as well as to reset a pendant alert. Facility documentation shows facility staff scanned in to check on resident on average 12.02 times a day between 04/01/2022 and 04/25/2022. Pendant alert documentation indicated the resident alerted 4 times in April 2022 and staff responded, on average, within 11 minutes. Based on interviews conducted and record review, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Feb 15, 2024 · control 22-AS-20220425101715

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c) · Plan of correction due date: Feb 29, 2024

Licensees shall maintain in the personnel records verification of required staff training and orientation. This req is not being met as evidenced by: Based on record review, Licensee failed to ensure verification of staff records are in the file. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 15, 2024

Plan of correction: Licensee to provide a statement of understanding regarding the regulation and forward proof to LPA by POC due date.