Be Well Senior Living II

Type of visit: Required - 1 Year

At approximately 2:15 p.m. on 06/03/26, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the licensee and disclosed the reason for the visit. A file review was conducted prior to this visit. The facility was last visited on 03/12/25 for an annual inspection. It is a single story building with eight (08) bedrooms, two (02) bathrooms, kitchen, office, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for four (04). At 2:25 p.m. LPA reviewed resident and personnel files. All files were complete, updated, and available for audit. The front entrance was gated and unlocked. The front yard was maintained. Once inside, LPA observed postings near the main entrance and the office area for Ombudsman contacts, confidential complaint contacts, facility license, COVID precautions, emergency disaster plan, facility sketch, personal rights, rights of resident councils, liability insurance, and emergency contacts. A screening station at the front contained a visitor log, gloves, masks, and sanitizer. Walls, floors, windows, screens, and blinds were clean and in good repair. At 3:20 p.m. LPA measured the room temperature to be 74 degrees Fahrenheit. The living room contained televisions, reading materials, board games, and exercise equipment. A fireplace was appropriately grated with the gas line turned off. Medications, first aid kit, and confidential files were locked near the dining room. The facility has eight (08) bedrooms. The bedroom nearest the main entrance is designated as a staff room. The staff room was free of hazards. Bedroom #7 was designated for storage and was free of hazards. All resident bedrooms contained a nightstand, storage, and a bed with adequate bedding. All beds with wheels were maintained in the locked position. All furnishings were clean and in good condition. Bedroom #3 had a sign posted stating “No Smoking – Oxygen In Use” The facility has 2 bathrooms. Both bathrooms contained liquid soap, paper towels, trash cans with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 3:40 p.m. LPA measured the hot water temperature in Bathroom #1 at 107.4 degrees Fahrenheit. LPA observed a shaded patio area in the rear of the facility. The patio contained two (02) tables with furniture in good condition. The back yard was maintained with fruit trees and shrubs. Two (02) out of two (02) emergency exit paths were free from obstructions. A locked shed near the main entrance contained extra supplies. Two (02) out of two (02) auditory alarms were turned on and functioning. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter top. Cleaning solutions were locked in a laundry room adjacent to the kitchen. Also located in the laundry room were a washer and dryer. Both were in working order. At 3:50 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 01/28/26 with a tag attached. At approximately 4:00 p.m. the smoke detector in Bedroom #1 was tested and operational. At approximately 4:05 p.m. the carbon monoxide detector in the dining room was tested and operational. LPA called out from the house phone at 4:10 p.m. and was deemed to be operational. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed during this visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 3, 2026

Type of visit: Required - 1 Year

At 9:15 a.m. on 03/12/2025, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the licensee and co-administrator and disclosed the reason for the visit. A file review was conducted prior to this visit. The facility was last visited on 09/20/2024 for a complaint visit. It is a single story building with eight (08) bedrooms, two (02) bathrooms, kitchen, office, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for four (04). At 9:25 a.m. LPA reviewed resident and personnel files. All files were complete and available for audit. The front entrance was gated and unlocked. The front yard was maintained. Once inside, LPA observed postings near the main entrance and the office area for Ombudsman contacts, confidential complaint contacts, facility license, COVID precautions, emergency disaster plan, facility sketch, personal rights, rights of resident councils, and emergency contacts. A screening station at the front contained a visitor log, gloves, masks, and sanitizer. Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:30 a.m. LPA measured the room temperature to be 73 degrees Fahrenheit. The living rooms contained televisions, reading materials, board games, and exercise equipment. A fireplace was appropriately grated with the gas line turned off. Medications, first aid kit, and confidential files were locked near the dining room. Also observed was a sufficient supply of emergency water. The facility has eight (08) bedrooms. The bedroom nearest the main entrance is designated as a staff room. The staff room was locked and free of hazards. It also contained emergency food supplies, PPE, and incontinence supplies. Bedroom #5 was designated for storage and was free of hazards. All resident bedrooms contained a nightstand, storage, and a bed with adequate bedding. All beds with wheels were maintained in the locked position. All furnishings were clean and in good condition. Four (04) out of four (04) bedrooms with oxygen in use had appropriate signage posted on their doors. The facility has 2 bathrooms. Both bathrooms contained liquid soap, paper towels, trash cans with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 10:45 a.m. LPA measured the hot water temperature in Bathroom #1 to be 105.4 degrees Fahrenheit. LPA observed a shaded patio area in the rear of the facility. The patio contained two (02) tables with furniture in good condition. The back yard was maintained with fruit trees and shrubs. Two (02) out of two (02) emergency exit paths were free from obstructions. A shed near the main entrance contained extra supplies. Two (02) out of two (02) auditory alarms were turned on and functioning. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter top. Cleaning solutions were locked in a laundry room adjacent to the kitchen. Also located in the laundry room were a washer and dryer. Both were in working order. At 10:55 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 02/21/2025. At approximately 11:00 a.m. the smoke detector in the hallway was tested and operational. At approximately 11:05 a.m. the carbon monoxide detector in the dining room was tested and operational. LPA, staff, and administrator reviewed resident medications at 11:15 a.m. All medications were maintained in the correct quantities with matching documentation. The house phone was called at 11:30 a.m. and deemed to be operational. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed during this visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 12, 2025

Allegation investigated: Facility staff are not providing records to responsible person

At 11:00 a.m. on 09/20/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with staff and disclosed the reason for the visit. To investigate the allegation above, LPA conducted an initial visit on 07/18/24 and toured the facility at 10:30 a.m., interviewed staff, residents, and family between 11:00 a.m. and 4:30 p.m., and conducted a records review at 1:00 p.m. of documents pertinent to the investigation, including but not limited to hospice records, medical assessments, admission agreements, identification forms, and service plans. Regarding the allegation “Facility staff are not providing records to responsible person” it was alleged the facility did not provide the hospice records of Resident #1 (R1) to their responsible person when requested. Interview with Family Member #1 (F1) at 2:30 p.m. on 07/18/24 revealed that they believed they were R1’s responsible person. F1 requested their hospice records from the facility prior to R1 moving out and the licensee did not provide them. Unsubstantiated Record review of R1’s Identification and Emergency Contact form and R1’s admission agreement revealed R1’s responsible person to be Family Member #2 (F2). Interview with F2 at 4:15 p.m. on 07/18/24 revealed they had never requested R1’s records. Interview with the licensee at approximately 12:00 p.m. on 07/18/24 revealed F2 signed R1’s facility admission documents upon admission and was designated as R1’s responsible person. The licensee confirmed F1 requested R1’s hospice records. Since F1’s request was not specific, the licensee referred F1 to R1’s hospice agency for the records. Based on interviews and record review, the facility was able and willing to provide R1’s records to their responsible person, and they maintained R1’s records’ confidentiality. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during today’s inspection. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 20, 2024 · control 31-AS-20240718083724

Allegation investigated: Staff neglect contributed to resident's death Facility staff do not ensure facility is maintained clean Facility staff do not properly address insects in the facility Facility staff do not meet residents' showering needs Facility staff do not meet residents' dietary needs Facility staff force the residents to eat

At 11:00 a.m. on 09/20/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with Staff #1 (S1) and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 07/18/24 and toured the facility at 10:30 a.m., interviewed staff, residents, and hospice staff between 11:00 a.m. and 2:30 p.m., and conducted a records review at 1:00 p.m. of documents pertinent to the investigation, including but not limited to hospice records, medical assessments, admission agreements, identification forms, and service plans. LPA obtained and reviewed pertinent hospital and hospice records at 1:00 p.m. on 08/30/24. Today, LPA interviewed S1 at 11:05 a.m. and Staff #2 (S2) at 11:15 a.m. Regarding the allegation “Staff neglect contributed to resident’s death” it was alleged Resident #1 (R1) died at the hospital from choking due to staff feeding them too quickly and forcefully. Interview with the licensee at Unsubstantiated approximately 12:00 p.m. on 07/18/24 revealed S1 was assisting R1 eat breakfast during the morning of 05/02/24 when R1 began choking. Interview with S1 revealed they stopped feeding R1 immediately after choking, administered first aid, and directed S2 to call 9-1-1. Record review revealed the facility submitted an incident report for the choking incident. The report noted R1 was eating soft food in an upright position. After R1 started choking, S2 called 9-1-1 and the licensee and other staff attended to R1. Record review of staff training records revealed all staff were sufficiently trained in assisting residents with feeding and residents with difficulty swallowing. Review of R1’s service plan from 03/05/24 noted they were able to feed themselves and staff were to assist with preparing and providing meals and drinks. R1’s medical assessment indicated they were diagnosed with Alzheimer’s dementia. Review of hospital records indicated that R1 experienced pneumonitis from choking on food and vomit on 05/02/24. R1 was discharged from the hospital back to the facility on 05/08/24 with hospice care. Review of R1’s hospice records indicated that R1 exhibited “dysphagia consistent with dementia” after the incident. A death report submitted by the facility and hospice records indicated that R1 passed away on 05/10/24 due to cardiopulmonary arrest along with end stage Alzheimer’s dementia. Based on record review and interviews, facility staff did not neglect R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility staff do not ensure facility is maintained clean” it was alleged placemats and bibs were unsanitary and never washed. During facility tour, LPA observed all interior surfaces to be sanitary. LPA observed residents eating lunch at approximately 11:30 a.m. on 07/18/24 with clean bibs and placemats. LPA also observed staff wiping placemats and the dining room table after lunch around 1:00 p.m. Interviews with the licensee, Staff #3 (S3) at 12:10 p.m. on 07/18/24 and Staff #4 (S4) at 12:35 p.m. on 07/18/24 revealed staff wash bibs in the laundry every day. Due to communication issues, LPA was only able to interview two (02) out of five (05) residents, Resident #2 (R2) at 11:00 a.m. on 07/18/24 and Resident #3 (R3) at 4:00 p.m. on 07/18/24. Both residents interviewed mentioned no issues with facility cleanliness. Based on observations and interviews, staff wash surfaces, placemats, and bibs every day ensuring the facility is clean. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility staff do not properly address insects in the facility” it was alleged the facility did not resolve an issue with ants. During facility tour, LPA observed no insects or trace of insects or vermin in the home. Interview with the licensee revealed a few ants were noticed in the past in the corners of the home but never on tables, in eating areas, or in resident rooms. Staff promptly used bug spray to kill the ants. S3 confirmed that they used bug spray to get rid of ants previously in the facility. Two (02) out of two (02) residents interviewed confirmed they had no issue with ants or pests in the facility. Based on observations and interviews, the facility was free of insects and vermin and properly addressed past issues with insects. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility staff do not meet residents' showering needs” it was alleged staff do not properly shower residents. Record review of staff training records revealed all staff had been trained on resident hygiene and bathing. Interviews with R2 and R3 revealed they receive enough assistance with showering from facility staff and an outside agency. Interviews with staff and the licensee revealed the facility revealed no hygiene issues were raised by residents, family, or visitors. Residents receive shower assistance twice a week and bed baths the other five (5) days. Based on record review and interviews, the facility meets residents’ showering needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility staff do not meet residents' dietary needs” it was alleged the facility did not provide sufficient amounts of food at night. Observations from facility tours today at 11:30 a.m. and at 10:30 a.m. on 07/18/24 revealed the facility had sufficient food supplies available in the refrigerator, freezer, and pantry. Interviews with residents revealed they are fed enough and have snacks available after dinner. Interview with staff and the licensee revealed residents eat food like sandwiches, fruit, nutritional shakes, and ice cream after dinner every night. No staff have heard of any issues with insufficient food at night. Based on observations and interviews, the facility meets residents’ dietary needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility staff force the residents to eat” it was alleged staff force feed residents too quickly. Record review of staff training records revealed all staff are trained to properly assist with resident feeding needs. Record review of resident service plans and medical assessments revealed four (04) out of five (05) residents did not require assistance eating. LPA observed staff monitoring residents during lunch on 07/18/24 and assisting Resident #4 (R4) with eating. LPA did not observe staff force feeding residents. Interviews with S3 and S4 revealed most residents can feed themselves, and staff provide assistance if requested or necessary. Interview with the licensee revealed all staff monitor and assist residents with meals. No immediate health and safety risks were observed during today’s inspection. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 20, 2024 · control 31-AS-20240717143523

Type of visit: Case Management - Deficiencies

At 10:30 a.m. on 07/18/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and later the licensee and disclosed the reason for the visit. Today's case management visit was conducted due to a deficiency discovered during the course of investigating complaints #31-AS-20240717143523 and 31-AS-20240718083724. During a physical plant tour at approximately 10:40 a.m. today, the toilet tank in the north bathroom was observed to be exposed and without a lid. LPA also observed this during the annual inspection on 03/22/2024 and provided a note of technical assistance. At approximately 11:15 a.m., the licensee stated that the part was ordered but never installed. Based on observations and interviews, the facility bathroom was in disrepair. A deficiency is cited on the corresponding LIC 809-D page. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 18, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(6) · Plan of correction due date: Jul 29, 2024

87303 Maintenance and Operation (e) ...plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in one (01) bathroom toilet which poses a potential Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 18, 2024

Plan of correction: Licensee has agreed to install the toilet fixture by the POC due date and send a photograph of the repair.

Type of visit: Required - 1 Year

At 8:30 a.m. on 03/22/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the licensee and co-administrator and disclosed the reason for the visit. The facility was last visited on 03/18/2022 for an annual visit. It is a single story building with seven (07) bedrooms, two (02) bathrooms, kitchen, office, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for four (04). LPA and staff toured the facility inside and out at 8:40 a.m. The front entrance was gated and unlocked. The front yard was maintained. Once inside, LPA observed postings near the main entrance for Ombudsman contacts, confidential complaint contacts, facility license, COID precautions and procedures, emergency disaster plan, facility sketch, personal rights, rights of resident councils, and emergency contacts. A screening station at the front contained a visitor log, gloves, masks, and sanitizer. Walls, floors, windows, screens, and blinds were clean and in good repair. At 8:50 a.m. LPA measured the room temperature to be seventy (70) degrees Fahrenheit. Surveillance cameras were observed at the main entrance and a hallway. The living rooms contained televisions, reading material, activities, exercise equipment, and karaoke equipment. A fireplace was appropriately grated with the gas line turned off. Medications were locked near the dining room. The house phone was tested to be operational at 9:00 a.m. At 9:05 a.m., LPA tested the carbon monoxide detector above the dining room to be operational. Two (02) other carbon monoxide detectors were observed in the facility. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter top. At 9:10 a.m. the refrigerator and freezer temperatures were measured to be forty (40) and zero (00) degrees Fahrenheit, respectively. Cleaning solutions were locked in a laundry room adjacent to the kitchen. Also located in the laundry room were a washer and dryer. Both were in working order. At 9:15 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 04/15/2023. The facility has seven (07) bedrooms. 1 bedroom is designated as an office. The office was locked and free of hazards. Bedroom #5 was designated for storage and was free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Bedrooms with oxygen in use contained appropriate signage. The facility has 2 bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash cans with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. LPA observed a shaded patio area in the rear of the facility. The patio contained furniture in good condition. The back yard was maintained with fruit trees and shrubs. Two (02) out of two (02) emergency exit paths were free from obstructions. Two (02) out of two (02) auditory alarms were turned on and functioning. At approximately 11:30 a.m. the smoke detector in the hallway was tested and operational. At approximately 11:45 a.m. LPA measured the water temperature to be 111.5 degrees Fahrenheit. LPA reviewed resident medications at 9:20 a.m., staff and resident files at 10:40 a.m., and conducted staff and resident interviews at 11:15 a.m. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed during this visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 22, 2024