Bayshire San Dimas

Allegation investigated: Facility staff abandoned resident at the hospital

Licensing Program Analyst (LPA) Daniel Konishi conducted a unannounced subsequent complaint visit in response to the above-mentioned allegation. LPA met with the Health Services Director, Laura Sanchez, and explained the reason for the visit. On 4/07/2026, the initial investigation visit was conducted. The investigation consisted of the following: LPA requested a copy of staff and resident rosters. LPA also requested copies from Resident#1 (R1’s) file such as the Face Sheet, Physician’s Report, Resident Assessment, and other pertinent documents. LPA interviewed the Staff #1 (S1) to Staff #5 (S5), and Resident #2 (R2) to Resident #9 (R9). LPA attempted to interview Resident #1 (R1) over the phone but LPA was unable to interview R1 since R1 did not answer any questions. LPA interviewed Witness #1 (W1) over the phone. Unsubstantiated On 4/7/2026, LPA interviewed Staff #6 (S6). On 6/3/2026, LPA contacted S1, S6 and W1 requesting documentation. During today's visit, the investigation consisted of the following: LPA interviewed S1. LPA obtained pertinent documents. The investigation revealed the following: in regard to the allegation, “Facility staff abandoned resident at the hospital” It is alleged that when R1 was ready to be discharged from the hospital, the facility would not take R1 back despite previously agreeing to do so. LPA attempted to interview R1 over the phone but LPA was unable to interview R1 since R1 did not answer any questions. R1 is no longer a resident of the facility as of 3/29/2026. LPA interviewed five (5) out of eight (8) residents that denied the allegation stating that when the resident was hospitalized and to be discharged from the hospital, the staff does not abandon the resident as they ensure that the resident are able to return back to the facility. LPA interviewed three (3) out of eight (8) residents stated that they have not been hospitalized during their stay at the facility. However, those three (3) out of eight (8) residents stated that they have not heard about staff abandoning residents at the hospital. LPA interviewed two (2) out of six (6) staff that denied the allegation stating that R1 was not abandoned at the hospital as they stated that there were discrepancies with R1’s Physician’s Report that the hospital physician filled out 3/27/2026 which did not include R1’s medication list and MRSA diagnosis which is a prohibited condition as it is a serious infection that is easily transmittable. S1 and W1 stated that R1 was admitted to the hospital on 3/20/2026. Per W1, R1’s MRSA isolation was cleared on 4/2/2026 which exceeded R1’s 14-day respite stay at the facility. Per W1 and one (1) staff, there was never an updated physician’s report completed by facility or hospital staff. Four (4) out of six (6) staff interviewed all stated they are not involved in R1’s matter being at the hospital. However, the four (4) out of six (6) staff indicated that they have not experienced any residents abandoned at the hospital while they have worked at the facility. S1 also stated that the facility did not refuse to accept R1 back to the facility since R1 was a resident on a respite stay for 14 days which R1 signed on 03/16/2026 and expired on 03/29/2026. Per interview with two (2) staff and record review, R1 did not pay for the respite stay as payment is provided prior to the respite stay and no payment was received from R1 during or after R1’s respite stay. There is not enough evidence to substantiate. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided to the Health Services Director, Laura Sanchez.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 28-AS-20260401120121

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with both Health Service Director Laura Sanchez and Administrator Jose Speede, and explained the purpose for today’s visit. The facility is licensed to serve 119 non-ambulatory residents of which 15 may be bedridden in rooms 151-155,213,215-217,219,224-227 and 229. Facility has an approved delayed egress and a Dementia Care Plan and a Hospice Waiver approved for (38) residents. There are currently (30) residents receiving hospice care. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility maintains the required Infection Control Plan. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and Care of Bedridden Residents Plan. The facility maintains the required liability insurance that expires on 11/1/26. Physical Plant & Environment Safety: LPA toured facility, a total of 8 residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms have signal systems located in each bathroom that were tested an operating properly. Residents have call pendants that were also tested and operable. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the resident private bathrooms and measured within the required range of 105-120 degrees. The facility had the required personal rights and complaint posters posted. (Continued on LIC809-C) Staffing & Personnel Records-Training: There appears to be sufficient staffing at all times in the facility. Staff have criminal record clearance, Health Screening, Negative TB test results, training in postural supports, Alzheimer’s and Dementia, medication assistance in the personnel files. LPA reviewed 5 staff files and observed 5 staff files missing their First-Aid training certificates from a certified agency such as American Red Corss (citation issued and will be detailed on LIC809-D page). Administrator Jose Speede certificate expires on 11/8/27. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 8 Resident Files and observed 2 residents missing their negative TB test results (citation will be issued and detailed on the LIC809-D page). Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conduct and evaluate planned activities. There are multiple shaded patio areas that allow for sufficient space for activities. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled and are centrally stored and are in their original containers. LPA reviewed 10 resident medications with no issues observed. Disaster Preparedness: The facility maintains the required Emergency Disaster Plan with 2 relocation sites. Facility has the required emergency evacuation chairs located at each stairwell. The last emergency drill was conducted on 3/31/26. Residents with Special Health Needs: Facility admits residents with dementia and resident with hospice services, staff files reviewed today all have required training documented. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit will be cited on the 809D. Exit interview held, a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 27, 2026

Allegation investigated: Unqualified staff member is providing care to residents in care.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint visit on 02/17/2026, to deliver a superseded report regarding the above allegation to provide additional and clarifying information not included on report dated 02/07/2026. The finding will remain the same. LPA Ramirez conducted an unannounced subsequent complaint visit on 02/07/2026, regarding the above allegation to deliver findings. On 01/08/2026, LPA Ramirez conducted an unannounced initial complaint investigation visit and a need further investigation was documented. During today’s visit, LPA Ramirez was greeted by LVN- Stephanie Guerreo and explained the purpose of the visit The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster, Resident Roster, copy of MedTech and licensed vocational nurse job descriptions/duties, copy of staff#1 (S1) and physical plant tour. LPA Ramirez conducted the following interviews: Staff#1 - 5 interviews (S1 – S5) and Resident#1-4 Interviews (R1- R4). Unsubstantiated The investigation revealed the following: regarding the allegation “Unqualified staff member is providing care to residents in care.” It is alleged an unqualified staff member is providing wound care to residents. Five (5) out of the five (5) staff interviewed denied this allegation. Four (4) out of the four (4) residents interviewed did not corroborate this allegation. Review of staff rosters revealed that two staff members have the same first name but hold different titles. Records reviewed revealed that S1 is a Licensed Vocational Nurse and S5 is a Medication Technician. Resident interviews revealed that residents feel well cared for by staff and feel staff meet their care needs. Staff interviews revealed that S1 holds a current Licensed Vocational Nurse (LVN) license with an expiration 12/2027 and S5 has received training on medication administration and other topics associated to their position. Interview with S2 revealed that S1 is qualified to provide wound care. During record review, LPA Ramirez observed S1’s valid Licensed Vocational Nurse license and S5’s recent Medication Technician training. Review of R1-R4 resident files revealed that they receive wound care from an outside agency and these outside agencies document the care provided. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited during this visit. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 13, 2026 · control 28-AS-20260105100606

Allegation investigated: Unqualified staff member is providing care to residents in care.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint visit on 02/07/2026, regarding the above allegation to deliver findings. On 01/08/2026, LPA Ramirez conducted an unannounced initial complaint investigation visit and a need further investigation was documented. During today’s visit, LPA Ramirez was greeted by LVN- Stephanie Guerreo and explained the purpose of the visit The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster, Resident Roster, copy of MedTech and licensed vocational nurse job descriptions/duties, copy of staff#1 (S1) and physical plant tour. LPA Ramirez conducted the following interviews: Staff#1 - 5 interviews (S1 – S5) and Resident#1-4 Interviews (R1- R4). See 9099-C Unsubstantiated The investigation revealed the following: regarding the allegation “Unqualified staff member is providing care to residents in care.” It is alleged an unqualified staff member is providing care to residents. Five (5) out of the five (5) staff interviewed denied this allegation. Four (4) out of the four (4) residents interviewed denied this allegation. Resident interviews revealed that residents feel well cared for by staff and feel staff meet their care needs. Staff interviews revealed that S1 holds a current Licensed Vocational Nurse (LVN) license with an expiration 12/2027 and S5 completed training on according to their position. During record review, LPA Ramirez observed S1’s LVN license and S5’s recent training. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited during this visit. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 7, 2026 · control 28-AS-20260105100606

Allegation investigated: Staff did not obtain medical care for resident in a timely manner

Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial unannounced complaint visit to investigate the allegation listed above. LPA met with Stephanie Guerrero, Wellness Nurse for the facility, and explained the purpose of the visit. The investigation consisted of the following: During today's visit LPA interviewed Staff #1 - 3 (S1 - S3), Residents #1 - 5 (R1 - R5), and also obtained the physician's report, service plan, assessments, Emergency Identification information, discharge paperwork, and physician's report for R1. The investigation revealed the following: In regards to the allegation that "Staff did not obtain medical care for resident in a timely manner," it was alleged that on 11/23/2025 there was a delay in transporting R1 to the hospital after it was revealed that they required medical attention at 7:00 PM. Unsubstantiated During interviews with the residents, three (3) out of five (5) interviewed did not corroborate the allegation. One resident interviewed stated that they recently required hospitalization, and that staff assisting them in obtaining medical care in a timely and prompt manner. Another resident interviewed stated that they staff have assisted them in an adequate time frame when they have required medical assistance. During interviews with staff, none of them corroborated the allegation. One of the staff interviewed stated that they became aware that R1 required medical attention on 11/23/2025 and contacted their hospice agency at around 11:00 PM to ask if they would be able to send a nurse to see the resident, however after an hour the hospice agency indicated they would not arrive until 8:00 AM on 11/24/2025, and at this time it was decided an ambulance would be called to take R1 to the hospital. Another staff interviewed also confirmed that a private ambulance was called at 11:00 PM per R1's request, and was sent to the hospital afterwards. Progress notes indicate that R1 was sent out to the hospital via private ambulance at 2:36 AM on 11/24/2025. Based on statements and interviews conducted with staff, residents, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report along with appeal rights were provided to the administrator. During interviews with the residents, one (1) out of five (5) corroborated the allegation. One resident interviewed stated that they were hospitalized and that their family was not notified of the visit until the family had called the facility the following day. During interviews with the staff, none of them corroborated the allegation. S1 stated that S3 called the primary relative of R1 following the incident on 11/24/2025 at 2:00 AM, however they are unsure if the contact was reached. S3 stated that they attempted calling family relatives of R1, however the call went to voicemail, and they cannot recall if they ever called back. During record review before the visit, LPA observed that no serious incident reports (SIRs) have been submitted to Community Care Licensing Division (CCLD). An SIR was provided to LPA during the visit dated 12/2/2025, however this is eight (8) days after the occurrence of the incident, which exceeds the seven (7) day time-frame required per Title 22 regulations. Based on LPA interviews conducted with the residents and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 is being cited on the attached LIC9099D page. Exit interview was held and a copy of the report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 28-AS-20251125113714

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Dec 5, 2025

(a) Each licensee shall furnish to the licensing agency such reports (...) including, but not limited to, the following: (1) A written report (...) within seven days of occurance (...) (D) Any incident which threatens the welfare, safety or health (...) of any resident. This regulation is not met as evidenced by: Based on interview and record review, LPA determined that an incident report was not submitted to the licensing agency within the required timeframe, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 2, 2025

Plan of correction: ***POC Cleared*** Licensee is to ensure that incident reports for all incidents that threaten the health and safety of residents are submitted within the required timeframe. Administrator is to provide an incident report for the related incident to the LPA by the POC due date.

Allegation investigated: Staff did not ensure alarmed exit doors work properly at all times Due to lack of supervision, resident eloped

This report today 10/10/25 supercedes the report dated 08/07/25 in which LPA inadvertently combined findings on the report. However the findings remain the same. In regards to the allegation Staff did not ensure alarmed exit doors work properly at all times, the complaint findings dated 12/10/2024 were previously addressed with Substantiated findings by LPA Pena. COMPLAINT CONTROL NUMBER: 28-AS-20241001133551. It notes that S1 stated that what she thinks happened was that R1 went out the back gate and the alarm did not go off. S1 showed LPA how the back gate’s alarm work and it involved 4 steps to secure the gate. S1 indicated that someone must have missed a step or two in locking it, hence the alarm failed to go off. LPA observed that the back gate leads to a driveway towards the main road next to the freeway. The facility rosters dated 10/03/2024 specified a total of 19 memory care residents including R1, 7 caregivers and 3 med techs assigned on different shifts in the memory care unit. However, when R1 wandered away from the facility on 9/30/2024, there were only (2) caregivers and (1) med tech working. Therefore, there was sufficient evidence to corroborate the allegation of lack of supervision which led to Substantiated R1 wandered from the facility. Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. It should be noted no deficiency issued at today's visit. Prior investigation on 09/30/2024 and 10/3/24 LPA Pena Substantiated and issued deficiency. In regards to the allegation Due to lack of supervision, resident eloped, the complaint findings dated 12/10/2024 were previously addressed with Substantiated findings by LPA Pena. It notes the following that S1 stated that what she thinks happened was that R1 went out the back gate and the alarm did not go off. S1 showed LPA how the back gate’s alarm work and it involved 4 steps to secure the gate. S1 indicated that someone must have missed a step or two in locking it, hence the alarm failed to go off. LPA observed that the back gate leads to a driveway towards the main road next to the freeway. The facility rosters dated 10/03/2024 specified a total of 19 memory care residents including R1, 7 caregivers and 3 med techs assigned on different shifts in the memory care unit. However, when R1 wandered away from the facility on 9/30/2024, there were only (2) caregivers and (1) med tech working. Therefore, there was sufficient evidence to corroborate the allegation of lack of supervision which led to R1 wandered from the facility. Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. It should be noted no deficiency issued at today's visit. Prior investigation on 09/30/2024 and 10/3/24 LPA Pena Substantiated and issued deficiency. was immediate. Staff stated that once the pull cord is pulled it will go to any staff who has a pager. Pager gives the location. Interview with Resident R1 who stated that the pull cord is working and staff always assist right away. Resident's R2-R9 stated the pull cord is working well and response time is quick. It should also be noted that findings were delivered 05/13/2025 for Staff do not answer resident's calls for assistance timely. This allegation was Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff did not ensure leaks were fixed timely, based on facility tour, interviews and information gathered it was observed by the LPA tour on the initial visit 11/26/2024 that there were no leaks. Interview with Health Services Coordinator Laura Sanchez who stated that. any leak is fixed right away. Staff S2 stated that any leaks are fixed within the hour and said they hadn't had one in awhile. Interview with Staff S3 who is Maintenance Director who stated that there are no leaks he is aware of and if there was you would see them now. Interview with Resident's R1- R 9 who all stated they didn't observe any leaks. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Residents have unexplained bruises based on interviews conducted and information gathered Resident's R1- R9 all stated they do not have unexplained bruises and have not seen anyone with Unexplained bruises. Also stated that staff have not told them to cover up bruises. Staff stated that they had not covered up residents bruising. Said if skin tear they may wear a hospital protective sleeve, but never anything malicious. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff are not reporting incidents to authorized representatives, based on interviews conducted and information gathered it was revealed by Health Services Coordinator Laura Sanchez that all incidents are always reported to Licensing. Special Incident Reports (SIR's) were submitted 09/30/2024 and 12/01/2024 both concerning the elopement of 2 residents. Incident reported 09/30/2025 states that resident was located by Highway Patrol off of the 57 entrance. Staff were able to bring the resident back. On the 12/01/2025 report the resident was across the street walking on the sidewalk and walking back to the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff do not safeguard residents personal property, based on interviews conducted and information gathered Resident's R1- R9 all stated they have never had any items stolen from their rooms. Said housekeeping does a good job. All stated staff are nice and helpful. Staff stated that Resident R1 or family never reported any items missing and they have a Personal Inventory List to ensure documentation of all resident's belongings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Oct 10, 2025 · control 28-AS-20241119083111

Allegation investigated: Licensee does not ensure that facility is kept in good repair.

Licensing Program Analysts (LPAs) Cynthia Chan and Elena Mallett conducted a complaint investigation for the allegation listed above. LPAs arrived unannounced and met with Staff, Stephanie Guerrero. The reason for the visit was explained. LPAs obtained copies of the staff and resident rosters, inspected 10 resident rooms, and the laundry rooms. Interviews were held with Staff #1-#5 and Residents #1-#10. The investigation revealed the following: Allegation – Licensee does not ensure that the facility is kept in good repair. It is alleged that there are ceiling leaks, and the washer has been broken for months. LPAs interviewed five (5) staff today. Staff stated the past leaks in the ceiling were repaired, and there are no current leaks they are aware of. Staff stated that if they observe anything in disrepair, they will inform maintenance right away. Substantiated The facility has recently implemented a laundry service and is using the industrial washing and drying machines. In addition, the facility has available washers and dryers for residents to use. Staff stated the washing machine currently working is located on the 3rd floor. LPAs interviewed ten (10) residents. Two (2) of the residents stated there were water leaks in their rooms, however, staff had repaired them. Nine (9) out of ten (10) residents stated the facility does their laundry once a week. During the walk through, LPAs selected ten (10) resident rooms to inspect. There were no leaks observed on the ceiling. LPAs also checked the laundry rooms. The washer in the memory care unit did not appear operable, and staff confirmed it is not working. The facility currently has one (1) functioning washing machine available for resident to use at this time. Staff stated it had repeatedly been broken down. Based on LPA observations and interviews conducted, 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 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Correction was reviewed and developed with House Service Director, Laura Sanchez. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 28-AS-20250923141425

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(g)(1) · Plan of correction due date: Oct 17, 2025

87303 Maintenance and Operation (g) Facilities which have machines and do their own laundry shall: (1) Have adequate supplies available and equipment maintained in good repair. This requirement is not met as evidenced by: Based on interviews and observation, the washing machine in the memory care unit is not operable which poses a potential health and safety and personal rights to residents in care.the state’s words, verbatim · CDSS document, Sep 30, 2025

Plan of correction: The licensee shall submit a plan to ensure all the washers are operable for staff and residents to use. This plan is due to LPA by 10/17/25.

Allegation investigated: Facility staff are not properly turning resident resulting in pressure injury. Facility staff are leaving resident in bed for extended periods of time.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit to investigate above allegations. LPA discussed the purpose of the visit with Health & Wellness Director Laura Garcia. The investigation consisted of: A physical plant inspection of the Memory Care Unit & AL common areas and R1's room was conducted. An interview with resident (R1) was attempted. Five (5) residents and 7 staff, and SCAN Nurse Practioner were interviewed. Review/copies of R1's file documents was completed [Physician's Report, Service Plan, Admission Record, Resident Assessment, SCAN Home health order [8/20/25], SCAN Provider Assessment, Angel Hospice records, Plan of Operation, resident roster, and staff rosters were obtained. Unsubstantiated Allegation: Facility staff are not properly turning resident resulting in pressure injury. The complaint alleges that staff are not moving Memory Care Unit resident (R1) often, and as a result in mid August 2025 the resident developed a new pressure injury on the resident's bottom/coccyx area. It was reported that R1 has past history of pressure injuries, with the most recent pressure injury being in their heel and toe. A total of 7 staff were interviewed, of which all denied the allegation. None of the residents interviewed acknowledged the allegation. Staff interviews revealed that in mid-August 2025 a caregiver reported to the Memory Care Unit lead staff/med-tech that R1 had redness and a small opening in the bottom area, whom then contacted primary care providers and family. Per document review, on August 20, 2025 a SCAN Nurse Practioner submitted a home health referral order for wound care services of the toe and coccyx skin breakdown. Picture evidence was obtained. The picture depicts redness with slight skin abrasion located in R1's bottom. Records indicate R1 is dependent for all ADL's due to advanced Dementia. According to staff, repositioning procedures have been followed and there is currently no pressure injury in R1's bottom. During today's visit, the SCAN Nurse Practioner was on-site; therefore LPA requested they conduct a full body assessment to determine if there is a pressure injury in the bottom/coccyx area. The nurse reported back to LPA that there is no redness or open wound to the coccyx and bottom area. There is insufficient evidence to support the allegation. Allegation: Facility staff are leaving resident in bed for extended periods of time. It is alleged that on September 24, 2025, at approximately 6:30 PM, resident (R1) was observed in their bed with a napkin with crumbs on the resident's chest, indicating the resident was fed dinner in their bed instead of being wheeled to the dining room in the resident's Geri chair. Memory Care Unit residents stated they are not left in bed for extended periods of time and are checked on frequently. According to staff interviews, caregiver staff are responsible for getting R1 up in the morning, transferring them to their Geri chair, taking the resident to the dining room for breakfast meal, and then to the activities room. Staff stated that R1 is typically put to bed for a nap after lunch time, and then transferred to their Geri chair prior to dinner meal time in the Memory Care Unit dining room. Staff interviews revealed that on 9/24/25, R1 was taken to their room for a nap after lunch. PM caregiver staff used the Hoyer lift on R1 at approximately 3 PM, and noticed that the resident's right outer bottom cheek had redness and the resident was sound asleep. The caregiver decided to keep the resident in bed because they thought the redness may have been a result of Geri chair use earlier in the day. According to the PM staff (S1) the resident was fed dinner in their room that day, continued checks and repositioning was performed, there was no neglect, and it was an isolated incident. Per document review, the Physician's Report states R1 is bedridden due to both physical and mental condition, spends all day either in bed or Geri chair and requires 2-person assist transfers are required with use of Hoyer lift. Therefore, the allegation cannot be supported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview and a copy of the report was issued to Health & Wellness Director Laura Garcia.the state’s words, verbatim · CDSS document, Sep 29, 2025 · control 28-AS-20250925100212

Allegation investigated: Licensee does not ensure that facility is kept in good repair. Staff do not ensure that residents' rooms are maintained in a sanitary condition.

Licensing Program Analyst (LPA), Mayra Cota, conducted a 10-day complaint visit to investigate the above-mentioned allegations. LPA met with Stephanie Guerrero, Wellness Nurse and the reason for the visit was explained. Laura Sanchez, Director, was contacted via phone call and the reason for the visit was also explained. Stephanie Guerrero facilitated today’s visit and Laura Sanchez arrived thereafter. The investigation consisted of the following: During today’s visit, LPA obtained copies of staff/resident rosters and laundry schedules, toured the physical plant with a focus on observing the kitchen, dining and activity rooms, (3) facility laundry rooms and (2) soiled linen closets. LPA also inspected (10) resident rooms and conducted interviews with Staff 1 – Staff 8 (S1-S8) and Resident 1 – Resident 6 (R1-R6). ***Continues on LIC 9099-C Unsubstantiated The investigation revealed the following: Regarding: Licensee does not ensure that facility is kept in good repair. It is alleged that there is a water leak in the kitchen ceiling and that the facility’s plumbing is in disrepair. During interviews, (5) staff denied the allegation. Five (5) interviewed staff indicated that the facility does not have a water leak in the kitchen nor anywhere else in the facility. S1-S3 stated that several weeks ago, the facility had water dripping from the dining and activity room ceiling in the Memory Care section of the building due to condensation building up in the drain pan of the air conditioning unit. However, interview with Plant Operations Director (S3) indicated, leak has been resolved. S3 stated, air conditioning unit was set at a lower temperature than usual and consequently, made the unit accumulate a high quantity of condensation which dripped from the drip pan and on to the ceiling tiles and floor in the dining and activity rooms. S3 stated, condensation accumulation is more common in times of high heat because the AC unit works harder to maintain a cool temperature. S3 further stated, “The water leak from the ceiling had nothing to do with the facility’s plumbing.” S3 indicated, in this facility, plumbing is nested along the inside of the walls and under the flooring and plumbing does not run above the ceiling. S1- S3 stated, no plumbing issues have been observed or reported. S1-S6 further indicated, they have not observed any more water leaking from the ceiling in the dining and activity rooms nor anywhere else in the facility. Interviews with (6) out of (6) residents have no concerns regarding water leaks. During LPA inspection of the physical plant, no water leaks were observed. Staff and resident interviews, and LPA observations do not corroborate the allegation. Regarding: Staff do not ensure that residents' rooms are maintained in a sanitary condition. It is alleged that blood, vomit and feces soaked garments are frequently placed in residents’ dirty clothes baskets which remain there for (7) days or more. During the visit, (8) out of (8) staff interviewed deny the allegation. Staff interviewed indicated that heavily soiled bedding, towels and clothing which may contain vomit, feces or blood, are never mixed with residents’ mildly soiled articles which are placed in their laundry baskets in their room. Staff further indicated, if linen or clothing become heavily soiled, items are removed immediately out of residents’ rooms and placed in bags and tied up to prevent fluids from transferring onto other surfaces. ***Continues on LIC 9099-C page 2 The bags are stored temporarily in the (2) soiled linen closets from which caregivers and housekeeping staff collect to wash. Bags collected are never kept for more than 24 hours before they are washed. Staff further stated, the facility has a laundry schedule for the AM, PM and NOC shifts which are followed to ensure residents’ linen and clothes are washed in a timely manner. Six (6) staff indicated, the facility has three laundry rooms equipped with commercial and industrial grade washers and dryers which accommodate large quantities of soiled items. Staff further indicated, laundry hampers in resident rooms are always monitored by caregivers and housekeeping staff and “emergency washes” are conducted in between scheduled laundry times particularly for items which should not remain in residents’ rooms to prevent contamination and odors from transferring. During the inspection of 10 resident rooms, no blood, vomit and feces soaked garments were observed in resident laundry baskets nor anywhere else in their room. Interviews with (6) out of (6) residents indicated their clothing gets washed in a timely manner and they have no concerns with clothes or linen not being collected or properly removed from their room to be washed. Review of laundry schedule indicated washing is conducted daily for every shift. At the time of visit, LPA observed laundry attendants washing clothes and linen. Staff and resident interviews, observation and record review, do not corroborate the allegation. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Stephanie Guerrero, Wellness Nurse, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 28-AS-20250818083342

Allegation investigated: Licensee does not ensure that facility is kept in good repair. Staff do not ensure that residents' rooms are maintained in a sanitary condition.

Licensing Program Analyst (LPA), Mayra Cota, conducted a 10-day complaint visit to investigate the above-mentioned allegations. LPA met with Stephanie Guerrero, Wellness Nurse and the reason for the visit was explained. Laura Sanchez, Director, was contacted via phone call and the reason for the visit was also explained. Stephanie Guerrero facilitated today’s visit and Laura Sanchez arrived thereafter. The investigation consisted of the following: During today’s visit, LPA obtained copies of staff/resident rosters and laundry schedules, toured the physical plant with a focus on observing the kitchen, dining and activity rooms, (3) facility laundry rooms and (2) soiled linen closets. LPA also inspected (10) resident rooms and conducted interviews with Staff 1 – Staff 8 (S1-S8) and Resident 1 – Resident 6 (R1-R6). ***Continues on LIC 9099-C Unsubstantiated The investigation revealed the following: Regarding: Licensee does not ensure that facility is kept in good repair. It is alleged that there is a water leak in the kitchen ceiling and that the facility’s plumbing is in disrepair. During interviews, (5) staff denied the allegation. Five (5) interviewed staff indicated that the facility does not have a water leak in the kitchen nor anywhere else in the facility. S1-S3 stated that several weeks ago, the facility had water dripping from the dining and activity room ceiling in the Memory Care section of the building due to condensation building up in the drain pan of the air conditioning unit. However, interview with Plant Operations Director (S3) indicated, leak has been resolved. S3 stated, air conditioning unit was set at a lower temperature than usual and consequently, made the unit accumulate a high quantity of condensation which dripped from the drip pan and on to the ceiling tiles and floor in the dining and activity rooms. S3 stated, condensation accumulation is more common in times of high heat because the AC unit works harder to maintain a cool temperature. S3 further stated, “The water leak from the ceiling had nothing to do with the facility’s plumbing.” S3 indicated, in this facility, plumbing is nested along the inside of the walls and under the flooring and plumbing does not run above the ceiling. S1- S3 stated, no plumbing issues have been observed or reported. S1-S6 further indicated, they have not observed any more water leaking from the ceiling in the dining and activity rooms nor anywhere else in the facility. Interviews with (6) out of (6) residents have no concerns regarding water leaks. During LPA inspection of the physical plant, no water leaks were observed. Staff and resident interviews, and LPA observations do not corroborate the allegation. Regarding: Staff do not ensure that residents' rooms are maintained in a sanitary condition. It is alleged that blood, vomit and feces soaked garments are frequently placed in residents’ dirty clothes baskets which remain there for (7) days or more. During the visit, (8) out of (8) staff interviewed deny the allegation. Staff interviewed indicated that heavily soiled bedding, towels and clothing which may contain vomit, feces or blood, are never mixed with residents’ mildly soiled articles which are placed in their laundry baskets in their room. Staff further indicated, if linen or clothing become heavily soiled, items are removed immediately out of residents’ rooms and placed in bags and tied up to prevent fluids from transferring onto other surfaces. ***Continues on LIC 9099-C page 2 The bags are stored temporarily in the (2) soiled linen closets from which caregivers and housekeeping staff collect to wash. Bags collected are never kept for more than 24 hours before they are washed. Staff further stated, the facility has a laundry schedule for the AM, PM and NOC shifts which are followed to ensure residents’ linen and clothes are washed in a timely manner. Six (6) staff indicated, the facility has three laundry rooms equipped with commercial and industrial grade washers and dryers which accommodate large quantities of soiled items. Staff further indicated, laundry hampers in resident rooms are always monitored by caregivers and housekeeping staff and “emergency washes” are conducted in between scheduled laundry times particularly for items which should not remain in residents’ rooms to prevent contamination and odors from transferring. During the inspection of 10 resident rooms, no blood, vomit and feces soaked garments were observed in resident laundry baskets nor anywhere else in their room. Interviews with (6) out of (6) residents indicated their clothing gets washed in a timely manner and they have no concerns with clothes or linen not being collected or properly removed from their room to be washed. Review of laundry schedule indicated washing is conducted daily for every shift. At the time of visit, LPA observed laundry attendants washing clothes and linen. Staff and resident interviews, observation and record review, do not corroborate the allegation. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Stephanie Guerrero, Wellness Nurse, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 28-AS-20250818083342

Allegation investigated: Resident pull cords are in disrepair Staff did not ensure leaks were fixed timely Staff did not ensure alarmed exit doors work properly at all times Residents have unexplained bruises Due to lack of supervision, resident eloped Staff are not reporting incidents to authorized representatives Staff do not safeguard residents personal property

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced subsequent complaint visit to investigate the above mentioned allegations and to deliver findings. LPA met with Laura Sanchez Health Services Director and explained the reason for the visit. The initial visit was conducted on 11/26/2024 and the following was done: LPA Trueman requested copies of the staff and resident rosters, and explained the reason for the visit. LPA interviewed Laura Sanchez Health Services Director, Staff 1 - Staff 3 (S1 - S3) and Resident R1. LPA also toured common areas in memory care. In memory care Rooms 160,161, 163, 164, 165, and 182 were inspected. At today's visit 08/07/2025 Resident's R 2-9 were interviewed. Staff S4 was interviewed. In regards to the allegation Resident pull cords are in disrepair, based on facility tour conducted on 11/26/2024, interviews conducted and information gathered it was revealed that in memory care tour of Rooms 160,161, 163, 164, 165, and 182 all were inspected and all were in good repair. Response time Unsubstantiated was immediate. Staff stated that once the pull cord is pulled it will go to any staff who has a pager. Pager gives the location. Interview with Resident R1 who stated that the pull cord is working and staff always assist right away. Resident's R2-R9 stated the pull cord is working well and response time is quick. It should also be noted that findings were delivered 05/13/2025 for Staff do not answer resident's calls for assistance timely. This allegation was Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff did not ensure leaks were fixed timely, based on facility tour, interviews and information gathered it was observed by the LPA tour on the initial visit 11/26/2024 that there were no leaks. Interview with Health Services Coordinator Laura Sanchez who stated that. any leak is fixed right away. Staff S2 stated that any leaks are fixed within the hour and said they hadn't had one in awhile. Interview with Staff S3 who is Maintenance Director who stated that there are no leaks he is aware of and if there was you would see them now. Interview with Resident's R1- R 9 who all stated they didn't observe any leaks. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff did not ensure alarmed exit doors work properly at all times, the complaint findings dated 12/10/2024 were previously addressed with Substantiated findings by LPA Pena. COMPLAINT CONTROL NUMBER: 28-AS-20241001133551. It notes that S1 stated that what she thinks happened was that R1 went out the back gate and the alarm did not go off. S1 showed LPA how the back gate’s alarm work and it involved 4 steps to secure the gate. S1 indicated that someone must have missed a step or two in locking it, hence the alarm failed to go off. LPA observed that the back gate leads to a driveway towards the main road next to the freeway. The facility rosters dated 10/03/2024 specified a total of 19 memory care residents including R1, 7 caregivers and 3 med techs assigned on different shifts in the memory care unit. However, when R1 wandered away from the facility on 9/30/2024, there were only (2) caregivers and (1) med tech working. Therefore, there was sufficient evidence to corroborate the allegation of lack of supervision which led to R1 wandered from the facility. Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. It should be noted no deficiency issued at today's visit. Prior investigation on 09/30/2024 and 10/3/24 LPA Pena Substantiated and issued deficiency. In regards to the allegation Residents have unexplained bruises based on interviews conducted and information gathered Resident's R1- R9 all stated they do not have unexplained bruises and have not seen anyone with Unexplained bruises. Also stated that staff have not told them to cover up bruises. Staff stated that they had not covered up residents bruising. Said if skin tear they may wear a hospital protective sleeve, but never anything malicious. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Due to lack of supervision, resident eloped, the complaint findings dated 12/10/2024 were previously addressed with Substantiated findings by LPA Pena. It notes the following that S1 stated that what she thinks happened was that R1 went out the back gate and the alarm did not go off. S1 showed LPA how the back gate’s alarm work and it involved 4 steps to secure the gate. S1 indicated that someone must have missed a step or two in locking it, hence the alarm failed to go off. LPA observed that the back gate leads to a driveway towards the main road next to the freeway. The facility rosters dated 10/03/2024 specified a total of 19 memory care residents including R1, 7 caregivers and 3 med techs assigned on different shifts in the memory care unit. However, when R1 wandered away from the facility on 9/30/2024, there were only (2) caregivers and (1) med tech working. Therefore, there was sufficient evidence to corroborate the allegation of lack of supervision which led to R1 wandered from the facility. Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. It should be noted no deficiency issued at today's visit. Prior investigation on 09/30/2024 and 10/3/24 LPA Pena Substantiated and issued deficiency. In regards to the allegation Staff are not reporting incidents to authorized representatives, based on interviews conducted and information gathered it was revealed by Health Services Coordinator Laura Sanchez that all incidents are always reported to Licensing. Special Incident Reports (SIR's) were submitted 09/30/2024 and 12/01/2024 both concerning the elopement of 2 residents. Incident reported 09/30/2025 states that resident was located by Highway Patrol off of the 57 entrance. Staff were able to bring the resident back. On the 12/01/2025 report the resident was across the street walking on the sidewalk and walking back to the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff do not safeguard residents personal property, based on interviews conducted and information gathered Resident's R1- R9 all stated they have never had any items stolen from their rooms. Said housekeeping does a good job. All stated staff are nice and helpful. Staff stated that Resident R1 or family never reported any items missing and they have a Personal Inventory List to ensure documentation of all resident's belongings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 28-AS-20241119083111

Allegation investigated: Staff inappropriately took resident's call pendant away

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced complaint investigation regarding the above allegations. LPA was met by Activity Director Tammy Garcia. Health Services Director Laura Sanchez arrived shortly. The investigation consisted of the following: LPA Gutierrez requested and obtained copies of staff roster, resident roster, resident (R1) identification and emergency information, physicians report, emergency pendant form, and preplacement appraisal information. LPA conducted interview with Administrator, staff (S1-S4), staff S4-S5 over telephone, and resident (R1-R5). See 9099C Substantiated In regard to the allegation” Staff inappropriately took resident's call pendant away”. It is alleged that R1’s call pendent was taken away. During interview with Administrator, and staff five out of six stated that R1 has his/her pendent taken away for excessive calling. Staff stated that R1 would continually press the call pendent for no reason taking away care from other residents. It was stated that staff check on R1 frequently and that there is a pull string in restroom. During interviews with residents four (4) out of five (5) all had call pendants. R1 stated that pendent was lost and when asked staff for it back was told staff did not know where it was. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Health Service Director. A copy of the report and appeal rights were emailed printer not working.the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 28-AS-20250730110835

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(b) · Plan of correction due date: Aug 6, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (b) (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on interviews/record review, R1’s call pendent was taken away due to excessive pushing. This posed an immediate health, safety, and personal rights risk to the resident.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Health Service Director agreed to give R1 pendent back until move to Memory Care unit. Director will conduct training on personal rights of residents and send to LPA by POC due date.

Allegation investigated: Staff did not fix the leak in the roof timely or properly.

Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial investigation to investigate the above allegation. LPA met with Tammy Garcia and discussed the purpose of today's visit. Laura Sanchez (Health Services Director) arrived at approximately at 8:45 A.M.. During this visit, LPA obtained a resident and staff roster, interviewed Staff #1 (S-1) through Staff #5 (S-5) and conducted a tour of the Memory Care Activity Room and Dining Room. During the tour of LPA observed ceiling tiles in the Memory Care Activity Room and Dining Room to have water damage. Refer to LIC 9099C for the continuation of this report. Substantiated Allegation: Staff did not fix the leak in the roof timely or properly. It has been alleged that the ceiling in the activity room has a leak and has not been fixed properly or in a timely manner. Staff interviews revealed that there is a leak in the Memory Care Activity Room and Dining Room. Interviewed staff indicated that ceiling leaks occur frequently during the Summer time as the HVAC (air conditioner) is being used. LPA toured the Memory Care Activity Room and Dining Room and observed ceiling tiles to have water damage. Interviews and tour corroborate this allegation. Deficiency cited. Refe4r to LIC 9099D. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. An exit interview was conducted. A copy of this report and appeals rights were provided to Laura Sanchez (Health Services Director).the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 28-AS-20250731121504

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 12, 2025

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This standard is not met at evidence by: Interviewed staff indicated that ceiling leaks occur frequently during the Summer time as the HVAC (air conditioner) is being used. LPA observed water damage on ceiling tiles.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Administrator to submit a written plan as to how the facility will maintain the ceiling tiles free of water damage and submit plan to LPA Irra by POC due date.

Allegation investigated: Facility staff is not allowing residents to select their own hospice agency

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Genesis Rivas and Nadia Batista Human Resources and explained the reason for the visit. Wellness Director arrived at 9:30am. The investigation consisted of the following: LPA requested staff/resident roster. LPA interviewed 8 residents, 6 staff, and reviewed files for 6 residents. Requested copies of Identification and Emergency sheet, Physician’s Report, and Hospice plan for 6 residents. LPA contacted 6 residents’ responsible parties over the phone. LPA requested Death reports within the last three months. The investigation revealed the following: Regarding allegation: Facility staff is not allowing residents to select their own hospice agency. It is alleged facility staff forces responsible parties/residents to choose a specific hospice agency which does not provide proper care. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews with residents revealed 3 out of 8 residents interviewed were not aware with process as their responsible party assisted with choosing a hospice agency. 3 out of 8 residents were unable to be interviewed due to cognitive skills. 2 out of 8 residents stated they did not know they had a choice in picking the hospice service agency. Interviews conducted with staff revealed some residents are admitted to the facility with their hospice agency in place. However, when the residents residing are assessed and need to obtain hospice care, the Health - Wellness Director meets with the responsible party and provides recommendations of different hospice agencies from which responsible parties or residents choose. Three of the responsible parties interviewed belief there was only one hospice service agency and were not aware there were other hospice agencies to choose from. One of the responsible parties interviewed stated they were aware they had different choices for hospice care. Documents reviewed revealed there are 27 residents currently in hospice and 8 different hospice agencies providing services to residents in care. A total of 7 death reports were reviewed, 4 different hospice agencies were noted providing care at the time of death for the seven residents. 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. Exit interview was conducted with Laura Sanchez Health-Wellness Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 4, 2025 · control 28-AS-20250728094323

Allegation investigated: Staff did not ensure resident's dietary needs were met resulting in the resident choking. Staff did not provide resident's advance directive and/or request to emergency personnel.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Health Services Director Laura Sanchez. The investigation consisted of: Record review, physical plant inspection of Memory Care Unit, interviews with staff (S1-S5) and residents (R1- R5). Copies of relevant documents pertaining to resident (R1) were obtained, as well as LIC 500 Personnel Report and resident roster. *See next page for narrative. Substantiated Allegation: Staff did not ensure resident's dietary needs were met resulting in the resident choking. The complaint alleges that on 6/15/2025 during breakfast meal time Memory Care resident (R1) was served the wrong diet plate and choked on a piece of sausage. According to information obtained, at the time of the incident R1 was on mechanical soft diet, but was given a regular diet plate. A total of five (5) residents were interviewed. None of the residents reported issues with the facility not following their physician order diet. Based on staff interviews, a staff person observed the resident choking and gasping for air. Staff immediately performed Heimlich maneuver and inserted two fingers when the food item was not being expelled. After the piece of sausage was expelled the resident displayed shortness of breath, which resulted in need of emergency services. All staff interviewed confirmed the resident choked because they were served the wrong food diet plate. Staff interviews revealed the staff person who served R1 their plate was unaware the resident required a special diet. Record review confirmed R1 required a mechanical soft diet at the time of the incident. There is sufficient evidence to corroborate the allegaiton. Allegation: Staff did not provide resident's advance directive and/or request to emergency personnel. It is alleged that facility staff did not provide emergency personnel resident (R1's) "Do Not Resuscitate [DNR]" form and other necessary records. A total of five (5) residents were interviewed. None reported issues with POLST or DNR documents. Staff interviews revealed that on June 15, 2025, when 911 emergency services personnel arrived at the facility and determined the resident required transport to the hospital, staff were not able to print any of the residents documents that are normally provided to emergency personnel. Staff stated that the med-tech room computer broke the day before, and the computer used the day of the incident had printing issues. Therefore, emergency personnel were not provided necessary documents i.e., Face Sheet, medication list, POLST/DNR, and medical assessment. Staff stated they asked paramedics to take a picture of the records. It is unknown which documents the paramedics took pictures of. Advance directive and/or request regarding resuscitative measures forms shall be presented to the responding emergency medical personnel. Therefore, there is sufficient evidence to corroborate the allegation. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. An exit interview was conducted with Human Resources Director Nadia Batista. A copy of the report and appeal rights were issued. Allegation: Staff did not report resident's incident to appropriate parties. It is alleged that on Sunday, June 15, 2025, during breakfast time resident (R1) choked on a piece of sausage, and staff called 911 for emergency services. The complaint alleges that R1’s responsible party was notified via text at 10:27 AM requesting a call back, and hospice nurse received a call at 10:32 AM. Information obtained revealed that emergency personnel evaluated the resident and transported R1 to a local community hospital at approximately 9:48 AM. Staff interviews revealed that the choking incident occurred at approximately 9:00 AM, and a call to 911 emergency was made at 9:14 AM. After the incident staff called R1’s responsible party and immediately after the hospice nurse was notified of the incident and medical transport. According to staff interviews, at 10:25 AM, R1’s responsible party did not answer the call, a voice message was left, and a text was sent. The responsible party returned the call at 11:22 AM and finally spoke to them at 11:44 AM. Based on interviews conducted and copies of text and phone screen shots provided by facility, the findings indicate staff notified appropriate parties i.e., responsible party and hospice agency within a reasonable time. Therefore, there is insufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is Unsubstantiated. Exit interview conducted with Human Resources Director Nadia Batista. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 26, 2025 · control 28-AS-20250620120801

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(7) · Plan of correction due date: Jun 27, 2025

General Food Service Requirements. The following food service requirements shall apply: Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met evidenced by: Based on interviews/record review, on 6/15/25 Memory Care Unit resident (R1) choked on a piece of sausage during breakfast time. Staff (S1) gave the resident a regular diet food plate instead of mechanical soft diet plate. Hospice orders (3/2/25) state R1 requires a mechanical soft diet. This posed an immediate health, safety, and personal rights risk to the resient.the state’s words, verbatim · CDSS document, Jun 26, 2025

Plan of correction: Administration staff agreed to conduct training. 1. Submit a written plan of correction by tomorrow. 2. Conduct in-service training to all staff on modified diets, choking/aspiration, and dietary restrictions. 3. Submit staff training evidence by 7/1/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87469(c)(1) · Plan of correction due date: Jul 8, 2025

Advanced Directives and Requests Regarding Resuscitative Measures. Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel and identify the resident as the person to whom the order refers. Based on record review, on 6/15/25 staff called 911 regarding R1's choking incident. However, med-tech staff did not provide emergency personnel POLST or indentifying forms. This posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 26, 2025

Plan of correction: Administration staff shall conduct staff training on Advance Directives and forms that need to be provided to emergency personnel at the time of an emergency. Submit proof of staff training.

Allegation investigated: Staff do not answer resident's calls for assistance timely Staff do not dispose of soiled diapers properly Licensee does not ensure sufficient training is provided to staff in the facility Staff does not ensure emergency evacuation drills are conducted at the facility for residents in care Staff does not ensure facility is kept free of dust on surfaces Staff does not ensure window screens are in good repair Staff do not ensure reporting requirements are being followed Staff does not ensure chemicals are made inaccessible to residents Staff does not ensure sharp objects are made inaccessible to residents Staff do not ensure proper hand hygiene is performed while providing care for residents

The purpose of this amended report dated 07/08/2025 is to correct the report (9099 C) dated 05/13/2025 in which LPA inadvertently listed that there were sharp objects when there were no sharp objects. Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced complaint visit to investigate the above-mentioned allegations and deliver findings. LPA met with Health Services Coordinator Laura Sanchez and explained the reason for the visit. At today's visit Resident's R4-R7 were interviewed. The initial visit was conducted on 09/17/2024 and included the following: LPA Trueman requested copies of the staff and resident rosters, and interviewed the Manager, Staff 1 - Staff 2 (S1 - S2) and Resident 1 - Resident 3 (R1 - R3) LPA also toured common areas in memory care and assisted living. In memory care Rooms 161, 180, 186 and 192 were inspected. In Assisted Living, Rooms 233, 236, 238, 364 and 368 were inspected. Documentation regarding monthly A/C and heating dated 04/03/24- 09/03/24 was submitted. Unsubstantiated Documentation from J & N Duct Cleaning dated 09/10/2024 was submitted. In regards to the allegation Staff do not answer resident's calls for assistance timely, based on interviews conducted, information gathered and tour of the facility it was revealed during inspection of rooms 161, 180, 186 ,192 , 233, 236, 238, 364 and 368 pull cord was initiated by LPA and staff responded within 5 to 10 minutes. Staff stated pendant is monitored at reception and staff will respond quickly. Stated that certain times of day are more busy than others and they have new pagers and have a plan to respond quickly. 5 of 7 residents interviewed stated that they used the pull cord for assistance and staff came quickly to assist. The other 2 residents stated they have not needed any assistance and are independent. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff do not dispose of soiled diapers properly based on interviews conducted, information gathered and facility tour it was revealed that all rooms inspected there were no bad smell or odors and no soiled diapers in the bathroom. Staff stated that there has been no complaints and they are really good about that. 3 of 7 residents stated they have had assistance with diaper changes and it has gone well and there has not been any soiled diapers left in the room. 4 residents changed their own diaper. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Licensee does not ensure sufficient training is provided to staff in the facility, based on interviews conducted and information gathered staff stated that they have an in-service every month and additional training's. Facility submitted staff training documentation covering 08/2024-10/2024. Training contained employee signatures of those who had attended. Topics covered were schedule guideline reminders 08/25/24, Med Tech refresher 09/04/2024, Pendant Response/Call Log 09/09/2024, Safety and Proper Body Mechanics 09/25/2024, Proper Transfer Mechanics 10/08/2024, and Elopements 10/09/2024. 7 of 7 residents stated they feel staff have been trained and that they are efficient and professional. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff does not ensure emergency evacuation drills are conducted at the facility for residents in care, staff stated that drills are done every month and also additional training's. 5 of 7 residents stated that evacuation drills have been conducted. 2 residents were unsure. Facility submitted Fire Drill Report conducted by Southwest Fire and Safety which included order of evacuation drill. Log of those who had attended was submitted for the following dates:08/25/2024, 09/14/2024 and 04/16/2025. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff does not ensure facility is kept free of dust on surfaces, based on interviews conducted and information gathered it was revealed on tour of the facility and resident rooms by the LPA that rooms were clean and there was no dust observed on the surfaces. Staff stated that housekeeping is here every day and in every unit. 7 of 7 residents stated that staff does a great job keeping the facility and rooms clean and they have not observed any dust on surfaces. Documentation of monthly A/C and heating dated 04/03/24- 09/03/24 was submitted in which a/c and heating are checked monthly and filter changed monthly. Documentation from J & N Duct Cleaning dated 09/10/2024 was submitted in which the air ducts are taken care of in the building. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff does not ensure window screens are in good repair, based on interviews conducted, information gathered and tour of resident rooms it was revealed during inspection of resident rooms 161, 180, 186, 192, 233, 236, 238, 364 and 368 that all screens were in good repair. Resident's R1-R7 all stated that the screens in their rooms are all in good condition. Staff stated that all screens are in good repair and that maintenance is on site to fix things right away. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff do not ensure reporting requirements are being followed, based on interviews conducted and information gathered staff stated that Special Incident Reports (SIR's) are always completed and submitted to licensing promptly. Facility submitted Special Incident Reports (SIR's) covering September 2024- November 2024 to LPA. LPA verified the reports which included 2 residents SIR reports 09/12/2024, SIR 09/14/2024, SIR 09/15/2024, Notification of Hospice Services 2 resident's 09/28/2024, and 09/30/2024 Death Report 09/30/2024. In October Death Report 10/06/2024, SIR 10/17/2024, Death Report 10/21/2024, SIR 10/23/2024, Notification of Hospice Services 10/24/2024, 2 SIR's 10/26 and Death Report 10/31/2024. In November Notification of Hospice Services 11/01/2024, SIR 11/02/2024, Death Report 11/03/2024, SIR 11/03/2024, Death Report 11/04/2024, SIR 11/07/2024, SIR 11/13/2024, Notification of Hospice Services 11/13/2024 and SIR 11/23/2024 and 2 Death Reports 11/23/2024. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did no t occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff does not ensure chemicals are made inaccessible to residents, based on interviews conducted, information gathered and tour of resident rooms it was revealed during inspection of resident rooms 161, 180, 186, 192, 233, 236, 238, 364 and 368 that there were no chemicals accessible to residents in their rooms. Resident's 1-7 all stated there are no chemicals in their rooms and nothing poisonous. Staff stated that all chemicals are locked up. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff does not ensure sharp objects are made inaccessible to residents, based on interviews conducted, information gathered and tour of resident rooms it was revealed during inspection of resident rooms 161, 180, 186, 192, 233, 236, 238, 364 and 368 that there were no sharp objects accessible to residents in their rooms. Resident's 1-7 all stated that there are no sharp objects in their rooms. Staff stated that any sharp objects are kept in an appropriate place away from residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff do not ensure proper hand hygiene is performed while providing care for residents 7 of 7 residents stated that staff do have proper hand hygiene and wear gloves when serving food and administering medication. Staff stated that they use universal precautions and wash their hands after resident care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted.the state’s words, verbatim · CDSS document, May 13, 2025 · control 28-AS-20240912093951

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Concierge Genesis Rivas at approximately 8:20 AM and explained the reason for the visit. Health Service Director Laura Sanchez arrived shortly.The facility is licensed to serve (119) older adults, ages 60 and over. There is a fire clearance approved for (119) non-ambulatory residents of which 15 may be bedridden in rooms 151-155,213,215-217,219,224-227 and 229.Facility has an approved delayed egress. It has an approved Dementia Care Plan and a Hospice Waiver approved for (38) residents. There are currently (30) residents receiving hospice care. LPA observed the physical plant, reviewed residents' medications, observed food supply, and reviewed staff and resident files. Resident bedrooms were randomly chosen for review on all three floors. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid mat. The hot water was between 107.2-115.5 degrees which is within the required 105 - 120 degrees. LPA observed bathroom sink faucet in room #151 to be broken. Fire extinguishers were observed throughout the facility. LPA observed cleaning supplies are scissors accessible to residents under kitchen sink and drawer located in the activity room. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and seem to be operating properly. Auditory devices were observed at all entrances/exits of the memory care unit and were operational. There is an electric fireplace in the lobby/dining room covered with a screen The common areas include the activity room, dining room, library, and patio areas. These areas are clean and have the required furniture. There are no firearms or weapons stored at the facility. There are (2) courtyards in assisted living and an enclosed patio in memory care with shaded seating areas. Evacuation chairs were observed at each stairwell. All required postings were observed throughout the facility. Sufficient additional linens/towels were observed. The facility does not have a swimming pool or bodies of water on the premises. Passageways and exits are free of obstruction. Five (5) staff files were reviewed and included Criminal clearance record, and health screening with TB. Two (2) staff files were missing training. Seven (7) residents files were reviewed and included physicians report, TB clearance. Two (2) resident files were missing an appraisal needs and service plan and one (1) resident was missing an admission agreement. Last fire/earthquake drill was conducted in January of 2025. Infectious control plan was reviewed. Facility was missing emergency disaster plan 610 D Two (2) staff, and six (6) residents were interviewed. Random resident medications were reviewed. Medications are centrally stored and locked MAR log is used. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 27, 2025

Allegation investigated: Staff neglect resulted in a resident's death. Staff had unauthorized access to a resident's personal funds.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 03/14/2025 regarding the above allegations. LPA Ramirez conducted subsequent complaint visit on 12/06/2024 and a needs further investigation was documented. LPA Trueman conducted Health & Safety check on 11/26/2024 and a needs further investigation was documented. During today’s visit, LPA Ramirez was greeted by Human Resources Manager, Nadia Batista, and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 4 interviews (S1 – S4), Attempted interview of resident#1 (R1), Resident#2-5 interviews (R2-R5), Interview with R1’s family, copies of Resident#1 (R1)- face sheet, emergency contact information, hospice care orders, hospice medications list, hospice progress notes, medical assessment, medication administration record (MAR) for the month of November 2024, death certificate for R1, facility staff care notes for R1 for the month of November 2024, and death report (LIC 624A) and physical plant tour. SEE 9099-C for continued report Unsubstantiated The investigation revealed the following. Regarding Allegation(s): Staff neglect resulted in a resident's death – It is alleged facility staff neglected R1 which resulted in R1’s death. Review of R1’s resident records revealed R1 was admitted into the facility on 06/21/2023 and was self-responsible. R1 was transferred from another hospice care provider on 11/04/2024 and new hospice care orders were placed. On 11/05/2024, during hospice care visit, hospice care staff documented R1 requested that medication ordered on 11/04/2024, not be ordered and administered unless “absolutely necessary”. On 11/05/2024, R1’s physician ordered R1 discontinue the use of Morphine Sulfate 10mg/0.5 ml- every 4 hours as needed, Lorazepam 1mg/0.5m- every 6 hours as needed, Morphine Sulfate 20mg/1ml- every 4 hours as needed, Morphine Sulfate 5mg/0.25ml- every 4 hours as needed, Lorazepam 1 tab- every 4 hours as needed. Review of R1’s hospice care notes and facility care notes revealed hospice staff and facility staff regularly documented R1’s care and supervision. Review of R1’s death certificate did not corroborate above allegation. Four (4) out of the four (4) staff interviewed denied above allegation. Four (4) out of the four (4) residents interviewed denied above allegation. R1 was not available for interview. Interview with R1’s family did not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff had unauthorized access to a resident's personal funds- It is alleged facility staff were monitoring R1’s financial situation. Review of R1’s resident records revealed R1 was admitted into the facility on 06/21/2023 and was self-responsible. Four (4) out of the four (4) staff interviewed denied above allegation. Four (4) out of the four (4) residents interviewed denied above allegation. Interview with R1’s family did not corroborate this allegation. Review of R1’s facility record, including payments made to the facility for services, did not corroborate above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited during this complaint investigation visit. Exit interview was conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, Mar 14, 2025 · control 28-AS-20241126105756

Type of visit: Office

An Informal Conference meeting was held at Monterey Park Adult and Senior Care Regional Office. Present during this meeting were License Program Manager (LPM) Fernando Fierros and License Program Analysts (LPAs) Blanca Gonzalez, Jose Villalobos, and Luis De Leon. The following representatives were present from Bayshire San Dimas: Operation Manager Tanner Peterson, Director of Operations Chad Coleman, and Health Services Director Laura Sanchez. The Informal Conference was conducted to discuss the oversight of the facility, specifically to address the number of complaints received since the facility was licensed and Title 22 violations, administrator hours and hospice waiver increase requests. The following topics were discussed: · Hospice Waiver Increase request from 30 to 38. Health Director Laura Sanchez provided a copy of the Hospice letter Increase from twenty (20) to thirty (30) hospice residents. · Title 22 regulations regarding administrator qualifications and administrator to be on site sufficient number of hours to permit adequate attention to the management and administration of the facility. · LIC-308 Designation of Facility Responsibility - Administrator to declare a responsible staff for each shift that meets qualification in the absence of the Administrator. · LIC 500 - Staff Schedule to contain administrator hours and be available to the department as needed. · High Volume of complaints for the facility and that the Administrator is to provide oversight regarding staff training and resident concerns. · Licensee Annual Fees · Bedridden Plan See Continuation Page LIC 809C. The following documents were requested: Updated Hospice Waiver Increase Request that includes statements that comply with Title 22 regulations for Section 87632 Hospice Care Waiver. Hospice Waiver Increase request letter signed by the licensee. LIC 500 Personnel Record which indicates the current staff schedule and includes the administrator schedule. During meeting Administrator agrees to the following: Provide an updated staff schedule upon the department’s request. Submit an updated LIC-308 Designation of Facility Responsibility to department that covers each shift. Operation Manager and Director explained internal procedures to mitigate the number of complaints. LPM Fierros discussed the number of citations issued to the facility from the date the license was issued to the current date and provided the Administrator with copies of Title 22 regulations for which facility had been cited. A copy of POC's were provide to Administrator. The following regulations were reviewed. 87468.1 Personal Rights of Residents in All Facilities 87405 Administrator - Qualifications and Duties 87355 Criminal Record Clearance 85707 Admission Agreement 87411 Personal Requirements 87303 Maintenance & Operation 87705 Care of Persons with Dementia 87309 Storage Space Exit interview was conducted and a copy of the report was provided to Administrator Chad Coleman.the state’s words, verbatim · CDSS document, Mar 12, 2025

Allegation investigated: Staff prevents the residents from having family councils Staff do not respond timely to the residents alerts Staff allow a resident to be soiled while in care

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced initial complaint visit to investigate the allegations listed above. LPA met with Laura Sanchez, Health Services Director, and explained the purpose of the visit. The investigation consisted of the following: During today's visit LPA conducted a tour of the facility, obtained the resident roster, staff roster, an admissions agreement for the facility, the alarm response report for the date of 3/6/2025, the admissions agreement for the facility, interviewed Staff #1 - 5 (S1 - S5), and also interviewed Residents #1 - 8 (R1 - R8). The investigation revealed the following: In regards to the allegation that "Staff prevents the residents from having family councils," it is alleged that the staff have been preventing the family council from meeting at the facility to address their concerns to the facility. Unsubstantiated During interviews with the residents, none of them corroborated the allegation. LPA interviewed four (4) different residents whose family members and friends participate in the family council, and they all stated that their families have not been prevented from participating in the family council. During interviews with staff, none of them corroborated the allegation. One staff member interviewed stated that they do permit the resident council to hold meetings at the facility, and they recently had one last month. Another staff member interviewed stated that they have never ended the resident council or have prevented family from attending the meetings, and that the staff do address the recommendations and concerns of the family council when they are brought to staff's attention. During review of the admissions agreement for the residents, it details the right of resident families to join the resident council. In regards to the allegation that "Staff do not respond timely to resident's alerts," it is alleged that staff have not been responding to the residents' call pendant requests for assistance in a timely manner, sometimes taking up to 45 minutes to an hour. During interviews with the residents, seven (7) out of eight (8) did not corroborate the allegation. One of the residents stated that whenever they have used their pendant that they also respond to them in an appropriate time frame. Another resident interviewed stated that staff do respond in a very timely manner whenever they request assistance through their call pendant. During interviews with the staff, none of them corroborated the allegation. One staff member stated that they have been conducting ongoing training amongst staff on how to respond to the resident's pendants in an appropriate time frame. Another staff member explained that if a pendant is not responded to in a timely manner the managers are alerted to ensure that the resident gets the assistance they require as soon as possible During review of the Alarm Response Report for the date of 3/6/2025, over 90% of the call pendant requests were answered within 20 minutes. S2 explained there were some aberrations in the report where residents had left the facility or where the pendant was not reset after the resident received assistance. In regards to the allegation that "Staff allow a resident to be soiled while in care," it is alleged that staff have left a resident in a soiled diaper which led to the resident developing a rash. During interviews with the residents, none of them corroborated the allegation. One resident stated that they do receive all of the assistance and services they require. Another resident interviewed stated that they believe that all of their needs are being met by the facility staff. During interviews with the staff, four (4) out of five (5) interviewed did not corroborate the allegation. One staff interviewed stated that they never intentionally leave residents soiled in their incontinence supplies while in care, and that there are constant training amongst staff with regard to their incontinence care. Another staff interviewed stated that they have not heard of any issues with residents developing a rash due to not being changed, but they added that if this were to ever occur they would immediately notify the resident's doctor for guidance on next steps to treat the rash. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 11, 2025 · control 28-AS-20250305143831

Type of visit: Case Management - Other

Program Analyst (LPA) Vaid made an unannounced visit to the facility to conduct a Case Management visit to evaluate the resident’s displacement by the Eaton Fire. LPA met with Health Service Director Laura Sanchez, and explained the purpose for the visit. There are currently seven (7) residents who were relocated from a facility in Altadena (MONTECEDRO 197610430) on 01/09/2025. LPA Vaid observed, and interviewed four (4) displaced residents. Three (3) residents were not available for interview. All residents interviewed feel safe and comfortable at the Bayshire facility but are anxious to return home to Montecedro. Residents interviewed stated, they are receiving good care, food is good, medications are administered timely as per physicians orders. Displaced residents interviewed reside in rooms: 155, 213, 214, 234. Residents room are clean and have bed, table, reading lamp, chair and linens. The water temperature was checked is between 105-120* F, within regulations. Residents are receiving the care and supervision they need. No health and safety concerns observed during the tour of the facility. Exit interview conducted and copy of this report was left with Health Services Director, Laura Sanchez.the state’s words, verbatim · CDSS document, Feb 11, 2025

Allegation investigated: Staff did not ensure that sharp objects are inaccessible to residents in care.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Laura Sanchez HSD (Health Services Director) who assisted with the visit. LPA explained the purpose of today’s visit. During today's visit, LPA obtained a copy of the staff and resident rosters, reviewed 7 residents files, interviewed Health Services Director (HSD), Facility Manager, Human Resources Director (HRD), Staff #1 - Staff #2 (S#1 - S#2), and Resident#1 - Resident#7 (R#1 - R#7). LPA also toured the facility including Memory Care Unit with the assistance of the HSD. Continue 9099C Substantiated Regarding Allegation: Staff did not ensure that sharp objects are inaccessible to residents in care. It was alleged that memory care kitchen has sharp items in drawers that residents can reach. Interviewed Health Services Director, Facility Manager, Human Resources Director denied the allegation. Interviewed S1 and S2 stated that they didn't see any sharps in the kitchen / dining area in the Memory care unit that accessible to residents. During today's LPA toured the facility including Memory Care Unit. LPA observed a spray bottle of cleaning supply and Heavy-Duty Construction Caulk Gun in the kitchen cabinet unlocked and accessible to the residents. Based on observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Deficiency is being cited today. A copy of this report, 9099-D and appeals rights were provided. Regarding Allegation: Staff are not responding to residents call button in a timely manner. It was alleged that the pendant response times are almost 45 min when residents call. Interviewed staff denied the allegation. They stated that all the calls go to caregivers pagers and they response time about 10 - 15 minutes and do not exceed more than 15 minutes. Interviewed Health Services Director, Facility Manager, Human Resources Director stated that there is a monitor in the front desk and receptionist can see calls in the monitor. On the monitor shows time of call and the time when it's cleared. Interviewed residents stated that they did not have issues with the response times and stated that staff arrive in a timely manner. They stated someone always response. At the time of tour LPA tested randomly chosen resident's pendant and noticed that staff responded to the calls very quickly. Regarding Allegation: Staff did not ensure that residents physician reports are being updated. It was alleged that LIC 602 /Physician's Reports are not proper at move in and not updated as needed. Staff interviewed denied the allegation. Human Resources Director stated that they don't have incomplete files for residents when they move into the community. Health Services Director stated prior to a person's acceptance as a resident, they obtained documentation of a medical assessment, signed by a physician, and keep on file, review of the residents files shows that the facility acquired physician reports (medical assessments) for the residents prior to admitting them to the facility. Also ensure that a resident with dementia shall have an annual medical assessment done at least annually, which shall include a reassessment of the resident’s dementia care needs. File review shows medical assessments done for residents with dementia within that timeline. Interviewed S1 and S2 stated that they didn't notice that residents’ files are incomplete and there are missing documents. Based on interviews conducted, files reviewed, and observations there was not enough supportive evidence to concur with the reported allegations; although the allegations may have happened or are valid, there is 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 copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 4, 2025 · control 28-AS-20250130173505

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Feb 5, 2025

The licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: At the time of visit LPA toured the facility, MCU and observed a spray bottle of cleaning supply and Heavy Duty Construction Caulk Gun in the kitchen cabinet unlocked and accessible to the residents, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 4, 2025

Plan of correction: Licensee/ HSD remove a cleaning supply and Heavy Duty Construction Caulk Gun during the visit. Additionally, licensee / administrator will conduct an in-service training about this section code with all staff and submit an attendance sheet with staff signatures to CCLD by POC due date.

Allegation investigated: Staff did not prevent resident from developing pressure injuries while in care.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Stephanie Guerrero and explained the reason for the visit. The investigation consisted of the following: On 11/13/24 LPA Flores conducted a health and safety check visit, interviewed Health Care Director and Administrator, and requested pertinent documents for resident #1(R1). On 11/18/24 LPA Flores interviewed hospice nurse over the phone. On 11/27/24 LPA requested hospice records for R1. On 12/17/24 LPA Flores conducted interviews with 4 staff and delivered findings for complaint. The investigation revealed the following: Regarding allegation: Staff did not prevent resident from developing pressure injuries while in care. It is alleged R1 developed wounds in the mid back area and an open sore in hand due to staff not following R1’s plan of care. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews conducted with staff revealed R1 full assistance with all activities of daily living (ADLs). R1 required staff to reposition at least every 2-3 hours. Per staff R1 was check for incontinence as well provided care as needed. If soil during the times R1 was reposition R1 was change. Staff stated to notify any changes in condition to hospice as soon as observed, including when noticing the wound patches were soiled. Hospice will come to the facility to change them after notifying them. Staff were provided training by facility and hospice and were knowledgeable on the topic. Interview conducted with hospice care nurse revealed facility staff have provided proper care to R1 and facility’s staff have notified hospice immediately after observing a change in condition. Documents reviewed revealed the following, per physician’s report dated 2/15/24, R1 had a history of skin breakdown and needed assistance with all ADLs. On 10/10/24, R1 was recertified into hospice care. Under circumstances for hospice, it was noted R1 has a recurrent “skin issue, with a healed decubitus to the sacrum/coccyx”. It was noted R1 was bedbound. On 10/30/24 hospice nursing notes, note R1 is being reposition every two hours by facility staff. On 10/31/24, a meeting was held and per hospice meeting notes, R1 is “high risk for skin breakdown and skin breakdown prevention was provided to facility’s staff, family and caregiver by demonstrating care”. On 11/4/24 nurse (LVN) hospice noted, R1 was observed to have “redness on coccyx, left buttock, right hip, and right upper back and shoulder”. R1’s facility resident assessment dated: 11/11/24 notes, R1 required “complex wound care”, which was to be provided by a nurse as order by physician. Hospice physician order dated 11/11/24 notes an x-ray was requested to rule out fracture for hand due to redness and swelling. Wound care was requested for right shoulder and lower back. Per Outside Agency - facility’s form, on 11/11/24 LVN visited R1 and provided wound care. On 11/11/24 facility provided skin integrity training to staff. Order summary report dated: 11/13/24, notes R1 will be receiving wound care for a stage II sacrum pressure ulcer three times a week. On 11/18/24 hospice physician conducted an in person visit and noted R1 has various lesions in the body and a stage I wound in the sacral area due to “frail skin”. Per physician these are "unavoidable" due to R1’s condition and may be "difficult to heal". Although the wounds may have developed based on physician’s notes on R1’s declining condition there is not enough evidence staff's lack of care would have cause the wounds. 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. Exit interview was conducted with Laura Sanchez Health Care Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 17, 2024 · control 28-AS-20241112124505

Allegation investigated: Staff did not adequately supervise resident in care resulting in resident wandering from the facility.

****This report supersedes the original complaint investigation report dated 10/03/2024. The report is being superseded to include additional information not included on the original report dated 10/03/2024 and to correct the deficiency that was cited from a Type B to a Type A, as well as to update the regulation that was cited. The investigation finding remains SUBSTANTIATED. ***** Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit to add additional information not included on the report dated 10/03/2024 and update the deficiency cited. LPA met with Laura Sanchez, Health Services Director and explained the reason for the visit. The investigation consisted of the following: On 10/03/2024, LPA obtained copies of the Resident & Staff Rosters and Resident #1 (R1) pertinent files. LPA conducted a walkthrough of the facility's common areas and Memory Care unit which included, inspecting the back gate in the Memory Care Unit and took pictures/video of the back gate. LPA along with S1 checked the back gate to confirm that the alarm is working. LPA interviewed Staff #1 (S1) - Staff #2 (S2), Witness #1 (W1) and Resident #1 (R1). LPA also interviewed Witness #2 (W2) telephonically and attempted to contact Staff #3 (S3 - Staff #4 (S4) but no response received. During today's visit, LPA obtained copies of the resident & staff rosters, Memory Care unit staff schedule (10/03/2024) and took additional photos of the back gate and exit doors in the MC unit. ****REPORT CONTINUED ON LIC9099-C***** Substantiated The investigation revealed the following: In regards to the allegation: “Staff did not adequately supervise resident in care resulting in resident wandering from the facility.” It is alleged that R1 was wandering into traffic and put herself in harm’s way. Interviews with S1-S2 corroborated the allegation. S1 stated that the incident happened early evening on 09/30/2024. S1 indicated that R1 was admitted to the facility recently. S1 stated that what she thinks happened was that R1 went out the back gate and the alarm did not go off. S1 showed LPA how the back gate’s alarm work and it involved 4 steps to secure the gate. S1 indicated that someone must have missed a step or two in locking it, hence the alarm failed to go off. LPA observed that the back gate leads to a driveway towards the main road next to the freeway. Interviews with W1-W2 also corroborated the allegation. W1 stated that she drove around to help in locating R1 and was handed over to her by the authorities and W1 took R1 back to the facility. W1 indicated that she did not observe injury on R1. Interviewed staff stated that they conducted a body check and assessed R1 as soon as she returned to the facility. W2 stated that she called the facility and 911 to report that a resident was walking next to the freeway. LPA interviewed R1 but cannot recall the incident. Based on file reviews, resident assessment record indicated that R1 is a wanderer who requires multiple behavioral interventions for redirection including wandering. The physician’s report dated 08/19/2024 indicates that R1 is diagnosed with dementia. The facility rosters dated 10/03/2024 specified a total of 19 memory care residents including R1, 7 caregivers and 3 med techs assigned on different shifts in the memory care unit. However, when R1 wandered away from the facility on 9/30/2024, there were only (2) caregivers and (1) med tech working. Therefore, there was sufficient evidence to corroborate the allegation of lack of supervision which led to R1 wandered from the facility. Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to Laura Sanchez, Health Services Director along with the Appeals Rights.the state’s words, verbatim · CDSS document, Dec 10, 2024 · control 28-AS-20241001133551

From the deficiency page — Deficiency type: Type A · Section cited: CCR 877705(c)(4) · Plan of correction due date: Dec 11, 2024

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by: Based on interviews, observations, records reviews, the Administrator did not ensure that R1 was supervised properly which resulted to R1 wandering into the traffic which poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Dec 10, 2024

Plan of correction: The facility shall ensure that there’s adequate number of direct care staff to support and maintain necessary supervision of residents. The administrator will ensure that appraisals are conducted on dementia residents on an ongoing basis and assessed annually. Administrator agreed to update the elopement policy in their plan of operation and conduct an in-service elopement training with all the staff. Lastly, administrator will develop a written instruction on how to secure the exit points correctly and properly. Training logs along with the written plan shall be submitted to LPA/CCL by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit during a complaint investigation visit. LPA met with Lisa Gomez and explained the reason for the visit. On 11/13/24 LPA Flores conducted a health and safety check tour at the facility and observed the following: A pair of large scissors and a knife in the dementia kitchenette in an accessible drawer A cabinet door was in disrepair. Water temperature was tested in each residents room and tested between 71.5-109.4 degrees F., which is not within the required 105-120 degrees F. Room #192 tested at 109.4 degrees F., room #167 tested at 102.8 degrees F., room #234 tested at 86.8 degrees F., room #224 tested at 71.5 degrees F., room #153 tested at 105.2 degrees F., and room #151 tested at 108.5 degrees F. Deficiencies were noted on LIC 809D per Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 13, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Nov 14, 2024

87705 Care of Persons with Dementia:(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidence by: Based on observation licensee did not ensure knife and scissors were stored inaccessible to the residents in the dementia kitchennete which poses an immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Nov 13, 2024

Plan of correction: Administrator will ensure maintenance provides a lock in drawer were knife and scissors are stored and will submit a picture to the department by POC due date 11/14/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a)(1) · Plan of correction due date: Nov 20, 2024

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: Based on observations licensee did not ensure dementia's unit kitchennete cabinet was in good repair, and that water temperature was within the required 105-120 degrees F., water temperature tested as follow in room #167- 102.8, room #234- 86.8, room #224 - 71.5 degrees F. (Cont)the state’s words, verbatim · CDSS document, Nov 13, 2024

Plan of correction: Administrator put a repair request order with maintenance to repair the cabinet and water temperature during this visit. Administrator will submit a picture of cabinet repair, and a water temperature log for 7 days by POC due date 11/20/24. which poses a potential risk to the health, safety, or personal rights of the persons in care.

Allegation investigated: Staff member works at the facility while under the influence. Facility is dirty. Facility is in disrepair. Staff members CPR Certificate are expired.

Licensing Program Analyst (LPA) Tyler Reyes conducted a subsequent complaint investigation visit for the allegations(s) above. LPA Reyes met with Administrator Lisa Gomez and the purpose of the visit was discussed. Initial visit conducted on 10/18/24 consisted of the following: LPA Vaid toured the physical plant. LPA requested copies of the resident/staff roster. LPA Vaid interviewed (2) staff and (2) residents, LPA Vaid collected the following in-service trainings for the month of August and September. The investigation consisted of: On 10/21/24, LPA Reyes conducted interviews with Staff #1 (S1- S6), and Residents #1 (R1- R6). LPA Reyes collected copies of Staff and Resident Rosters, Employee Handbook 2024, and October Staff Schedule 2024. **Continued-LIC9099-C** Unsubstantiated The investigation revealed the following: In regard to allegation “Staff member works at the facility while under the influence” it was alleged that a staff member is arriving to work under the influence of alcohol. (6) of (6) denied the allegation. Staff member indicated that they do not come to the facility drunk and does not drink while at work. Staff indicated the following that they have not heard or witnessed an employee arriving to work intoxicated or drinking while working. Staff indicated they would follow reporting requirements if observed or suspected an employee working while intoxicated or drinking while working. (6) of (6) residents could not corroborate the allegation. Residents indicated they have not heard or witnessed a staff member working while intoxicated. In regard to allegation “Facility is dirty” it was alleged that kitchen and kitchen silverware is dirty. (6) of (6) denied the allegation. Staff indicated that they have not observed a dirty kitchen or residents eating with dirty silverware. Staff indicated a recent purchase of silverware was made on 10/17/24 for the reason of replacing current silverware with a matching set. Another reason for the purchasing of new silverware was to replace the current silverware that has water spots. (6) of (6) residents denied the allegation. Residents indicated they have not observed using dirty silverware. Resident indicated when at times observing water spots on the silverware but always clean. LPA Reyes observed with S3 the dish washer clean and operational. LPA Reyes observed S3 perform precision chlorine test paper and on the dish washer. Test paper indicated that dish washer is operating within operational requirements In regard to allegation “Facility is in disrepair” it is alleged that the facility’s doors are not being locked at night. (6) of (6) staff denied the allegation. Staff indicated that when they arrive in the early morning that doors are locked. Staff indicated the only way to gain entrance is through the main entrance of the skilled nursing facility or by contacting the telephone number listed at the facility’s main entrance. (6) of (6) residents could not corroborate the allegation. Residents have indicated no knowledge of the doors of the facility remaining unlock at night. In regard to allegation “Staff members do not have the required training” it is alleged staff CPR certificates are not current. (6) of (6) denied the allegation. S2 provided LPA Reyes with copies of the October 2024 staff schedule and a list of staff with current CPR certification. Per Title 22, Health and Safety code 1569.618 (3) for Residential Care facilities for the Elderly (RCFE) at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. (6) of (6) residents could not corroborate the allegation. However,neither resident had knowledge if the staffs on duty if CPR was current. **Continued-LIC9099-C** Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 21, 2024 · control 28-AS-20241011123713

Allegation investigated: Staff do not ensure that resident(s) are provided with activities while in care. Licensee is not ensuring that staff provide adequate care to resident(s). Staff are not addressing resident(s) developing skin breakdown while in care.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation visit regarding the above allegations. LPA Margaryan met with Health Services Director (HSD), Laura Sanchez who assisted with the visit. Shortly after, LPA met with Lisa Gomez, Administrator. Purpose for the visit was explained. During today's visit, LPA Nune Margaryan obtained a copy of the resident and staff roster, copy of the staff schedule for monts of April and May 2024, R1's Physician's Report. LPA tour the facility and inspected randomly choosen residents rooms. Interviewes condacted with Health Service Director, Administrator, Staff #1 - Staff #4 (S#1 - S#4) and Resident #1 - Resident #6 .(R#1 - R#6). Continue 9099C Unsubstantiated Regarding the allegation: Staff do not ensure that resident(s) are provided with activities while in care. It was alleged that Resident #1 who is bedridden, can't watch TV, because TV is not working in the resident room. LPA tour the facility with HSD. Upon walking into the R1 room LPA observed that TV is on and R1 is watching TV. TV is working properly. Interviewed Administrator, HSD stated that they ensure that all residents have the opportunity to participate in activities. Residents care needs are individualized depending on their mobility and what they enjoy. Some residents like to watch TV, listen to music while others prefer visits from team members / staff. Interviewed S3 and S4 stated that if resident can't participate in a group activity, they have alternative activities for them. They do in room visits. They will bring sensory objects, read for residents or music therapy with the residents. 5 out of the 6 residents stated the staff would do activities with them. R1 stated that they liked to watch TV and TV was working in their room. Regarding the allegation: Licensee is not ensuring that staff provide adequate care to resident(s). It was alleged that facility did not have sufficient staff to provide care to resident, resident needs were not met. Staff didn’t change the resident diaper of extended period of time. R1 lays in their room without having diaper changed. Interviewed HSD, Administrator and staff denied the allegation. They stated that facility has enough staff to provide adequate care to residents in care. They assist residents with all their needs including diaper change all day and night. Facility has a 3-shift scheduled for morning, day, and night. They stated if there is a call off, they will replace the shift. It will be facility staff to work an extra shift or have an med. tech. or RCC (Resident care coordinator) fill in for that shift. Also, they have a contract with outside agencies if needed. Staff indicated that residents' diapers are changed every 2 hours, or as needed to keep them clean and dry. They also stated that each resident has pendant, and they can call/page staff if they need assistance and to have their diaper changed as well. LPA interviewed 6 residents of which 5 are incontinence. The residents interviewed stated the staff check their diapers often and change them as needed. R1 stated that staff do not leave them in soiled diapers. R1 shows their pendant and stated will call if need assistance. While LPA walked around to conduct resident interviews, LPA observed enough staff assisting residents. Continue 9099C Regarding the allegation: Staff are not addressing resident(s) developing skin breakdown while in care. It was alleged that a lot of residents have bad skin breakdown. Interviewed HSD, Administrator and staff denied the allegation. They stated that protocol is to report any skin breakdown changes to the Med Tech and HSD (Health Service Director) who then discuss appropriate interventions with staff including Hospice care or Home health. Staff interviewed stated that they do rounds regularly to check on residents. Staff indicated that residents' diapers are changed every 2 hours, or as needed to keep them clean and dry. Staff also stated that they reposition resident to prevent rashes, skin breakdown. Staff also stated that when caregivers notice rashes or skin breakdown while assisting residents, they report it immediately to the Med Tech for assessment. Interviews conducted with residents were consistent with their response that the facility is providing adequate care to meet the needs of the residents. Based on the observations and interviews conducted with staff and residents, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to HSD Laura Sanchez.the state’s words, verbatim · CDSS document, Oct 7, 2024 · control 28-AS-20240930084614

Allegation investigated: Staff did not adequately supervise resident in care resulting in resident wandering from the facility.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with Laura Sanchez, Health Services Director and discussed the purpose of the visit. Shortly after, LPA met with Lisa Gomez, Administrator who provided assistance. The investigation consisted of the following: LPA obtained copies of the Resident & Staff Rosters and Resident #1 (R1) files such as: Face sheet, Admission's Agreement, Physician's Report, Preplacement Appraisal, Personal Rights, Resident Assessment and Current medication list. LPA conducted a walk through of the facility's common areas and Memory Care unit which included, inspecting the back gate in the Memory Care Unit. LPA along with S1 checked the back gate to confirm that the alarm is working. LPA interviewed Staff #1 (S1) - Staff #2 (S2), Witness #1 (W1) and Resident #1 (R1). LPA also interviewed Witness #2 (W2) telephonically and attempted to contact Staff #3 (S3 - Staff #4 (S4) but no response received. *****CONTINUED ON LIC 9099-C***** Substantiated The investigation revealed the following: In regards to the allegation: “Staff did not adequately supervise resident in care resulting in resident wandering from the facility.” It is alleged that R1 was wandering into the traffic and put herself in harm’s way. Interviews with S1-S2 corroborated the allegation. S1 stated that the incident happened early evening on 09/30/2024. S1 indicated that R1 was admitted to the facility recently. S1 stated that what she thinks happened was that R1 went out the back gate and the alarm did not go off. S1 showed LPA how the back gate’s alarm work and it involved 4 steps to secure the gate. S1 indicated that someone must have missed a step or two in locking it, hence the alarm failed to go off. LPA observed that the back gate leads to a driveway towards the main road next to the freeway. Interviews with W1-W2 also corroborated the allegation. W1 stated that she drove around to help in locating R1 and was handed over to her by the authorities and W1 took R1 back to the facility. W1 indicated that she did not observe injury on R1. W2 stated that she called the facility and 911 to report that a resident was walking next to the freeway. Interviewed staff stated that they conducted a body check and assessed R1 as soon as she returned to the facility. LPA interviewed R1 who cannot recall the incident. Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to Lisa Gomez, Administrator along with the Appeals Rights.the state’s words, verbatim · CDSS document, Oct 3, 2024 · control 28-AS-20241001133551

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87461(a)(1) · Plan of correction due date: Oct 10, 2024

87461 Mental Condition..(a) The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual: (1) tends to wander; This requirement is not met as evidenced by: Based on interviews, observations, records reviews, the Administrator did not ensure that R1 was supervised properly which resulted to R1 wandering into the traffic which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Oct 3, 2024

Plan of correction: The administrator agreed to conduct an in-service elopement training with all the staff and develop a written instruction on how to secure the exit points correctly and properly. Training logs along with the written plan shall be submitted to LPA/CCL by POC due date.

Allegation investigated: Facility air conditioner is in disrepair Staff does not provide comfortable room temperature for residents

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegations. LPA met with Lisa Gomez (Manager) and explained the reason for the visit. The investigation consisted of the following: LPA Mora requested for copies of the staff and resident rosters, and interviewed the Manager, Staff 1 - Staff 3 (S1 - S3), Resident 1 - Resident 8 (R1 - R8) and third party AC contractor. LPA also toured common areas and rooms 154, 227, 232, 233, 243, 317, 319, and 340 Regarding the allegation "facility air conditioner is in disrepair" and "staff does not provide comfortable room temperature for residents", it is alleged that the AC has been in disrepair for the past few months and multiple residents rooms and dining room have been affected. (Continued to LIC 9099-C) Unsubstantiated Administrator and staff interviewed stated that the recent heat wave did cause some AC issues, but they immediately contacted a third party AC contractor to come and repair the AC issues. Administrator stated that portable AC were provided to residents affected to maintain a comfortable temperature. The third party AC contractor was interviewed and stated that it is normal for buildings like this facility to have AC problems here and there, but recently the heat wave caused a lot of AC units to stop working properly. The facility contacted him and he came to the facility on 09/06/24, 09/07/24, 09/08/24, 09/09/24 and 09/11/24. He stated he brought portable AC to install in rooms and areas that were affected while he worked on fixing the AC units. Every resident room has their own AC unit and thermostat. Six (6) out of eight (8) residents interviewed did not had any AC issues and had no complains about the temperature in their rooms. Two (2) of the eight (8) residents stated that their AC was blowing air, but not cold enough air especially during the recent heat wave, however, the facility provided them with a portable AC. LPA observed the thermostat in these 8 residents room and saw temperatures between 72 degrees F and 78 degrees F. Per Title 22 Section 87303(b)(2) and Section 87303(b)(3), the facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), however, nothing in this section shall prohibit residents from adjusting individual thermostatic controls. LPA confirmed with the 8 residents if they were comfortable with the temperature showing on their thermostat and they stated they were. The residents are able to adjust the temperature in their bedrooms to their liking. Five (5) out of the eight (8) residents interviewed stated the temperature in the dining room was comfortable. Three (3) out of the (8) residents stated it was hot or warm in the dining room. These three residents stated that the temperature showing on the dining room thermostat showed temperatures of 81, 82, and 83 degrees F. These temperatures provided are within the temperature range per Title 22 Section 87303(b)(2). During today's visit, LPA observed a temperature of 78 degrees F in the dining room thermostat. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Sep 12, 2024 · control 28-AS-20240906142814

Allegation investigated: Staff do not respond to resident's call for assistance in a timely manner. Staff do not meet resident's dental hygiene and toileting needs.

Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegation. LPA met with Lisa Gomez and discussed the purpose of today’s visit. Laura Sanchez/S-1 arrived at approximately 9 A.M.. and assisted with this visit. LPA Irra conducted the initial investigation visit on 08/01/24. During this visit, LPA obtained a copy of the resident and staff rosters, a list of residents that are currently receiving hospice services, pendant call log, interviewed Staff #1 (S-1) through Staff #5 (S-5) and interviewed Resident #1 (R-1), Resident #3 (R-3) and Resident #4. LPA was unable to interview Resident #2 (R-2) as R-2 was asleep during this visit. LPA also interviewed Resident #5 (R-5). Refer to LIC 9099C for the continuation of this report. Substantiated Staff do not respond to resident's call for assistance in a timely manner. It has been alleged that residents press their call button and it takes (30) minutes for staff to come check on residents. (4) out of (5) resident interviews revealed that staff have taken more than (30) minutes to respond to residents’ pendant calls to assist with their care needs. LPA also obtained and reviewed this facility’s alarm response report (pendant call log for 07/31/24 through 08/01/24 [8:40 A.M..]) and observed approximately (14) pendant alarms which reflect that staff took more than (30) minutes to respond residents’ pendant calls. Resident interviews and alarm response report (pendant log) corroborates this allegation. Staff do not meet resident's dental hygiene and toileting needs. It has been alleged that staff are not providing oral care to residents who need assistance and toileting is not being done timely. (4) out of (5) resident interviews revealed that residents are not receiving oral care and/or assistance with toileting in a timely manner. Interviewed residents revealed that staff (at times) take (30) minutes to (1) hour to attend to residents’ dental hygiene and/or toileting needs. LPA also obtained and reviewed this facility’s alarm response report (pendant call log for 07/31/24 through 08/01/24 [8:40 A.M..]) and observed approximately (14) pendant alarms which reflect that staff took more than (30) minutes to respond residents’ pendant calls. Resident interviews and alarm response report (pendant log) corroborates this allegation. Based on LPAs' observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiency cited on the attached. Exit interview conducted, appeal rights and a copy of this report was provided to Laura Sanchez/S-1 Allegation: Staff are pushing residents that do not require hospice to agree to hospice care. It has been alleged that staff are forcing residents who do not require hospice care to agree to hospice services or they will be evicted. Per staff interviews, staff are not pushing residents that do not require hospice to agree to hospice care. Per staff interviews, residents are not threatened to be evicted if they do not agree to hospice care. Staff interviews revealed that S-1 is the person responsible to work with hospice care agencies. Per S-1, S-1 works with hospice care agencies once the resident’s physician has ordered hospice services. Per S-1, once the residents are referred to hospice services by their physician, S-1 provides the resident with different hospice agency options to select from. Per S-1, there are (7) different hospice agencies that provide hospice care for residents under hospice services at this facility. Resident interviews revealed that staff are not pushing residents into receiving hospice care or are threatened to be evicted if hospice services are not obtained. Interviewed residents indicated that hospice services were ordered by their physicians and not staff from this facility. Interviewed residents also indicated that they were provided with different hospice agency options. Interviewed residents indicated they do not have any concerns pertaining to this matter. Interviews do not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, appeal rights and a copy of this report was provided to Laura Sanchez/S-1.the state’s words, verbatim · CDSS document, Aug 27, 2024 · control 28-AS-20240724144927

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Sep 6, 2024

Personnel Requirements-General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. This standard is not met as evidence by: At times, staff are taking more than (30) minutes to respond to residents’ pendant calls and to meet residents’ oral care and/or toileting needs in a timely manner.the state’s words, verbatim · CDSS document, Aug 27, 2024

Plan of correction: Facility Administrator to ensure this facility has personnel at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Facility Administrator to provide a training for staff and discuss the importance of responding to resident needs in a timely manner. Facility Administrator to submit proof of training and statement pertaining to this regulation to LPA Irra by POC due date.

Allegation investigated: Facility is in disrepair. Facility does not ensure equipment is properly maintained. Facility staff are not trained in the operation of the Hoyer lift. Staff does not have appropriate qualifications. Facility forced resident to change hospice companies against resident’s will. Staff did not meet resident’s care needs in a timely manner.

Licensing Program Analyst (LPA) Tao conducted an unannounced complaint investigation for the allegations listed above. LPA met Laura Sanchez, health service director and explained the purpose of today's complaint investigation visit. The investigation consisted of the following: obtained staff / resident roster and resident#1’s (R1) records; interviewed residents from resident#1 (R1) to resident#4 (R4); interviewed staff from staff#1 (S1) to staff#4 (S4); and conducted a physical plant. The investigation revealed the following: In regard of allegation that the facility is in disrepair, it was alleged that the facility's air conditioner (AC) is leaking. LPA interviewed residents and all four (4) out of four (4) residents could not corroborate the allegation. Residents’ interview revealed the facility AC is not leaking and working. (-continued in LIC9099C-) Unsubstantiated All four (4) staff interviewed denied the allegation. Staff interviews revealed the facility AC is not leaking. LPA conducted a physical plant and observed the AC is working and not leaking. Thus, the facility’ AC is not in disrepair. In regard of allegation that the facility does not ensure equipment is properly maintained, it was alleged that the facility Hoyer lifts are outdated and not maintained. LPA interviewed residents, all four (4) out of four (4) residents could not corroborate the allegation. Residents’ interviews revealed that the facility Hoyer lifts were working properly and maintained by either hospice or home health agencies. All four (4) staff interviewed denied the allegation. Staff stated facility Hoyer lifts were operational and maintained. LPA observed staff operating the Hoyer lifts and they were working appropriately. Thus, the facility had maintained equipment and worked properly. In regard of allegation that the facility staff are not trained in the operation of the Hoyer lift, it was alleged that the facility staff are not trained to use the Hoyer lifts. LPA interviewed residents, all four (4) out of four (4) residents could not corroborate the allegation. Residents’ interviews revealed that the facility staff were able to use Hoyer lifts when providing cares. All four (4) staff interviewed denied the allegation. Staff stated facility had provided training to staff on how the operate Hoyer lifts properly. As mentioned above, LPA observed staff operating the Hoyer lifts and they were handling / working the Hoyer lifts appropriately. Thus, the facility staff were able to operate the Hoyer lifts. In regard of allegation that staff does not have appropriate qualifications, it was alleged that the facility’s acting Administrator is not qualified while the administrator was absent. LPA interviewed residents, all four (4) out of four (4) residents could not corroborate the allegation. Residents’ interviews revealed that the facility’s acting administrator was able to provide cares to residents as needed. All four (4) staff interviewed denied the allegation. Staff stated the acting administrator was able to perform the acting administrator’s job descriptions and provided guidance to staff. LPA reviewed staff records and current administrator certificates were observed. Thus, the facility staff have appropriate qualifications. (-continued in LIC9099C-) In regard of allegation that facility forced resident to change hospice companies against resident’s will, it was alleged that a resident was allegedly forced to change hospice companies against resident’s will. LPA interviewed residents, all four (4) out of four (4) residents could not corroborate the allegation. LPA interviewed the claimed resident who was forced to change hospice agencies. Resident’s interviews revealed that resident was aware of the changes and was not forced to change. Changes of hospice cares were due to the resident’s care needs and resident’s own wish. All four (4) staff interviewed denied the allegation. Staff stated staff would not force residents to choose their hospice agencies. Thus, the facility staff did not force residents to change hospice companies. In regard of allegation that staff did not meet resident’s care needs in a timely manner, it was alleged that that staff takes long time to respond to resident’s calls. LPA interviewed residents all four (4) out of four (4) residents could not corroborate the allegation. Resident’s interviews revealed that it usually took 10-15 minutes for staff to respond to resident’s calls and it was acceptable to residents. All four (4) staff interviewed denied the allegation. Staff stated they would response to resident’s calls as soon as they received them. Facility staff may assist with other residents while other residents called for assistance at the same time, staff would assist the new call as soon as they finished assisted other residents. LPA tested the call buttons during the physical plant, it took about 5-10 minutes to have a staff arrived at the rooms to assist residents. Thus, the facility staff did not fail to provide care to residents in a timely manner. Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Laura Sanchez, health service director and findings were discussed. A copy this report was provided at time of visit.the state’s words, verbatim · CDSS document, Aug 26, 2024 · control 28-AS-20240819084930

Allegation investigated: Staff were not fingerprint cleared prior to working with residents in care.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit on the allegation listed above. LPA met with Staff, Nadia Bautista, and explained the reason for the visit. On 5/28/24, LPA Chan toured the facility and obtained copies of the staff and resident rosters. Interviews were held with the Manager, 5 Staff, and 5 Residents. LPA requested copies of documents for Staff #2 - #6 to be emailed to LPA: Personnel Record with date of hire and Background clearance letter. On 7/18/24, LPA Chan interviewed another staff and reviewed personnel files. For allegation, staff were not fingerprint cleared prior to working with residents in care. LPA interviewed staff who denied working before they obtained background clearance. Staff indicated the process before they start is to obtain fingerprint clearance. LPA reviewed the background clearance letters for 6 personnel files. One out of the six staff received the background clearance letter on 5/3/24 but was hired on 4/1/24. Substantiated It is confirmed today that Staff #3 began working on 4/1/24. Based on record review, 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 and Chapter 8), are being cited on the attached LIC 9099D. A civil penalty is also assessed for this deficiency. An exit interview was conducted. The Plan of Correction was reviewed and developed with the facility manager. A copy of this report and appeal rights were provided. The personnel files included the personnel record, health screening, TB results, and training hours. The administrator has the required training to receive the administrator’s certificate. LPA interviewed a total of 7 staff, and all stated they received their initial training during orientation and receive continuous training during the year. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Manager Gomez. A copy of this report along with the appeal rights was provided.the state’s words, verbatim · CDSS document, Aug 22, 2024 · control 28-AS-20240523135252

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g)(1) · Plan of correction due date: Aug 23, 2024

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees...shall: (1) Obtain a California clearance....as required by law or Department regulations This requirement is not met as evidenced by: Based on record review, Staff #3 started working prior to obtaining verification of background clearance which poses an immediate health and safety concern to residents in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: Administrator shall review the regulation 87411 and ensure all employees obtain a background clearance prior to working. A statement acknowledging this regulation shall be submitted to LPA by 8/24/24. Note: Staff #3 had received the background clearance letter on 5/3/24. ***A civil penalty has been assessed for this deficiency.****

Allegation investigated: Staff are mishandling the residents medications

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/20/2024 regarding the above allegation. LPA Ramirez was greeted by Human Resources Manager- Nadia Batista and explained the purpose of the visit. Resident Services Director- Laura Sanchez arrived shortly after to assist with tour. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster, Staff#1 - 5 interviews (S1 – S5), Resident Interviews #1-5 (R1 – R5), Medications Destruction Log (LIC 622), Facility Narcotics Shift Log for July 1, 2024, through August 19,2024, and physical plant tour. SEE 809-C for continuation. Unsubstantiated The investigation revealed the following. Regarding Allegation: Staff are mishandling the residents’ medications- It is alleged staff did not document the destruction of medications, ensure medications and narcotics were centrally stored and inaccessible to persons other than employees responsible their supervision, and missing medications. Five (5) out of the five (5) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. Interviews with staff revealed on or around 8/14/2024, several resident medications which were scheduled to be destroyed, were observed to be secured in the facility medications cart but, still needed to be logged for destruction. Facility management became aware on 8/14/24 and medications were logged for destruction and destroyed. Interviews with residents revealed staff provides residents with medications as needed and residents receive their medications as ordered. Per Title 22, Incidental Medical and Dental Care-87454(i)(1)(2)(3)(4)- Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: (1) Name of the resident. (2) The prescription number and the name of the pharmacy. (3) The drug name, strength and quantity destroyed. (4) The date of destruction. LPA Ramirez reviewed medications destruction log for twenty (20) residents and observed the logs to list the name of the resident, prescription number and name of the pharmacy, name of drug, strength and quantity destroyed, and date of destruction. LPA Ramirez reviewed and obtained copies of July 2024 and August 2024 Narcotic Shift Count log for the facility memory care unit and assisted living. LPA Ramirez did not observe any documented discrepancies on these logs. During tour of facility, LPA Ramirez observed memory care medications room to be inaccessible to residents in care and observed one (1) staff to have sole custody of the key required to open the medications room door. LPA Ramirez observed the assisted living medications cart to be inaccessible to residents in care and observed one (1) staff to have sole custody of the key required to access medications cart. LPA Ramirez toured the facility health center room located on the 3rd floor. Room was observed to be inaccessible to residents in care. LPA Ramirez did observe resident charts in this room and did not observe medications in this room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited today. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 20, 2024 · control 28-AS-20240814123547

Allegation investigated: Facility staff does not provide food of good quality to resident(s) in care.

Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an initial complaint visit to investigate the above allegation. LPAs met with Lisa Gomez, General Manager and discussed the purpose of today's visit. The investigation consisted of the following: LPAs conducted a tour of the facility focusing in the kitchen, and dining areas in the Assisted Living (AL), Skilled Nursing Facility (SNF) and Memory Care Unit (MC), reviewed facility's food supply and menu for the day. LPAs obtained copies of the Resident & Staff Rosters, Weekly and Always available menus and Work estimate pricing from Pro Refrigeration, Inc (dated 8/01/2024 & 8/09/2024). LPAs also interviewed Staff #1 (S1) - Staff #6 (S6) and Resident #1 (R1) - Resident #8 (R8). *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: "Facility staff does not provide food of good quality to resident(s) in care." It is alleged that the facility serves resident cold food, but no further details given. (6) out of (6) staff interviewed denied the allegation. Some staff interviewed stated that they serve good quality of food and food is always served hot/warm. Interviewed staff stated that the facility has food warmers in the kitchen/serving areas in the Assisted Living (AL), Skilled Nursing (SNF) and Memory Care (MC) units to keep the food hot before serving. S1 stated that the facility has an electric food cart to keep the food hot/warm while transporting to different units in the facility. (8) out of (8) residents were unable to corroborate the allegation. Interviewed residents stated that food is always served warm to medium warm, not cold. Additionally, residents stated that they are satisfied with the quality of food and servings. During the facility tour, LPAs observed the food warmers were all set up in the kitchen/serving areas and the facility has sufficient supply of food. LPAs also observed today's lunch and observed good quality of food served. Therefore, there was insufficient evidence to corroborate with this allegation. Based on observations, statements and interviews conducted with residents and staff, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Lisa Gomez, House Manager. The investigation revealed the following: In regards to the allegation: "Facility refrigerator is in disrepair." It is alleged that it was overheard that the refrigerator is not functional and is being used for storage. No additional specifics provided. (4) out of (6) staff interviewed are aware that the refrigerator in the main kitchen was broken S1 stated that the refrigerator broke in July 2024 and it used to store drinks such as water, juice, soda cans, but no protein or salad stored in there. S1 also stated that a refrigeration company came 2x (8/01/2024 & 8/09/2024) to inspect and provide estimates to repair the refrigerator. According to S1, the estimates were being reviewed by the Management for approval. Interviewed residents are not aware that the refrigerator was broken. During the tour, LPAs observed that the refrigerator has a sign "Broken, Out of service" on the door. LPAs observed that although the refrigerator is unplugged, drinks and some paper cup supplies are stored inside and being used as storage. Based on LPAs' observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to Lisa Gomez, General Manager along with the Appeals Rightsthe state’s words, verbatim · CDSS document, Aug 20, 2024 · control 28-AS-20240814091739

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(29) · Plan of correction due date: Sep 3, 2024

87555 General Food Service Requirements ....(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair ...... This requirement is not met as evidenced by: Based on LPA's observations, interviews and records review, the refrigerator in the main kitchen has been broken since July 2024, currently not yet scheduled to be fixed and being used as storage which posed a potential risk for residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2024

Plan of correction: The Administrator will submit service report/invoice that the refrigerator has been fixed and in use to CCL/LPA by POC due date.

Allegation investigated: Licensee is not ensuring that the personal property of resident(s) in care is being safeguarded.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met Laura Sanchez with and explained the reason for the visit. The investigation consisted of the following: LPA requested a copy of staff/resident roster. LPA reviewed interviewed 6 residents and 5 staff. LPA requested a copy of resident’s #1(R1) physician’s report, needs and care plan, and preplacement appraisal, and identification and emergency information. The investigation revealed the following: Regarding allegation: Licensee is not ensuring that the personal property of resident(s) in care is being safeguarded. It is alleged money has been stolen from residents’ rooms. Interviews conducted with residents revealed 5 out of 6 residents interview stated their personal belongings have not gone missing, and they feel comfortable that items will not be missing from their rooms, 1 out of 5 residents stated to have not been able to find money that was left on dresser overnight on one occasion. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews with staff revealed 3 out of 5 staff stated to not been aware of residents reporting any items missing, and staff usually assist when a resident leaves their personal belongings around. Administrator and health service coordinator stated that they had one resident report that money had gone missing, and they assisted the resident to look for the money, staff found money. However, the resident stated that was not the money that was missing. There have not been other reports of money missing from other residents in the last four months. Documents review revealed R1 is independent. Although the allegation may have happened there is not enough evidence that the money was stolen from the resident's room at this time. 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. Exit interview was conducted with Lisa Gomez and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 13, 2024 · control 28-AS-20240805164945

Allegation investigated: Facility did not update physicians reports for residents with a change in condition.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint investigation visit for the above-mentioned allegation. LPA met with Nadia Batista, HR Director and explained the purpose of the visit. Shortly after, Administrator Chad Coleman arrived and assisted LPA with the investigation. The investigation consisted of the following: LPA conducted a tour of the physical plant, interviewed Staff #1 (S1) - Staff #5 (S5) and Resident #1 (R1) – Resident #6 (R6). LPA reviewed and obtained copies of the Resident & Staff Rosters, Random Memory Care and Assisted Living residents - Resident #1 (R1) - Resident #6 (R6) files such as: Identification and Emergency Information (Face sheet), Appraisal/Needs and Services plans and Physicians’ reports. The investigation revealed the following: In regards to the allegation: “Facility did not update physicians reports for residents with a change in condition.” It is alleged that the residents’ physicians’ reports are not updated timely and the true needs of residents are not current. No other information provided. All (5) staff interviewed denied the allegation. S2 stated that residents physicians reports are updated regularly and facility follows Title 22 regulations. *****CONTINUED ON LIC9099-C***** Unsubstantiated S2 stated that a resident is reassessed when there's a change in condition and at that time, the appraisal/needs services plan and the physician's report are completed/updated. S2 indicated that dementia residents receive an annual medical assessment or as needed. Some staff interviewed stated that they address the needs of the residents based on the daily care assignments given to them and they ensure that residents are cared for with their activities of daily living. (6) out of (6) residents interviewed stated that they are comfortable living in the facility and staff attend to their needs. There was no mention of the specific resident(s) nor information provided as to which physician’s report was not updated timely. Documentation reviewed for (6) random residents in Memory Care and Assisted Living reveals that the facility maintains records of their Physicians’ report signed and dated by a physician, made within the last year. Some files also included up to date reassessment of the residents’ dementia care needs. Reviewed files also show the completed appraisal/needs and services plans identifying the functional capabilities and limitations of the residents. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview and a copy of this report was provided to Chad Coleman, Administrator.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 28-AS-20240725121434

Allegation investigated: . Hazardous chemicals are left accessible to residents. 2. Staff not monitoring resident with sharp objects. 3. Staff left resident unattended. 4. Staff interfere with family council meetings. 5. Staff did not follow up on family council meeting concerns in a timely manner.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit for the above allegations. LPA met with Lisa Gomez and explained the reason for the visit. The investigation consisted of the following: On 5/28/24, LPA Chan conducted the initial visit to gather documents and interviewed the facility manager, 5 staff and 5 residents. During the visit today, LPA interview a staff and reviewed personnel files. The investigation revealed the following: For allegations – “Hazardous chemicals are left accessible to residents” and “Staff not monitoring residents with sharp objects”. LPA toured the assisted living and memory care unit and interviewed staff and residents. LPA did not see any chemicals or sharp objects left accessible to residents. The cleaning solutions were locked in the cleaning carts or the storage room. Per staff, scissors are put away after usage. Unsubstantiated Residents interviewed stated they had not seen any lying around. In the memory care unit, anything that needs to be cut is usually prepared beforehand. Therefore, staff do not normally give residents scissors to cut and if they do, they will monitor the resident(s). Allegation - Staff left resident unattended. It is alleged that the staff left a resident with dementia alone in the assisted living side because the resident did not want to finish the walk. LPA toured the memory care unit which requires a code to exit. Per staff, residents are taken to the front of the facility for walks and to do community activities. They are always supervised by the wellness director and/or care staff. All the staff interviewed denied ever leaving a resident unsupervised in the assisted living area. They are aware that the residents residing in the memory care unit must be monitored at all times. Residents interviewed have not seen any residents being left unsupervised when they come out for walks or activities. For allegations - “Staff interfere with family council meetings” and “Staff did not follow up on family council meeting concerns in a timely manner”. It is alleged that the facility does not send out mailings or families are not made aware of the monthly meetings. The facility manager stated that they have a separate resident and family council meeting each month. The council meetings are posted by the sign-in sheet in the front lobby to inform them of upcoming meeting. She stated that the meetings are coordinated by the activity director. It was also noted that family members did not want residents to attend their council meetings as there is a separate resident council and would invite staff if they wanted them at the meeting. LPA interviewed residents who also stated they do not usually go to the family council meetings as those are mainly for families. As for following up on family concerns, the facility manager and staff who attended the meetings indicated they listened to their concerns and address them right away. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Manager Lisa Gomez. A copy of this report along with the appeal rights was provided.the state’s words, verbatim · CDSS document, Jul 18, 2024 · control 28-AS-20240523135252

Allegation investigated: Facility did not update Needs and Services Plans for residents Facility did not update physicians reports for residents with a change in condition

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation visit for the allegation(s) above. LPA met with Facility Manager Lisa Gomez and the purpose of the visit was discussed. LPA conducted the following on todays visit: Toured the physical plant, Interviewed staff #1-#5 (S1-S5) and Residents #1-#5 (R1-R5). LPA reviewed and collected the needs and services plans and physicians reports for R1-R5. LPA also collected a copy of the staff and resident roster. The investigation revealed the following: In regards to the allegaiton "Facility did not update Needs and Services Plans for residents" it is alleged that the needs and services plans for residents on file are outdated and do not reflect the residents actual care needs. (5) of (5) Staff interviewed denied the allegation... Continued on LIC 9099-C Unsubstantiated (5) of (5) Residents interviewed could not corroborate the allegation. Residents interviewed stated to have been receiving the proper services to care for their needs. File review shows that the facility has been updating and creating needs and services plans for residents every 6 months or when needed. Interviews with staff all explained that needs and services plans are also updated when there are any change in conditions to residents and it will be detailed on the same form. Based on interviews conducted, files reviewed, and observations there was not enough supportive evidence to concur with the reported allegation; although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. In regards to the allegation "Facility did not update physicians reports for residents with a change in condition" it alleged that resident physicians reports are outdated and not updated as needed. (5) of (5) Staff interviewed denied the allegation. (5) of (5) Residents interviewed could not corroborate the allegation. LPA was not provided with specific information as to which residents had changes in condition not updated. Per Title 22 Regulation, Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. Regulations add that the licensee shall obtain an updated medical assessment when required by the Department. Review of the residents files shows that the facility acquired physician reports (medical assessments) for the residents prior to admitting them to the facility. There are no documents on file of the department requiring the facility to update physicians reports. Per Title 22 the facility must also ensure that a resident with dementia shall have an annual medical assessment done at least annually, which shall include a reassessment of the resident’s dementia care needs. File review shows medical assessments done for residents with dementia within that timeline. Based on interviews conducted, files reviewed, and observations there was not enough supportive evidence to concur with the reported allegation; although the allegations may have happened or are valid, there is 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 copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 16, 2024 · control 28-AS-20240710093533

Allegation investigated: Staff are preventing resident from receiving telephone calls.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with Lisa Gomez, General Manager and explained the purpose of the visit. During today’s visit LPA toured the facility’s common areas, lobby, reception area, obtained resident & staff rosters and Staff #2 (S2)'s timecard. LPA interviewed Staff #1 (S1) – Staff #5 (S5), Resident #1 (R1) – Resident #6 (R6). In regards to the allegation: “Staff are preventing resident from receiving telephone calls.” It is alleged that facility is never opened at 8am, front door is locked until 9am and calls were unanswered. (5) out of (5) interviewed staff denied the allegation. Interviewed staff stated that they are aware of the residents personal rights to have reasonable access to telephones, to both make and receive confidential calls. However, staff stated that residents in the Assisted Living unit have their own cell phones and do not have land lines set up in their rooms. Staff stated that the type of calls they receive are mostly for Skilled Nursing Facility (SNF) residents because they have telephones set up in their rooms.*****CONTINUED ON LIC9099-C***** Unsubstantiated All interviewed staff stated that the Assisted Living's main telephone line is switched to night mode at 8pm. On night mode, all calls are automatically transferred to the SNF's nursing unit station where staff are available to answer calls. S4 also stated that she is the back up receptionist and comes in early. (1) out of (6) residents interviewed stated that she had seen the staff come in late and that the front door does not get opened until after 8am. (6) out of (6) residents interviewed stated that they are receiving calls through their cell phones and not transferred from the main line. All interviewed residents stated that they never had an issue with receiving or making calls. During today’s visit, LPA observed the residents carrying their cell phones and staff answering the incoming calls from the main line. LPA also observed (3) after hours phone numbers posted outside the main door. Therefore there was insufficient evidence to corroborate with this allegation. Based on observations, statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Lisa Gomez, House Manager.the state’s words, verbatim · CDSS document, Jul 2, 2024 · control 28-AS-20240625124331

Allegation investigated: Air conditioner is in disrepair

Licensing Program Analyst (LPA) Jose Villalobos conducted an initial unannounced complaint investigation visit for the allegation listed above. LPA met with Manager Lisa Gomez and the purpose of the visit was discussed. LPA's visit consisted of the following: a tour of the phyical plant which included the common rooms and memory care unit, LPA inspected room #'s 161, 165, 166, 170, 180, 181, and 186 which are all part of the memory care unit, LPA interviewed staff #1-6 (S1-S6) and residents #2-5 (R2-R5), Resident #1 (R1) is not available for interview. LPA collected maintenance notes fro the month of June 2024, LPA collected documents from R1's file as well as a copy of the staff and resident roster. The investigation revealed the following: Continued on LIC 9099-C Unsubstantiated In regards to the allegation "Air conditioner is in disrepair" it was alleged that the AC in room #166 was not working and the HVAC system for the facility has not been working for a month. (6) of (6) Staff interviewed denied the allegation. (4) of (4) Residents interviewed could not corroborate the allegation. Room #166 is in the facilities memory care unit and LPA observed the AC to be working. LPA observed the AC for the rooms in the memory care unit that were toured to be operating. Staff interviewed denied knowledge that any rooms have a broken AC and added that temperatures are set on the thermometer for each room. Staff interviewed stated they will address any issues as soon as they are aware of them. File review shows that for the month of June there was (1) room with AC issues and it was addressed for room #240. There are no documents on file showing that the HVAC system has been out for a month or that the AC in room #166 was in disrepair. Based on interviews conducted, files reviewed, and observations there was not enough supportive evidence to concur with the reported allegation; although the allegations may have happened or are valid, there is 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 copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 28-AS-20240612155319

Allegation investigated: Staff are not meeting residents' dietary needs. Staff do not provide adequate amount of food to residents.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit regarding the above allegations. LPA met with Nadia Batista, Human Reseources Director and explained the reason for the visit. At 1pm, Lisa Gomez, General Manager arrived and assisted LPA with the investigation. The investigation consisted of the following: LPA obtained copies of the staff and resident rosters, Weekly meal menu (May-June 2024), Always available menu, Residents' Dietary Communication list, and Dietitians information. During today’s visit, LPA along with Staff #3 (S3) toured the Kitchen, Dining room and inspected the food supplies. LPA interviewed Staff #1 (S1) – Staff #5 (S5) and Resident #1 (R1) – Resident #12 (R12). The investigation revealed the following: In regards to the allegation: “Staff are not meeting residents' dietary needs.”, it is alleged that staff is not following residents diets, that salt is added to no salt diet and food allergies are not being followed. Interviewed staff denied the allegation and stated that the food provided to residents meet their dietary needs.*****CONTINUED ON LIC9099-C***** Unsubstantiated S3 stated that the facility has a dietitian that reviews and approves their weekly menu or when there’s any changes to the menu. Staff indicated that med tech or charge nurse provides the kitchen staff a list of residents with special/restricted diet. Staff indicated that food requirements for residents are communicated to the kitchen staff verbally and also through a kitchen bulletin board. Interviewed staff stated that there is a board in the kitchen to pass notes among the kitchen staff and board also reflects Residents dietary needs (diabetic, no/low salt, food allergies, preference, requests, etc.). Interviews conducted with residents revealed that staff meet their dietary needs. (5) out of (12) interviewed residents are on a special diet. (12) out of (12) interviewed residents indicated they do not have any concerns regarding their diets. During the review of the facility records, LPA observed that the facility keeps a list of the dietary needs and restrictions of the residents as ordered by their physicians. LPA toured the kitchen and the dining area and observed the food served to residents were on the menu. LPA also observed that the residents dietary needs list is posted on the board. Therefore, there was insufficient evidence to corroborate with this allegation. In regards to the allegation: “Staff do not provide adequate amount of food to residents.”, it is alleged that too small quantities of food are provided to the residents without second servings being offered. No other details provided. Staff interviews revealed that staff provide adequate food service to residents. Staff indicated they follow a menu reviewed and approved by a dietitian. Staff also stated that they provide alternative food menu for residents. Interviewed staff stated that they always provide huge amount of servings to the residents. Per staff interviewed, they have not heard or received complaints regarding the amount of food being served to the residents. Interviewed residents indicated the staff provide adequate food service including snacks and do not have any concerns. Interviewed residents indicated that the food servings and portions are adequate. During today’s visit LPA along with S3 toured the Kitchen and pantry areas and LPA observed sufficient food supplies. Between 12pm-12:30pm, LPA toured the dining area during lunch and observed the quantity of food served to the residents are adequate. Therefore, there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with staff, residents, review of facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Lisa Gomez, General Manager.the state’s words, verbatim · CDSS document, Jun 18, 2024 · control 28-AS-20240610142018

Allegation investigated: Staff are violating residents’ personal rights by telling them not to file complaints with CCLD Staff did not treat resident with dignity and respect

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegations. LPA met with Lisa Gomez (Manager) and explained the reason for the visit. The investigatiion consisted of the following: LPA Mora requested for copies of the staff and resident rosters, and interviewed the Manager, Staff 1 - Staff 9 (S1 - S9), and Resident 1 - Resident 8 (R1 - R8). LPA also toured rooms 152, 169, 183, 186, 219, 241, 319, and 341, staff office, kitchen and common area restrooms. LPA reviewed memory care caregivers' files and obtained a copy of caregivers' job duties. Regarding the allegation "staff are violating residents’ personal rights by telling them not to file complaints with CCLD", it is alleged that management is telling staff, residents, and family not to file complaints or concerns with state. (Continued to LIC 9099-C) Unsubstantiated The manager stated that this is not true and that they have the CCLD complaint hotline poster in the main lobby and anyone is free to call CCLD to file complaints. LPA confirmed that the CCLD complaint hotline poster is posted in the main lobby where is visible. Staff and residents interviewed denied the allegation. Regarding the allegation "staff did not treat resident with dignity and respect", it is alleged that the manager is mean to the residents. The manager denied this allegation and stated she is respectful towards all residents. Staff and residents interview did not corroborate the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Jun 13, 2024 · control 28-AS-20240606082847

Allegation investigated: Staff does not ensure food service sanitation practices are followed

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit to determine the validity of the above-mentioned allegations. LPA met with Lisa Gomez (Manager) and explained the reason for the visit. The investigatiion consisted of the following: LPA Mora requested for copies of the staff and resident rosters, and interviewed the Manager, Staff 1 - Staff 9 (S1 - S9), and Resident 1 - Resident 8 (R1 - R8). LPA also toured rooms 152, 169, 183, 186, 219, 241, 319, and 341, staff office, kitchen and common area restrooms. LPA reviewed memory care caregivers' and kitchen staff files, and obtained a copy of caregivers' job duties. Regarding the allegation "staff does not ensure food service sanitation practices are followed", it is alleged that the caregivers in memory care do not have a food handlers card and they plate all the food in memory care, they do not use hair nets or have temperature logs. (Continued to LIC 9099-C) Substantiated Interviews with memory care caregivers revealed that they do plate the food in the memory care dining room and that they have to wear hairnets and gloves. They also stated they do not have a food handlers certification. During lunch, LPA observed that the food is cooked in the kitchen and then transported in a hot box food warmer to the memory care dining room. The caregivers were wearing hairnets and gloves when they were plating the food. There is no Title 22 regulation that state that caregivers need to have a food handlers certification, however per Title 22 Section 87411 Personnel Requirements they have to have on the job training in regards to principles of good nutrition, good food preparation and storage, and menu planning. LPA requested for proof of this training for the memory care caregivers and S1 checked the caregivers files and told the LPA that there was no such training in their files. There was a temperature log located at the top of memory care dining room refrigerator, but there is no Title 22 regulation that state that the facility needs to have a temperature log, however per Title 22 Section 87555(b)(23) it states "all readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures". The food was transported in a hot box and when the food was being served and the LPA observed that it was at an appropriate temperature. Furthermore, residents interviewed stated that the food is served at an appropriate temperature. Based on interviews conducted, observation and documents reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. Exit interview held and a copy of the report and appeal rights was provided. Regarding the allegations "staff does not ensure facility is kept free of mal odors of residents" and "staff does not ensure toilets are kept in good repair", it is alleged that the toilets in rooms 219, 241, 319, and 341 are not functioning and there is a rancid sewer odor coming from the drains and toilets of these rooms bathrooms. Staff interviewed denied the allegations. Residents interviewed could not corroborate the allegation. LPA observed the toilets to be properly functioning and did not smell any odors coming from the toilet or drains in all the rooms toured during this visit (152, 169, 183, 186, 219, 241, 319, and 341). Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Jun 13, 2024 · control 28-AS-20240529144857

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(1) · Plan of correction due date: Jun 27, 2024

Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (1) Principles of good nutrition, good food preparation and storage, and menu planning. This requirement is not met as evidenced by: Based on interviews, observation and records, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Memory care caregivers do not have the training in regards to preparing and handling food.the state’s words, verbatim · CDSS document, Jun 13, 2024

Plan of correction: Licensee is to comply with Title 22 Section 87411 at all times. Additionally, Licensee will provide training to memory care caregivers in regards to Title 22 Section 87411(d)(1) and submit proof of the training to Community Care Licensing Division (CCLD) by 06/27/2024.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff do not give residents medication as prescribed

Licensing Program Analyst (LPA) Glenn Trueman conducted the initial complaint investigation for the allegation listed above. LPA arrived unannounced and met with Lisa Gomez, Manager. The purpose of the visit was discussed. During the visit today, LPA obtained copies of the staff roster and resident roster. Interviews with Lisa Gomez, Manager and Staff S1 were conducted from 10:15 AM to 10:45 AM. Interview was conducted telephonically with Staff S2 at 10:50 AM. Interviews were conducted with Residents R1-R6 from 11:10 AM to 11:55 AM. LPA toured the medication room and reviewed medication records for R1-R6. In regards to the allegation Staff do not give residents medication as prescribed, based on interviews conducted, medication review and information gathered it was revealed in review of medication for R1-R6 that all medication was given as prescribed and R1-R6 did not miss any doses. Review of pain medication showed that all doses were given as prescribed. Interviews with R1-R6 who all stated that Staff S2 does a great job and they have never missed a dose. Unsubstantiated R1-R6 all stated they have not observed S2 not giving anyone their medication and that it is always given per physician's directions. 1 resident who takes an inhaler stated that Staff S2 has never given more than 2 puffs as prescribed by the doctor and gives it the way she is suppose to. R1-R6 all stated that Staff S2 does not bully anyone and does her job. Spoke with staff who stated that there have been no complaints against Staff S2. Also stated that they will look at the MAR's Log on the computer and if eligible will get the pain med. Order will be for either every 6 hours or 8 hours and only if not eligible would a resident get Tylenol. All staff stated they follow doctor's orders and don't give any medication that is not prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Manager Lisa Gomez.the state’s words, verbatim · CDSS document, Jun 4, 2024 · control 28-AS-20240531152939

Allegation investigated: Facility is in disrepair resulting in leaks. Staff does not ensure facility carpet is clean and sanitized.

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint investigation regarding the above allegations. LPA met with Manager, Lisa Gomez who assisted with the visit. Regarding the allegation that : Facility is in disrepair resulting in leaks. The investigation consisted of tour of facility, including memory care, interviews with Staff #1 - Staff #4, and Resident #1 - Resident #6. LPA did not observe any leaks during facility tour. Staff interviewed stated that there are no leaks in the facility. Staff indicated that if any leaks are reported or observed, maintenance staff will repair it right away. Residents interviewed did not corroborate the allegation. Six out of six residents stated that they have not observed any leaks in the facility. Regarding the allegation that : Staff does not ensure facility carpet is clean and sanitized. The investigation consisted of tour of facility, including memory care, and interviews with Staff #1 - Staff #4, and Resident #1 - Resident #6. Unsubstantiated Staff interviewed stated that they do ensure that the carpet is clean and sanitized. Residents interviewed did not corroborate the allegation. Six out of six residents stated that the staff frequently clean the carpet. Although the allegations may have happened or are valid, there is 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 copy of the report was provided to Ms. Gomez.the state’s words, verbatim · CDSS document, May 30, 2024 · control 28-AS-20240521095500

Allegation investigated: Staff was under the influence while on shift Staff yelled at residents in care

On 5/30/2024 at 9:15 a.m., Licensing Program Analyst (LPA) Baptiste made an unannounced complaint visit to the facility to investigate the allegations listed above. LPA Baptiste met with the Manager, Lisa Gomez, and explained the purpose for the visit. During the visit today, LPA obtained a copy of staff roster and client roster. LPA Baptiste toured the facility with Plant Ops Director and reviewed facility files for the Manager and Staff #1(S1). LPA Baptiste also interviewed the Manager and a total of three (3) staff, whom shall be known as Staff #1 through Staff #3. LPA also interviewed a total of six (6) residents, whom shall be referred to as Resident#1 through Resident# 6. LPA attempted to interview Resident #7, but they declined to be interview. (Report continued on LIC9099-C...) Unsubstantiated The investigation reveals the following: Regarding “Staff was under the influence while on shift”. It was alleged that staff came to work under the influence of alcohol and drugs. The Manager denied the allegation and expressed that staff do not come to work under the influence nor do they smell of drugs and alcohol. 3 out 3 staff denied the allegation stating they have never came to work under the influence or witness other staff coming to work under the influence. 6 out of 6 residents denied the allegation stating they have not witness staff influence of drugs or alcohol at the facility. The investigation reveals the following: Regarding “Staff yelled at residents in care”. It was alleged staff yelled at the residents in care. The manager denied the allegation, stating staff has never yelled at the residents and none of the residents complained about being mistreated. 3 out of 3 staff denied the allegation stating they have never yelled at the residents and have never witness other staff members yelling at the residents. 5 out 6 residents denied the allegation stating the staff treat them well. 1 out of 6 residents stated one (1) caregiver handles them roughly. Based on LPA's interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Manager Lisa Gomez and a copy of this record provided.the state’s words, verbatim · CDSS document, May 30, 2024 · control 28-AS-20240523091436

Allegation investigated: Licensee did not complete an admission agreement for resident.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Manager Lisa Gomez. Administrator Chad Coleman was interviewed telephonically. The investigation consisted of: A physical plant tour of interior common areas and resident bedrooms was conducted.Staff (S1- S4), residents (R1- R8), and family (F1) Resident (R1 & R2's) file documents were reviewed. Copies of Residence and Care Agreement, Move In-Record, Physician's Report, Pre-placement Appraisals, Resident Care Evaluation Admission Appraisals, staff roster, and resident roster were obtained. ***See narrative summary on next page.*** Substantiated Allegation: Licensee did not complete an admission agreement for resident. The complaint alleges that resident (R1) moved in to the facility on May 14, 2024 without a signed admission agreement. Resident (R2) moved in on 5/24/2024. Bayshire San Dimas was licensed on April 1, 2024. A total of two (2) new residents moved in after licensure. Record review revealed that R1 does not have signed Residence and Care Agreements on file. Resident (R2's) Residence and Care Agreement was electronically signed today, within the seven days following admission. Both residents (R1 & R2) did not know whether their responsible parties have signed the admission agreement. R1's responsible party stated that they received the admission agreement 1 week after R1 moved in, and has not signed the agreement because they had questions, and preferred to meet with staff prior to signing the agreement. R1's responsible party stated they plan to visit the facility today and will be signing the agreement. File review indicates that resident (R1's) Resident Care Evaluation (Appraisal) has not been completed; only sections A. [I- III] are filled out. Per Clinical staff interview, a thorough coordination of care has not been discussed or implemented by the clinical team. A total of eight (8) residents were interviewed, of which all stated they or their responsible parties have not signed Residence and Care Agreements for Bayshire San Dimas; however, 6 out of 8 residents moved in prior to the change of ownership. Administrator Chad Coleman and Manager Lisa Gomez acknowledged the facility failed to obtain signed copies of R1's admission agreement. There is sufficient evidence to corroborate the allegation. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being cited. See LIC 9099D. Exit interview was conducted with Manager Lisa Gomez. A copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, May 30, 2024 · control 28-AS-20240524124243

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(c) · Plan of correction due date: Jun 6, 2024

Admission Agreements. Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement was not met evidenced by: Based on record review and interviews conducted findings indicate R1 moved in on May 14, 2024, and as of today the facility has not obtained a signed admission agreement, which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 30, 2024

Plan of correction: Administrator agreed to obtain a signed copy of R1's Residence and Care Agreement. Submit a copy of the agreement.

Allegation investigated: Licensee does not ensure the facility has an administrator present a sufficient number of hours to adequately manage facility. Staff are preventing resident from receiving telephone calls.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced initial complaint visit to the facility for the purpose of investigating the above mentioned allegations. LPA Maldonado met with Health Services Director, Heather O'Neel and explained the purpose of the visit. Executive Director, Chad Coleman arrived shortly after to assist with the visit. During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, and obtained pertinent documents for Staff#1-2 (S1-S2). Interviews were also conducted with Staff#1-9 (S1-S9) and Residents#1-5 (R1-R5). The investigation revealed the following: (Report continued on LIC9099-C...) Substantiated Regarding allegation: Licensee does not ensure the facility has an administrator present a sufficient number of hours to adequately manage facility. It is alleged that facility operational concerns are not being addressed due to the administrator never present at the facility. Per interviews conducted with staff, (6) of (9) staff corroborated the allegation. (2) of (6) staff stated the listed administrator is present at the facility once every (2) to (3) weeks. (4) of (9) staff stated the administrator has only been present at the facility twice since the facility was licensed, on April 1, 2024. Per resident interviews, (3) of (5) residents corroborated the allegation. Residents stated to not know who the listed administrator is and stated that S2 is actually the administrator. Regarding allegation: Staff are preventing resident from receiving telephone calls. It is alleged that the facility is not answering the telephone during their listed hours of operations to reach residents in care. Per staff interviews, (4) of (9) staff corroborated the allegation. Staff stated that the receptionist is responsible for answering the telephones and unlocking the facility front doors at 8:00am. However, the receptionist is not always on time, so the phone calls get answered upon staff arrival. Per resident interviews, (1) of (5) residents corroborated the allegation. Residents stated the receptionist is responsible for unlocking the front doors and answering the phones at 8:00am, however the receptionist is late and this is not being done timely. R1 stated to have opened the front door for a visitor last week because they were knocking and there was no staff present at the front desk to answer it. Based on LPA's observation and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on LIC9099-D. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 21, 2024 · control 28-AS-20240517121025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: May 24, 2024

87405 Administrator - Qualifications and Duties (a)The administrator...shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. This requirement was not met as evidenced by: Based on interviews conducted, the Licensee failed to ensure the administrator is at the facility a sufficient amount of hours to address operational concerns of the facility, which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2024

Plan of correction: Licensee will submit a written plan to the Licensing department on how they will ensure the administrator will be on the premises a sufficient amount of hours to ensure operational needs/concerns are addressed. Plan to be emailed to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(14) · Plan of correction due date: May 21, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(14)To have reasonable access to telephones, to both make and receive confidential calls... This requirement was not met as evidenced by: Based on interviews conducted, the Licensee failed to ensure the facility telephone is answered during normal business hours so that residents may be contacted, which poses a potential Health, Saftey, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2024

Plan of correction: Licensee will submit a written plan to the Licensing department on how they will ensure the facility telephones are answered regularly during business hours to meet resident needs. Plan to be emailed to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of issuing citations. LPA Maldonado met with Health Services Director, Heather O'Neel and explained the purpose for the visit. During a complaint visit to the facility on 5/21/24, LPA Maldonado reviewed facility files for Staff#1-2 (S1-S2). During the file review, LPA discovered that although S1 has an administrator certificate# 6065866740, valid 1/10/23 - 5/10/25, S1 does not meet the qualifications of being an administrator for a Residential Care for the Elderly (RCFE). Per interview with S1, S1 stated to have never worked in an RCFE before or provided care to residents. LPA Maldonado also discovered that S2 does not have appropriate criminal background clearance and has been working at the facility since 4/01/24. Per interview with S2, S2 confirmed to have been hired and working here since 4/01/24. Per California Code of Regulations, Title 22, deficiencies were observed and cited on the LIC9099-D page. Additionally, immediate Civil Penalties in the amount of $500 were issued. An exit interview was conducted and copy of the appeal rights were provided.the state’s words, verbatim · CDSS document, May 21, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: May 22, 2024

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review...shall prior to working...in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement was not met as evidenced by: Based on interview and record review, the Licensee failed to ensure that S2 had appropriate criminal record clearance prior to working at the facility, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2024

Plan of correction: S2 will be removed from the facility immediately and Licensee will submit proof of clearance prior to allowing S2 back to the facility. Proof to be emailed to LPA once obtained.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(f) · Plan of correction due date: May 31, 2024

87405 Administrator - Qualifications and Duties (f) The administrator in facilities licensed for fifty (50) or more shall have two years of college; at least three years experience providing residential care to the elderly; or equivalent education and experience as approved by the licensing agency. This requirement was not met as evidenced by: Based in interview and record review, the Licensee failed to ensure the listed administrator has appropriate qualifications to manage the facility, which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2024

Plan of correction: Administrator to submit proof to reflect that Administrator meets the qualifications noted in this regulation or provide new qualified administrator with the specified qualifications noted above to LPA Irra by POC due date.

Allegation investigated: Facility in disrepair Facility staff do not provide meals of the quality necessary Laundry room does not have adequate supplies Facility does not have a qualified administrator

***This is an amended report which supersedes the original report dated 04/16/24. The purpose of this report is to remove confidential information. The amendment to the report does not affect or change the findings on this complaint***. Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation visit regarding the above allegations. LPA Margaryan met with Health Services Director (HSD), Heather O'Neel who assisted with the visit. Purpose for the visit was explained. During today's visit, LPA Nune Margaryan obtained a copy of the resident and staff roster, copy of the facility menu, Personnel Records and Administrator Certificates for the facility Administrator Chad Coleman and Health Services Director (HSD), Heather O'Neel. LPA toured the facility including the kitchen, dining room, laundry rooms and randomly chosen residents rooms. Interviewes condacted with HSD Heather O'Neel , Staff #1 - Staff #5 (S#1 - S#5) and Resident #1 - Resident #7 .(R#1 - R#7). Continue 9099C Unsubstantiated Regarding the allegation: Facility is in disrepair. it was alleged that " Place is in disrepair”. Staff interviewed denied the allegation. Staff stated that if anything is in disrepair, they put online maintenance/ work order, and the maintenance person will repair it in a timely manner. LPA toured the facility including randomly chosen residents rooms and observed that facility is in a good condition. All interviewed residents stated that everything works in their rooms and not aware of facility being in disrepair. Regarding the allegation: Facility staff do not provide meals of the quality necessary. It was alleged that "Kitchen doesn’t offer adequate food". Interviewed staff and residents denied the allegation. LPA obtained a copy of the facility menu, and reviewed facility food supply. LPA observed a variety of food available and a sufficient quality. LPA toured the facility kitchen and observed an ample supply of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed bread, grains, meats, fruits, vegetables, eggs, juice, milk, and snacks in the kitchen / refrigerator / freezer. Staff and residents interviewed stated that residents can request an alternate meal if they don't want what is being served. Interviewed staff indicated they have not received any complaints about food/meal. Interviewed residents had no concerns about quality of food/meal. Regarding the allegation: Laundry room does not have adequate supplies. It was alleged that "Laundry room isn’t equipped with supplies". Interviewed Staff denied the allegation. Health Services Director (HSD) and Staff # 4 denied the allegation stating that facility never runs out of the laundry supplies. LPA toured the laundry rooms and observed that each laundry room has a laundry detergent / soap dispenser, and they are full. Several large gallons of laundry detergent / soap observed in the main laundry room located at the first floor. LPA also observed boxes of plastic bags that staff use to separate the resident’s dirty and clean clothes, and different kind of laundry / cleaning supplies. Interviewed residents stated that they are not aware of laundry supplies at the facility. Continue 9099C Regarding the allegation: Facility does not have a qualified administrator. It was alleged that "Administrator doesn’t qualify for managing". Chad Coleman is the administrator of the facility and on this position since 04/01/24. LPA reviewed the administrator file and observed that Chad Coleman has a Bachelor’s Degree, which meets the educational requirements for the administrator. He has an experience providing residential care to the elderly since 2019. He has an active Administrator Certificate, which expired on 05/10/2025. HSD O'Neel mentioned that she also has Administrator certificate for RCFE, and she is designated person in case of administrator absence (Copy of LIC308 was provided). She has (2) years completed of college, which meets the educational requirement of (2) years and has experience in providing residential care to the elderly since 2018. She currently has an active Administrator Certificate, which expired on 12/08/2024. Based on interviews, records review and observations the investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with HSD Heather O'Neel, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 16, 2024 · control 28-AS-20240411122938

Allegation investigated: Staff do ensure the facility's communication devices are properly operating.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Heather O'Neel HSD (Health Services Director) who assisted with the visit. LPA explained the purpose of today’s visit. During today's visit, LPA obtained a copy of the staff and resident rosters, work note from Facility Operational Analyst / IT, interviewed Heather O'Neel - HSD, Staff #1 - Staff #5 (S#1 - S#5), Facility Operation Analyst / IT and Resident#1 - Resident#6 (R#1 - R#6). The Facility Operation Analyst / IT was intervewed over the phone. LPA also toured a random selection of resident rooms on each floor with the assistance of the HSD. Continue 9099C Unsubstantiated Allegation: Staff do ensure the facility's communication devices are properly operating. It was alleged that during the last weekend of March and thru the April first there was no internet at the facility and communication systems have stopped, including individual resident pendants each resident carries to call / page for assistance. It was reported that residents could not call for and get assistance. Interviewed HSD stated that on April 1st, 2024, Bayshire took over ownership of the building / facility. During that transition they replaced all the internet / Wi-Fi access points and internet switches in the building. Work started April 1st in the morning, approximately from 7am.- 12 pm. During that time the pendant system was down. All interviewed staff stated that for residents safety, 30 minutes to 1 hour checks were done on every resident. All staff including Care staff, Med. Techs, RCC (Residents Care Coordinator) and nurses were involved in these checks. Interviewed IT confirmed that work done at the facility on April 1st, and it took about 4-5 hours. All interviewed residents stated that their pendants are working, and they can call for the assistance if they needed. During the visit LPA ask randomly chosen residents to push the pendant button and observed that residents pendants are operational, and the staff came in to check with residents in 2-3 minutes. Based on the observations and interviewed conducted with staff and residents, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Heather O'Neel.the state’s words, verbatim · CDSS document, Apr 11, 2024 · control 28-AS-20240403151615

Type of visit: Prelicensing

Licensing Program Analyst (LPA) V. Maldonado made an announced visit at the facility for the purpose of conducting a Pre-Licensing Inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Applicant, Scott Kirby, and explained the purpose for the visit. This is a Change of Ownership. Applicant has requested to operate as a Residential Care Facility for the Elderly. Per the application received, applicant has requested a fire clearance to serve (114) older adults, ages 60 and over, of which (104) will be non-ambulatory, and (10) will be bedridden. Applicant has also requested to care for residents with dementia, and has a pending Dementia Care Plan. The dementia unit currently has delayed egress. The department has not received an approved fire clearance yet. Per the applicant, a Hospice Waiver was requested to care for (20) residents. However, LPA did not receive any documentation from the Centralized Application Bureau indicating it has been approved. There are currently (12) residents receiving hospice services. The facility is a three-story building. The assisted living section has 90 resident bedrooms and has a separate dementia unit with 23 resident bedrooms. An Infection Control plan has been submitted and approved by the department. The facility has an active and current liability insurance policy on file. During today's visit, LPA Maldonado conducted a tour of the physical plant with Applicant, observed the facility food supplies, reviewed (5) resident medications, (5) resident files, and (5) staff files. LPA inspected random bedrooms on all (3) floors. Resident bedrooms were observed to have the required furniture, sufficient lighting, and closet/storage space. Resident bathrooms and shared shower rooms were equipped with required grab bars and non-skid mats. The hot water was tested and measured between 113*F-117*F, which is in compliance. Food supplies was observed and was sufficient as required. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. There is an electric fireplace in the lobby/dining room covered with a screen. The last fire drill was conducted on 2/16/24. Auditory devices were observed at all entrances/exits of the memory care unit and were operational. (Report Continued on LIC9099-C) The signal system in resident bedrooms were tested and operational. There is sufficient indoor and outdoor activity space for residents. There are (2) courtyards in assisted living and an enclosed patio in memory care with shaded seating areas. Evacuation chairs were observed at each stairwell. Water fountains were observed in the courtyards of assisted living and are inaccessible. All required postings were observed throughout the facility. Sufficient additional linens/towels were observed. The laundry areas are kept locked and inaccessible to residents at all times. Resident files and staff files were reviewed and observed to be complete with all required documentation. Resident medications were reviewed and observed to be documented properly and given as prescribed. During the pre-licensing inspection, items were observed which do not comply with applicable laws and regulations. The following items must be corrected: An approved Fire Clearance has not been received by the department Applicants have been notified to contact LPA Maldonado once the corrections have been made. The physical plant was not cleared during today's inspection, due to the corrections needed. Component III orientation has been waived by applicant today, due to being completed for another licensed facility within the last year. An exit interview was conducted with applicant and a copy of this report has been furnished. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.the state’s words, verbatim · CDSS document, Mar 28, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 114 Interview Method: Telephone interview On 3/19/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Mar 19, 2024