Atria Park of Lafayette

Allegation investigated: Lack of supervision resulting to resident sustaining injury from assault by another resident.

On 03/25/2026 at 02:45 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct an initial 10-day complaint investigation and to deliver findings regarding the allegation above. LPA met with Executive Director Jonathan Woolbright and explained the purpose of the visit. During the course of the investigation, LPA obtained copies of Physician’s Reports, Appraisal Needs and Services Plans, After Visit Reports, Unusual Incident Report LIC624, and the Identification and Emergency sheets for two (2) residents. LPA interviewed two residents, three (3) staff, and one (1) one-on-one care provider. Allegations: Lack of supervision resulting to resident sustaining injury from assault by another resident. Investigation Findings: It was reported to the department that R1 was brought by an ambulance with a complaint of left shoulder, left forearm and left leg skin tears with left hip pain post "assault by another resident”. RP reported that Charge RN Grace at Atria, informed RP that R1 was found on a floor in room with another resident In the room on 3/19/26 at 4:30AM. Both residents are from the memory unit. S2 reported that in the early morning hours on the day of the incident, staff reported that R1 called out for help after falling. Upon arrival R1 was seen on the floor with skin tears on left elbow and left knee consistent with a fall. Continued on LIC9099C Unsubstantiated Continued from LIC9099 The caregiver then called for assistance from the night shift nurse as the caregiver saw R2 in R1’s bathroom. S1, S2, S3 informed LPA that protocol for a fall is for staff to call 911 for any unwitnessed fall. As the night shift nurse called 911 and assisted R1, the caregiver then tried to redirect R2 out of R1’s bathroom. R2 informed the caregiver that R2 was trying to find the bathroom and did not want to leave the bathroom due to R2’s urgent need. The caregiver was able to redirect R2 out of R1’s room and into a public bathroom nearby. Paramedics arrived, addressed R1’s skin tears, and took R1 to the Emergency Room. The paramedics also took R2 to the Emergency Room for evaluation. No Urinary Tract Infection noted for R2. R1 has a history of skin tears due to falls as noted in R1’s medical records and a history of Dementia. R1 Physician’s Report shows R1 has thin skin prone to tears. R1 does require assistance with toileting, wears diapers, but will still try to use the toilet on R1’s own. S1, S2, and S3 all informed LPA that R1 has a history of getting up at night to use the toilet and falling. R1 uses a wheelchair but will still try to walk on own thus causing R1 to fall. Staff have been monitoring R1’s sleep patterns to assist with toileting needs and encourage R1 to ask for assistance before getting up. R1 was brought back to the facility the next day with bandages covering the skin tears. No bruising or signs of physical abuse noted on the After Care Summary. LPA interviewed R1. R1 had no recollection of the incident. R1 did still have bandages on the skin tears. R1 could not recall why the bandages were there. R1 informed LPA R1 feels safe in the community. R2 moved into the facility two days prior to the incident. S2 noted the R2 had not slept the first full night, and very little the next. R2 was still very unfamiliar with the facility on the day of the incident. S3 did the initial move in assessment. S3 reported R2 showed no signs of aggression prior to moving in. S1, S2, and S3 all reported R2 being polite, easy going, and non confrontational with staff or fellow residents. After returning from the Emergency Room, S2, and S3 both suggested R2’s family hire a one-on-one care provider as R2 was still having difficulties sleeping and adjusting to new surroundings. LPA interviewed R2. R2 had family over who stayed in the room during the interview. R2 had no recollection of the incident. R2 reported still getting use to the facility, but enjoys it. LPA met R2’s one-on-one care provider, S4< who reported S3 being polite and respectful. Continued on LIC9099-C Continued from LIC9099-C LPA toured the memory care unit. LPA observed R1’s room is close to a common bathroom and to R2’s room. Residents in the memory care unit do not usually have their doors closed as confirmed by S2. It would therefore not be unreasonable for a resident with dementia and new to the facility to get confused and walk into the wrong room while looking for a bathroom. R1 did have an unwitnessed fall, and R2 happened to walk in at the same moment. LPA reviewed the staff schedule. There are two Resident Services Assistants and one nurse on night shift for memory care. All were working that morning. No resident before the day of the incident required a one-on-one care provider. LPA determined sufficient staffing needs were met on the day of the incident. Based on interviews and record review conducted, the above allegation is unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy this report was provided.the state’s words, verbatim · CDSS document, Mar 25, 2026 · control 15-AS-20260320102443

Type of visit: Required - 1 Year

On 03/25/2023 at 10:30 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct an annual required inspection. LPA met with Executive Director Jonathan Woolbright and explained the purpose of the visit. LPA toured the facility including but not limited to, bedrooms, bathrooms, multiple activity rooms, kitchen, outside, and common areas. LPA observe lighting in all rooms adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees Fahrenheit. The hot water temperature is controlled in a boiler room. The temperature was measured at 115 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and two-days of perishable foods. Centrally stored medications, sharps are locked and inaccessible to residents in care. Fire extinguisher was last serviced on 06/01/2025. Emergency disaster drills are conducted monthly. Last drill conducted on 02/25/2026. LPA reviewed five (5) resident records and five (5) staff records, all were complete. No deficiencies observed or cited during this visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 25, 2026

Allegation investigated: Staff violated resident's personal rights

On 10/20/2025 at 10:40 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regards to the allegation above. LPA met with Community Business Director Grace Abaeg and explained the reason for the visit. During the course of the investigation, LPA obtained and reviewed resident roster, staff roster and staff schedule for October, as well as the Physician’s Report (602), Notification of Incident or Change in Condition forms, and Functional Needs Assessment for R1. LPA interviewed R1, W1, S1, S2, S3, S4, S5. S6 was interviewed by phone. Allegations: Staff violated resident's personal rights. Continued on LIC 90099-C Unsubstantiated Continued from LIC9099 Investigation Finding: It was reported to the department that a male caregiver touched R1’s breast in an inappropriate manner. R1 reported the incident to her private companion through UPLIFT Home Care Agency, who then reported the incident to the owner of UPLIFT, who ultimately reported it to CCLD. LPA interviewed R1 in R1’s room. W1 was present and would not leave during interview. R1 felt more comfortable with W1 present, and W1 did not want R1 to be interviewed alone despite LPA asking W1 for some privacy for the interview. R1 told LPA that a male caregiver, who’s name R1 could not readily remember, assisted R1 back from a common room where R1 and other residents were watching a movie. R1 said the caregiver took R1 by the arm and led R1 up 6 steps and down the hall to R1’s room. At the door R1 informed the caregiver that R1 did not need further assistance. R1 said the caregiver insisted on assisting in removing R1’s blouse. While removing the blouse, the caregiver touched R1’s breast making R1 feel uncomfortable. When LPA asked R1 if R1 could remember any features, or the name of the caregiver, R1 hesitated, as if to think, and W1 prompted R1 with a name. R1 thought about it, then repeated the name. R1 said R1 sees the caregiver from time to time around the facility prompting W1 to say this is how W1 knows the name of the caregiver. R1 did not seem to really know it was in fact that caregiver. R1 is certain it was a male caregiver. W1 was more certain. LPA interviewed W1 in the hallway. W1 feels R1 gave a detailed description of the event and, although R1 has some memory issues with time, W1 thinks R1 remembers the event well enough. LPA interviewed S1 who was present the day in question as well as the day before. S1 reported that R1 has been found on multiple occasions wandering around the facility and forgetful as to why R1 was out in the halls and where R1 was going. S1 recalled that the day before, another caregiver S4, had to walk R1 back to R1’s room after staff saw R1 wandering the hallway appearing disoriented and with a lean to R1’s walk. S4 informed LPA that S4 had the day before assisted R1 back to R1’s room from the other side of the building, but on the same floor. Continued on LIC9099-C Continued form LIC9099-C S4 walked R1 back into R1’s room and left. S1 then radioed S4 and asked S4 to check on R1 as S1 felt R1 needed to be checked on. S4 entered R1’s room and asked R1 if R1 would like assistance getting ready for bed. R1 agreed, and S4 went to grab R1’s bed clothes. While bringing over the clothes, R1 took R1’s own top and underwear off unassisted. S4 handed R1 the clean clothes but did not touch R1. S4 offered R1 S4’s hand to get out of the chair. S4 then guided, from behind, R1 to bed, lifted R1’s legs onto the bed, and left. S1 confirmed S! asked S4 to assist in that manner. S4 is not the caregiver R1 named as the one who touched R1. The named caregiver, S6, worked NOC shift that night. LPA interviewed S6 by phone. S6 informed LPA S6 did not interact with R1 that night but had in the past gone into R1’s room to clear a Pedant alarm. S2, S3, and S5 have all interacted with R1. Each have reported that R1 confuses easily and will wander out of R1’s room at different hours both day and night. Neither S2, S3, nor S5 witnessed anything. No staff interviewed by LPA witnessed any interaction between a caregiver and R1 that appeared inappropriate in nature. S5 is usually assigned R1 in the evenings. S5 does not assist R1 with changing. S5 informed LPA that R1 did not need assisting the day of. S5 was not on shift the night before when S4 assisted. The night before S4 was assigned to cover R1. Based on interviews and no corroboration of the incident, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff made inappropriately comment to resident in care is unsubstantiated. No deficiencies observed during visit.the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 15-AS-20251013153349

Allegation investigated: Staff made inappropriately comment to resident in care.

On 09/05/20245 at 10:40 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to further investigate and deliver findings for the allegations above. Upon arrival, LPA met with Memory care Director Susana Chavez and explained the purpose of the visit. During the course of the investigation, LPA interviewed six (6) staff, and four (4) residents. LPA also, obtained the following information: R1’s Physician’s Report (602), and staff roster. Allegation: Staff made inappropriately comment to resident in care. Investigation Finding: Based on staff and resident interviews this allegation is Unsubstantiated. LPA interviewed multiple staff and residents. Staff shared that residents can, at times, become stern in communication during care services. Continued of LIC9099-C Unsubstantiated Continued from LIC9099 Staff have responded by asking that resident to be less stern, which could be perceived as inappropriate. Staff and residents recognize a lack of communication during one on one care can lead to misunderstandings. Residents interviewed feel staff are friendly, kind, and have never seen staff be inappropriate to residents. Staff interviewed reported not seeing, hearing, nor themselves being inappropriate towards residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff made inappropriately comment to resident in care is unsubstantiated. No deficiencies observed during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 5, 2025 · control 15-AS-20250818102737

Allegation investigated: Staff did not respond to resident's requests for assistance in a timely manner

At 12:05 pm on this day, June 5, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with National Operations Specialist/Interim Executive Director Kawana Anthony, and informed the reason for visit. During the course of investigation, the Department obtained copies residents roster and staff schedule. Copies of including but not limited to the following residents’ documents were obtained: Resident Face Sheets; LIC601 Identification and Emergency Contact Information; Admission Agreements; LIC602A Physician's Reports; Pre-placement Appraisals; Functional Needs Service Plans; Unusual Incident Reports; Notification of Incident or Change of Condition; call button logs/records for November 17, 2024 to November 23, 2024.The following were interviewed: resident’s family member (FM1) on 2/26/25; staff (S1, S4) on 3/12/25; 3 residents on 4/10/25 ......continued on 9099C (page 2) Substantiated Page 2 It was alleged that resident pushed the call button more than once and was not responded timely. FM1 stated that on 11/18/24, around 8 pm, R1 needed help with getting to the bathroom. R1 pushed his call button for assistance four times, and nobody responded, so R1 got up on his own and fell. The Department interviewed former Resident Services Director (S1) who stated that call button calls should be answered within 10 minutes. One of the 3 residents interviewed stated that staff responded to her call in 10, 15 minutes and at times this resident waited for 20 minutes. The other resident stated that staff know who is calling and may have a different response to each resident. Review of call button call records confirmed R1 pressed the call button 4 times on 11/18/24 and was responded only after 14 minutes. Documents also showed several residents pressed their call buttons more than once to as many as 7 times and took the staff to respond longer than 10 minutes to 30 minutes. Based on interviews and records review, the preponderance of evidence standard has been met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with Kawana Anthony, Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. Page 2 Allegation: Staff neglect led to the death of resident (R1). It was reported that resident (R1) had fallen prior to moving to the facility and that facility staff were aware that R1 was a fall risk. Reporting party (RP) also indicated that R1 fell twice at the facility and on the first fall, R1 was not sent out to the hospital. On the 2nd fall incident on 11/18/24, R1 needed help at around 8:00 pm and was not responded timely, R1 got up by himself, fell, broke the right leg, and sustained injuries to the back and hip. It was further reported that at some point, staff found R1 on the floor, picked up and put R1 back to bed. RP further indicated that R1 was sent to the hospital the following day and diagnosed with aspiration pneumonia and injury. R1 was moved to another facility where R1 passed away on 1/04/25 due to injuries and trauma from fall and pneumonia. FM1 stated that R1 fell at the facility on 10/2024. R1 fell again on 11/2024 resulting to R1 sustaining serious injuries that contributed to R1’s death. FM1 further stated that on 10/2024, R1 was dropped by S2 in the bathroom and put R1 back to bed. S2 denied the allegation and stated he was not assigned to R1 and only escorted R1 back to his room one time. FM1 stated that R1 was trying to use the bathroom and fell going to the bathroom on 11/2024. R1 sustained injuries to the right fibula, hip and back. R1 was assisted by S4 back to bed before S4 left at the end of S4’s shift. S4 stated he found R1 near R1’s walker on the night of the incident and that he could tell R1 was physically hurt as R1 kept saying “head hurt”. S4 further stated helping R1 to R1’s wheelchair and went to get the facility nurse, S5, who called 9-11. S5 confirmed that R1 fell on 11/2024 and that S4 called and informed S5. S5 stated she called R1’s wife, FM2, and FM2 later agreed to send R1 out to the hospital due to R1 was in pain. S3 was not assigned to R1. S6 stated she was given instruction by S1 to investigate the fall incident that was reported by R1’s family. S6 further stated that R1 was not able to provide information about the fall incident that happened on 10/2024 and that R1 was not in pain. S1 confirmed that she instructed S6 to investigate because she wanted to complete an incident report. S1 stated that S2 denied picking up and putting R1 back to bed when R1 fell on 10/2024. S1 also stated that R1 fell again on 11/2024 and that 9-11 was called. .......continued on 9099C (page 3) Page 3 Review of records showed R1 fell the first time on 10/27/24, no injuries sustained and R1 refused transport to the emergency. R1 fell the second time on 11/18/24, 9-11 called and R1 was sent out and diagnosed with a closed displaced fracture of lateral malleolus of right fibula and no other injuries. Death certificate indicated R1 passed away on 1/04/25. Cause of death was due to aspiration pneumonia and Parkinson’s disease and no other significant conditions contributing to death. Based on records review and interviews, there is not a preponderance of evidence standard to prove that violations occurred, therefore the allegation is unsubstantiated. Allegation: Staff did not seek medical attention for resident in a timely manner. It was reported that on 11/18/24, R1 needed help at around 8:00 pm and was not responded timely, R1 got up by himself, fell, broke the right leg, and sustained injuries to the back and hip. It was further reported that at some point, staff found R1 on the floor, picked up and put R1 back to bed. RP further indicated that R1 was only sent to the hospital the following day. Review of Emergency Medical Services (EMS) records indicated that there were two visits on 11/18/2024 to the facility for R1. The first EMS response and visit occurred at about 2210 hours and the second at about 2313 hours. During the first visit, Emergency Medical Technicians (EMTs) contacted R1’s wife, FM2, and informed FM2 about what happened to R1. FM2 and R1’s daughter, FM1, decided there was no need for R1 to go to the hospital. The EMTs left at about 2305 hours. The second visit at about 2313 hours resulted in R1 being transported to the hospital due to complaints of pain in his leg and back. The Department was not able to interview R1 due to R1 had passed away prior to the Department receiving the complaint. Therefore, the allegation is unsubstantiated. Based on records review and interviews, and the Department unable to interview R1, the two allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 15-AS-20250123123225

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Jun 6, 2025

§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. -This requirement is not met as evidenced by: -Based on records review and interviews, the licensee did not comply with the section when staff did not respond to residents' call timely which posed an immediate safety and/or personal right risks to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: Interim Executive Director to in-service the staff and copy of training topic(s) with attendees signatures to be submitted by 6/06/25.

Allegation investigated: Lack of care and supervision resulting in resident sustaining serious injury while in care

On 04/02/15 at 10:30 am, Licensing Program Analyst (LPA) arrived unannounced to deliver complaint investigation findings for the above allegation. LPA met with Operations Specialist, Kawana Anthony and explained the purpose of the visit. During the course of the investigation, the Department obtained information, interviewed 4 residents and 8 staff, and reviewed records. The Department obtained the following documents, including but not limited to: Personnel Report (LIC 500), Resident Notes, Preplacement Appraisal, Needs and Services Plan, Visitor Log, Resident Sign in/out Sheet, and Staff Contact Information. The Department investigated allegation neglect/lack of supervision resulting in resident sustaining serious injury while in care. On 06/04/2023, Resident 1 (R1) exited the facility after a visitor held the front door open for R1. Continued on 9099C... Unsubstantiated ...Continued from 9099 According to the incident report dated 6/6/23, R1 was found on the ground in front of community entrance with R1’s chair behind R1 at approximately 3:40 p.m. on 6/4/23. 9-1-1 was called and R1 was transported to John Muir Emergency. According to the triage record dated 6/4/23, the chief complaint was a fall. Triage record indicated that R1 fell out of the wheelchair and was down on the ground with wheelchair on top of R1. R1 was diagnosed with traumatic subarachnoid hemorrhage (HCC) and returned to the facility under Suncrest Hospice on 6/8/23. On 7/11/23, the Department interviewed 4 staff (S1, S2, S3 and S4) and 4 residents (R1, R2, R3 and R4), and reviewed the facility’s video camera footage. Video camera footage confirmed that an unknown male held the door opened for R1 to exit and R1 was seen leaving the facility lobby and headed to the left of the facility property. Approximately four (4) minutes later, unknown elderly went into the facility and walks to the front desk, then S3 was seen exiting the facility, and other staff were seen responding outside to the left of the facility. The Department attempted to interview R1, but unable to obtain additional information. On 7/18/23, the Department interviewed 2 staff (S5 and S6). Additionally, interviews with S7 and S8 were conducted on 8/21/23 and 8/23/23 respectively. Although R1’s Physician’s Report dated 5/2/23 indicates R1 is unable to leave the facility, 4 of 8 staff stated residents are able to sit outside in the sun without supervision. Prior to the fall, 3 of 8 staff stated R1 was communicative of R1’s needs to staff. S7 stated that R1 was not a risk of AWOLing. S1 and S8 stated R1 did not require constant supervision and the facility does not monitor front door at all times. S2 stated the facility’s policy is for residents to sign out when they leave the property but not when sitting outside. Based upon the interviews conducted and information obtained during investigation. The above allegations are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 2, 2025 · control 15-AS-20230628163332

Allegation investigated: Due to neglect/lack of supervision, resident sustained multiple unexplained bruises while in care. Staff did not provide resident with pain medication. Staff did not safeguard resident's personal belongings.

On 3/24/2025 at 12:20 p.m. Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Executive Director, Corrine Tanchoco(ED) explained the purpose of the visit. Allegation: Neglect/Lack of Care: Due to neglect/lack of care, resident sustained multiple unexplained bruises while in care. Report continue on LIC 9099c... Unsubstantiated Finding: Unsubstantiated During the investigation, the department conducted residents and staff interviews, obtained and reviewed R1’s including medical records, Suncrest Hospice Records, care notes, death Certificate. On 09/08/2023, R1 fell out of her bed and sustained bruising to R1 chest and back. Staff did not call 911 and called Suncrest hospice to have R1 assessed for injuries. The hospice stated that R1 did not have any injuries after her initial fall. Staff admitted that R1 was a fall risk due to her “wiggling” out of R1 wheelchair. Staff confirmed that R1 never fell out of Hoyer lift, was never transferred by one caregiver, and was a two person assist. Staff admitted that they would place R1 in the middle of the bed and face R1 toward the wall so that R1 would not fall out of the bed. S7 admitted that R1 bruises came from R1 falling out of her bed at the facility. Allegation: Staff did not provide resident with pain medication Finding: Unsubstantiated On 9/9/2023, 9/13/2023, 9/14/2023, 9/18/24, 9/20/2023, 9/21/2023, and 9/24/2024 Skilled nursing visit stated R1 seemed comfortable with no indication of pain. R1 did not have a routine pain medication. On 9/12/2023 Medical Social Worker (MSW)- Visit Notes- Observed to be well groomed and no pain behavioral issues. Care staff (S2 and S3) stated “With R1 we are trained to observed R1 pain by, R1 body language, and facial expression. During those time that S2 and S3 are assisting R1 if S2, and S3 noticed R1 have anybody/ facial expression of pain they would notify Med-techs (S4 and S5) right away. S4 stated when S4 are notified by S2 or S3 S4 would attend to R1 with a floor Nurse and evaluate R1 pain level, and if R1 need PRN(Tylenol) we would provide that, but there’s no doctor ordered on a given time of PRN (as needed). S4 stated if our nurse evaluate R1 need morphine S4/ floor nurse would contact Hospice Nurse because R1 is on Hospice, and they need to give permission. S4 stated there was not a time that R1 is in pain and was not provided with pain medication. Report continue on LIC 9099c... Allegation: Staff did not safeguard resident's personal belongings. Finding: Unsubstantiated During the investigation, the department conducted residents and staff interviews. The department interviewed S2, S3, S7, and S8, all four staff was working with R1. 4 out of 4 stated that there was not a time that R1 have anything missing. They have not heard any complaint from R1 family members. 4 out of 4 stated they did not see R1 wearing anyone else clothing, nor left R1 sleeping on the bed without any bedsheet. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a report provided to ED.the state’s words, verbatim · CDSS document, Mar 24, 2025 · control 15-AS-20231023143344

Type of visit: Required - 1 Year

On 02/11/2025 at 09:00 AM, Licensing Program Analyst (LPA) D. Doidge arrived unannounced to conduct an annual required inspection. LPA met with Resident Services Director Beverly Mercurio and explained the purpose of the visit. LPA toured the facility including but not limit to, bedrooms, bathrooms, multiple activity rooms, kitchen, outside, and common areas. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees Fahrenheit. The hot water temperature is controlled in a common boiler room. The temperature is set to 112.3 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps are locked and inaccessible to residents in care. Fire extinguisher was last serviced on 06/21/2024. Emergency disaster drill are conducted quarterly. Last drill conducted on 12/01/2024. LPA reviewed five (5) resident records and five (5) staff records, all were complete. Continued on LIC809-C Continued from LIC809 LPA requested the following documents to be submitted to CCLD by 02/18/2025. · LIC 308 Designation of Administrative Responsibility · LIC 309 Administrative Organization · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan · Liability Insurance No deficiencies observed or cited during this visit. . Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 11, 2025

Type of visit: Case Management - Health Checks

On this day, January 27, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 1 complaint (Complaint #15-AS-20250123123225). LPA met with Resident Services Director (RSD) Beverly Mercurio, and informed the reason for visit. LPA toured the facility inside out with the RSD. The facility is a 3 level building. LPA inspected the common areas, game room on the 1st floor, dining room, kitchen, multi purpose room, grand view room and theatre on the 3rd floor. The electrical room on the 2nd floor and salon on the 3rd floor were observed locked. LPA randomly selected 8 apartments for inspection - 3 on the 1st floor, 3 on the 2nd floor and 2 on the 3rd floor. No deficiency observed. Exit interview conducted and copy of this report provided to RSD.the state’s words, verbatim · CDSS document, Jan 27, 2025

Allegation investigated: Resident sustained severe injury due to staff neglect resulting in death Staff did not respond to resident's call button in a timely manner Staff did not prevent resident from having bed bugs Staff are not providing adequate food service to residents

Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to deliver findings on the above allegation. LPA met Robert Gomez, Executive Director and explained the purpose of the visit. On the allegation: Resident sustained severe injury due to staff neglect resulting in death. The Department reviewed records and conducted interviews. Resident (R1) had a fall on March 28th 2023 at 4:25pm. Staff were present in the activities room with R1 but was not facing her when the fall occurred. R1’s medical records showed that there was no injury from the fall, but the hospital did additional testing and R1 was discharged on March 31st, 2023. R1 was readmitted to the hospital on 4/11/23 and admitted to hospice on 4/15/23, listing protein calorie malnutrition and Odynophagia, Diastolic CHF, Right Coronary Artery Disease, Atrial Fibrillation. R1 passed away 4/24/2023 and the immediate causes of death listed are cardiopulmonary arrest (onset seconds), myocardial infarction (onset minutes), and atherosclerosis (onset years). This allegation is unsubstantiated. Continued on LIC9099-C... Unsubstantiated ...Continued from LIC 9099 On the allegation: Staff did not respond to resident's call button in a timely manner. LPA spoke with staff (S1) who stated that they do not keep an archive of calls from the call buttons, and they no longer have the records from 2023. Review of current call button logs indicated that the average call button response time is 6 minutes and 9 seconds. This allegation is unsubstantiated. On the allegation: Staff did not prevent resident from having bed bugs. LPA spoke with S1 who stated that they have not had any resent situations involving bed bugs or any other insects. S1 stated that if they were to have any sort of report of bugs/pest from the residents they would contact their contracted pest control company to do come to do additional services on top of the quarterly preventative services they are already scheduled for. R1’s medical records have no mention of bug bites on resident. This allegation is unsubstantiated. On the allegation: Staff are not providing adequate food service to residents During investigation, LPA interviewed staff (ED, S1, S2) who stated they purchase food supplies for clients’ meals every week and prepare meals as scheduled on their weekly meal plans. Residents (R2, R3, R4) confirmed with LPA that staff provide them with adequate meals and that they are satisfied with the food service. Therefore, the allegation that staff are not providing adequate food service to residents is unsubstantiated. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Dec 20, 2024 · control 15-AS-20240618132309

Type of visit: Case Management - Health Checks

On 06/19/2024 at 11:45 AM, Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted an unannounced Health & Safety inspection. LPA met with Operations Specialist, Kawana Anthony. LPA toured facility including but not limited to the common areas, courtyard, bathrooms, kitchens, medication room, theater, game room and Life Guidance (memory care unit). Hot water temperature in common area temperature was at a comfortable degrees; each resident has their own individual apartment. There are 2-days of non-perishables and 7-days of perishable food supplies. Facility food supplies are checked daily by chef and staff. Resident's medications were kept locked in the medication room. Smoke and carbon monoxide detectors are combined and observed throughout the facility and the bedrooms. First-aid kit was complete. No accessible bodies of water were observed. Indoor and outdoor passageways were free of obstruction. No deficiencies are cited on this date. Exit interview conducted. A copy of this report provided to ED.the state’s words, verbatim · CDSS document, Jun 19, 2024

Type of visit: Required - 1 Year

On 03/20/24 at 10:00 AM, Licensing Program Analysts (LPAs) K. Nguyen and L. Holmes conducted an unannounced required annual inspection. LPAs met with Barbara Tudda, Executive Director (ED); Administrator Standard Certificate #7013847740 exp. 10/09/2025. LPAs toured facility including but not limited to the common areas, courtyard, bathrooms, kitchens, medication room, theater, and game room. Hot water temperature in common area temperature was at a comfortable degree at 108.2 degrees Fahrenheit; each resident has their own individual apartment. There are 2-days of non-perishables and 7-days of perishable food supplies. Facility food supplies are checked daily by chef and staff. Resident's medications were kept locked in the medication room. Smoke and carbon monoxide detectors are combined and observed throughout the facility and the bedrooms. Fire extinguisher was observed full and last inspected 3/26/2024. No accessible bodies of water were observed. Indoor and outdoor passageways were free of obstruction. Emergency Disaster Plan (EDP) on file and following COVID-19 precautionary guidelines. Disaster drills completed every other month. Certificate of Liability Insurance exp. 06/01/24. LPAs reviewed 7 residents records. LPA reviewed 5 staff records and 5 of 5 have current first aid training and associated to the facility. LPAs reviewed a sample of resident’s medications. No deficiencies cited on this date. Exit interview conducted and a copy of this report provided to ED.the state’s words, verbatim · CDSS document, Mar 20, 2024

Type of visit: Case Management - Health Checks

On 10/25/23 at 1:30 PM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Health & Safety inspection as result of a priority 2 complaint. LPA met with Barbara Tudda, Executive Director. LPA toured facility including but not limited to the common areas, courtyard, bathrooms, kitchens, medication room, theater, game room and Life Guidance (memory care unit). Hot water temperature in common area temperature was at a comfortable degree; each resident has their own individual apartment. There are 2-days of non-perishables and 7-days of perishable food supplies. Facility food supplies are checked daily by chef and staff. Resident's medications were kept locked in the medication room. Smoke and carbon monoxide detectors are combined and observed throughout the facility and the bedrooms. First-aid kit was complete. Fire extinguisher was observed full and last inspected 05/28/23. No accessible bodies of water were observed. Indoor and outdoor passageways were free of obstruction. Emergency Disaster Plan (EDP) on file and following COVID-19 precautionary guidelines. No deficiencies are cited on this date. Exit interview conducted. A copy of this report provided to ED via email.the state’s words, verbatim · CDSS document, Oct 25, 2023