Belmare Senior Living

Allegation investigated: Staff did not ensure that resident's room was free of hazards

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegation. LPA Lund met with Executive Director Kurtis Woody and explained the reason for the visit. Census: 77 Staff did not ensure that resident's room was free of hazards- LPA Lund reviewed facility paperwork and interviewed staff. LPA Lund reviewed Unusual Incident/Injury Report (LIC624) dated 4/6/2026 from the facility. The report stated that there was a bottle of cleaner found in Resident’s (R1) refrigerator. LPA Lund interviewed staff (S1) who stated that on 4/2/2026 a resident’s (R1) family member came into the lobby with a bottle of cleaner, per family member it was found in the refrigerator of R1. There were no signs of ingestion or any other exposure from R1. Substantiated Based on reviewed facility paperwork and interview with staff, the information provided, it clear that staff did not ensure that resident's room was free of hazards the therefore the allegation was deemed SUBSTANTIATED. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. Per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were observed or cited and noted on LIC 809D. An exit interview was conducted, and copies of the report and appeal rights left.the state’s words, verbatim · CDSS document, Jul 23, 2026 · control 27-AS-20260403135309

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 24, 2026

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:There was a bottle of cleaner found in Resident’s (R1) refrigerator. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: On 4/17/2026 the facility had training Hazardous Materials.

Allegation investigated: Staff do not provide timely assistance to residents in care due to lack of staffing

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegation. LPA Lund met with Executive Director Kurtis Woody and explained the reason for the visit. Census: 77 Staff do not provide timely assistance to residents in care due to lack of staffing- LPA Lund reviewed facility paperwork and interviewed staff. LPA Lund reviewed March 2026 schedule for the facility and most days there are one or more shifts open per day. Staff interviewed stated that most shifts they are short staff to help the residents with their care. Substantiated Based on reviewed facility paperwork and interviews with staff, the information provided, it clear that staff do not provide timely assistance to residents in care due to lack of staffing the therefore the allegation was deemed SUBSTANTIATED. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. Per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were observed or cited and noted on LIC 809D. An exit interview was conducted, and copies of the report and appeal rights left.the state’s words, verbatim · CDSS document, Jul 23, 2026 · control 27-AS-20260330154018

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411 · Plan of correction due date: Jul 24, 2026

Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The requirement is not met as evidenced by Based on interviews with staff and reviewed March 2026 schedule licensee did not ensure basic needs were being met by staff. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: The facility will continue to hire staff

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a health and safety check on this day. The LPA met with Director of Health & Wellness Anelisse Ramirez and explained the reason for the visit. Census: LPA Lund and Director of Health & Wellness Anelisse Ramirez inspected/toured the physical plant. LPA inspected the facility with Director of Health & Wellness including but not limited to the kitchen area, resident rooms, bathrooms, dining room, and storage areas. LPA observed the facility to be free of odor and clean. There was 2- days of perishable food and 7- days of non-perishable food. LPA Lund observed sufficient staffing. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 19, 2026

Allegation investigated: Staff member(s) are verbally abusive to residents in care.

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegation. LPA Lund met with the Director of Health & Wellness Anelisse Ramirez and explained the reason for the visit. Census: 81 Staff member(s) are verbally abusive to residents in care - LPA Lund interviewed staff, former staff, residents in care and witnesses. Based on interviews with Management staff who stated that when they did internal investigation of staff verbally abusing a resident in care they could not find any prove that it happened. LPA Lund interviewed staff, residents in care and witness who stated that they have never seen any staff verbally abuse any residents in care. Unsubstantiated Based on interviewed staff, former staff, residents in care and witnesses, on the information provided, it was unclear if staff member(s) are verbally abusive to residents in care, therefore the allegation was deemed UNSUBSTANTIATED. As a result of this investigation, this Department finds the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegations may have happened or is valid, there is not preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and report left.the state’s words, verbatim · CDSS document, Feb 5, 2026 · control 27-AS-20251016091920

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Albert Johnson conducted a health and safety check on this day. Health and Safety check included overall safety of the facility including food supply, physical plant and staffing. LPA was following up on non-compliance information from the meeting held on 8/15/2025 and to clear citations from 2025. LPA provided the facility with emailed copies of the citations from 2025 that need to be cleared. The facility has requested an increase in their hospice waiver. The department has requested that in areas that have not been given a plan of correction from prior visit from August of 2025 through November of 2025 or the facility has not identified or developed a plan of correction from the above dated; a plan of correction will be developed and submitted. Exit interview conductedthe state’s words, verbatim · CDSS document, Jan 22, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Albert Johnson conducted a health and safety check on this day. Health and Safety check included overall safety of the facility including food supply, physical plant and staffing. LPA was following up on non-compliance information from the meeting held on 8/15/2025. The Licensee was requested to provide CCL with the requested information which includes: Complete and submit the LIC 500 for the most current staff, shifts, and coverage for designated shift leads. Submit the LIC 308. Submit payroll for October 2025. Complete and submit proof of most recent training in the areas of Resident Care, and Resident Supervision. Continued In areas that have not been given a plan of correction from prior visit from August of 2025 through November of 2025 or the facility has not identified or developed a plan of correction from the above dated; a plan of correction will be developed and submitted by 12/3/2025. The licensee will also place the CCL license number on the bus and any other advertising the facility uses. Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited during this visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 19, 2025

Allegation investigated: Lack of Supervision led to resident sustaining serious injury from fall.

On 10/29/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to deliver complaint findings. LPA Lindstrom identified herself, met with the Memory Care Director, and explained the purpose of the visit. Allegation: Lack of Supervision led to resident sustaining serious injury from fall. Resident 1 (R1) had an unwitnessed fall on 7/31/2025 that resulted in a laceration to the forehead. The resident was transported to the hospital for treatment and discharged on 8/1/2025. R1 had a second unwitnessed fall on 8/8/2025 that resulted in scalp wounds and shoulder and rib fractures. The resident was transported to the hospital for treatment. On 8/10/2025, the resident was placed on hospice care and on 8/12/2025, the resident was moved to another senior care facility. On 8/13/2025, the resident passed away. According to R1’s Death Certificate, the resident’s cause of death was respiratory failure and Alzheimer’s disease. Unsubstantiated R1’s Physician’s Report, dated 1/17/2024, stated that R1 was non-ambulatory based on mental condition, but that R1 could transfer independently to and from bed. Community Care Licensing Division (CCLD) personnel interviewed R1’s Responsible Party. The Responsible Party stated that R1 walked without assistance before moving to the facility in Spring 2025 and used a walker provided by staff after moving in. CCLD personnel interviewed four facility staff. Staff stated that R1 was able to walk unassisted with a walker and transfer from bed to the walker independently. Staff and R1’s Responsible Party stated that when R1 returned to the facility after the 7/31/2025 fall, R1 continued to be able to walk unassisted with a walker. Staff stated that there was no lack of supervision. Staff frequently saw R1 enjoying walking around the facility and observed R1 every two hours during rounds and approximately every thirty minutes during informal checks. Based on interviews, observations, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.the state’s words, verbatim · CDSS document, Oct 29, 2025 · control 27-AS-20250805162157

Type of visit: Required - 1 Year

On 10/29/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required annual inspection and was greeted by a staff member. The LPA identified herself, explained the purpose of the visit, and asked to meet with the Administrator. The Health and Wellness Director/acting Administrator Kurtis Woody was on-site (Administrator Certificate #6073581740, expiration date 01/03/2026), and an interview followed. The Administrator accompanied the LPA on a tour of the interior and exterior of the physical plant. The CARE inspection tool was used during this inspection. The facility includes Assisted Living, Memory Care, and Independent Living units. The licensed one-story Memory Care unit is located across a paved walkway from the two-story Assisted Living unit. The facility is licensed for a capacity of 114 residents, including 23 ambulatory and 77 non-ambulatory, of which 14 can be bedridden. It had a hospice waiver for 7. At the time of the site visit, the census was 77 residents, including 24 in Memory Care and 53 in Assisted Living. The LPA inspected the physical plant, including but not limited to the dining areas, kitchens, storage rooms, activity rooms, common areas, resident bedrooms and bathrooms, laundry rooms, and outside patios to ensure compliance with Title 22 regulations. The Facility License, Complaint Hotline Poster, Ombudsman information, menus, and activity calendars were publicly posted. The LPA toured the kitchen and interviewed the Kitchen Manager. The entire kitchen, including its appliances, working surfaces, floor, and storage areas were clean, sanitary, and odor-free. The LPA observed a two-day supply of perishable food and seven-day supply of non-perishable food, located in upright freezers and refrigerators, storage rooms, and a walk-in refrigerator/freezer. Food was properly stored, and safe food storage guidelines were prominently displayed on the wall. Daily cleaning schedules for the AM and PM shifts were posted. Refrigerator/freezer temperature logs and food temperature logs were posted in visible locations and actively used daily. Appliances were in working order. The stove hood was clean and last serviced by IC Refrigeration in June 2025. The LPA observed lunch service. Food portions were adequate, and the meal contained a variety of food types. Daily menus were located on each table. The LPA observed residents eating and socializing. The LPA toured common areas intended for resident use, including hallways, theater, game room, gym, and bistro. These areas were decorated, clean and odor-free. They had adequate furnishings and lighting in good repair and working order. The thermostat was set at 76 degrees Fahrenheit. There was an evacuation chair at the top of each staircase and evacuation maps posted throughout the facility. The elevator was last inspected on 3/6/2025. The facility had an Ansul fire suppression system that included sprinklers and pull alarms; it was last serviced by Imfeld Cloutier Fire Protection on 7/28/2025. The fire extinguishers were last serviced by the same company on 7/23/2025. Chemicals were properly stored in locked housekeeping storage rooms. There were smoke and carbon monoxide detectors in working order in resident rooms and hallways. In the Memory Care unit, the LPA exited the building through a side door. The alarm sounded immediately and a staff responded to the alarm within a minute. The LPA observed ten residents’ living quarters. The resident apartments were clean and odor-free. Apartment units contained the required furnishings, and each was personalized with residents’ own belongings. The windows were in good repair and there were large closets for storage. The bathrooms contained working water fixtures, sturdy grab bars, and non-slip flooring. The LPA measured the temperature of the hot water in two resident bathroom sinks. The hot water was 108 degrees Fahrenheit, which was within the required regulation of 105 to 120 degrees Fahrenheit. While in a resident room, the LPA pushed the call button. Staff responded within three minutes. The LPA toured the outside areas. Walkways were flat, smooth, and free from obstruction. The grounds were manicured and decoratively planted. Interior courtyards in both the Memory Care and Assisted Living units contained seating and shaded areas for residents. Due to time constraints this required 1 year annual will be continued at a later date. An exit interview was conducted with the Memory Care Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 29, 2025

Allegation investigated: Staff dispensed medication to resident that was not prescribed.

On 10/1/2035, Licensing Program Analyst (LPA) Triel Ellen Lindstrom visited the facility unannounced to open this complaint and deliver findings. LPA Lindstrom met with Emily Parker, Memory Care Director, and explained the purpose of the visit. The purpose of the visit was to open the complaint, interview staff, review records, and deliver findings. Allegation: Staff dispensed medication to resident that was not prescribed. LPA Lindstrom reviewed an Unusual Incident/Injury Report (LIC624) that was submitted to the Department by the Administrator on 9/25/2025. This report stated that a resident (R1) was administered a narcotic medication between 9/6/2025 - 9/17/2025 without a prescription order on file at the facility. According to the LIC 624, staff reported seeing a bottle of oxycodone in R1’s room on 9/4/2025. Staff (S1) removed it from R1’s room that day and gave it to staff (S2) to count the contents, create a ‘narc count sheet,’ confirm the doctor’s prescription, and store until then. On 9/6/2025, S2 started to administer the Substantiated medication to R1. When asked why, S2 told S1 that there was an order and a paper medication administration record (MAR). Every Med Tech after 9/6/2025 also administered the medication, but they used the narc count sheet to track administration instead of the paper MAR. No other Med Tech saw a prescription order. According to the LIC624, the administration of this medication came to the attention of management when S1 received a call from a pharmacy asking why staff requested a refill for a medication that was not on R1’s medication list. The internal investigation revealed that staff were alternating administration of R1’s pain medication between the prescribed pain medication that he was already on and the medication with no order. On 9/13/2025, S3 administered both pain medications at once, according to the narcotic count sheet and electronic MAR. When discovered by management, they informed R1’s family and doctors. On 9/29/2025, LPA Lindstrom spoke with S1 about the incident reported in the LIC624. S1 stated that they asked S2 why they began to administer this pain medication. S2 reported that she had seen an order for the medication and so created a paper medication administration record. S1 has since reviewed the document that S1 referenced and determined that it was not an order. S2 told S1 that they contacted R1’s primary doctor, who confirmed that they had not written the prescription, and then contacted the doctor listed on the medication bottle, who did not respond. S1 stated that the found medication had been prescribed to R1 by a surgeon on 7/16/2025. S1 was unsure how the bottle came to be in R1’s room. The medication bottle contained fourteen tabs when it was removed from R1’s room. Staff administered these fourteen tabs to R1 between 9/6/2025 and 9/17/2025. Based on the LPA’s interviews which were conducted and records 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, Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted with Emily Parker and a copy of this report was provided, along with appeal rights. throughout the day. On 9/13/2025, staff (S3) administered both pain medications during the same medication pass. On 9/29/2025, LPA Lindstrom interviewed two staff (S3 and S4) about the incident reported in the LIC624. S3 stated that they had never heard R1 indicate they felt unwell or symptomatic because of pain medication, nor had they ever thought that R1 needed medical attention for the side effects of pain medication. S3 stated that R1 could be a little sleepy and that they were very insistent about getting their pain medication. S4 stated that when R1 first moved in, they reported not liking how the pain medication made them feel, but then never mentioned it again. S4 stated that they never observed any negative side effects or heard R1 express anything negative about pain medication between 9/6/2025 – 9/17/2025. Based on interviews, observations, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 27-AS-20250926085746

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87208(a) · Plan of correction due date: Oct 8, 2025

87208(a) Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation…The licensee shall operate the facility in accordance with the terms specified in the plan… This requirement is not met as evidenced by: Based on interview & record review, staff did not follow facility’s Plan of Ops re: that caregivers receive training in proper handling of meds, that meds be centrally stored along w/ its record, that a physician order be on file, which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 1, 2025

Plan of correction: The Licenseee will discipline the staff involved in the improper administration of the narcotic; The Licensee will provide training for all Med Techs regarding administration of narcotics,and the procedures for handling medication without orders and for obtaining the needed orders.

Type of visit: Case Management - Incident

On 10/1/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived unannounced at the facility to conduct a case management visit related to recent elopements at the facility that were self-reported to the Department on two separate Unusual Incident/Injury Reports (LIC624). LPA Lindstrom met with the Memory Care Director, explained the purpose of the visit, and conducted an interview. Since the elopement, management has replaced the door on the back fence of the Memory Care Unit's garden. The new door has an egress with a lock that stays locked when pushed and sounds an alarm. An exit interview was held with the Memory Care Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 1, 2025

Allegation investigated: Lack of supervision resulted in residents sustaining multiple falls

On 9/02/2025, Licensing Program Analysts (LPA) Triel Ellen Lindstrom and Arielle Pascua arrived unannounced at the facility to deliver the findings on a complaint received on 5/1/2025. The LPA met with Administrator Lacy Vincent and explained the purpose of the visit. LPA Lindstrom had toured and made observations at the facility, reviewed records and work schedules, and interviewed residents, staff, and family members. This investigation was conducted during site visits on 5/5/25, 5/28/25, 6/9/2025 and 8/4/2025. Allegation: Lack of supervision resulted in residents sustaining multiple falls On 5/5/25, R6 stated that when the facility is inadequately staffed, staff do not respond timely to resident call buttons. R6 stated that when she was unable to reach her call button, she had to scream, and that it can take up to an hour to receive help. R7 stated that the facility is often short-staffed, and staff work a lot of overtime. R7 stated that typically the response time to her call button is 15 to 20 minutes, although (Continued on 9099-C) Substantiated sometimes it is 30 to 45 minutes. R7 stated that due to inadequate staffing, staff are unable to assist her when walking with her walker. On 7/25/25, the Department received an incident report that stated a resident’s family member found this resident bent over his wheelchair and bleeding from his knee. Camera footage showed that the resident had vomited three times and run his wheelchair into a pillar hurting his knee. No care staff were nearby to witness the incident. On 8/2/25, the Department received an incident report that the resident was found on his floor by a care staff bleeding from his elbow. The resident stated he was walking without his walker when he slipped and fell. There were no care staff nearby to witness the fall. On 8/4/25, F1 stated that there was only one person working in memory care that morning. A review of the August Caregiver Work Schedule showed only one person working in memory care on the A.M. shift on August 7th, 13th, 14th, 19th, 20th, 25th, and 26..The current census shows that there are twenty-eight residents in memory care. Between August 4th and August 22nd, 2025, the Department received twelve incident reports of unwitnessed falls. On 8/5/25, S7 stated in a text sent to staff to stop telling residents and family that the facility is short staffed. On 8/8/25, the Department received an incident report of an unwitnessed fall. R1 had been found on the floor of his room with his head in a pool of blood. On 8/8/25, F1 stated that R1 had another unwitnessed fall and was in the hospital with a brain bleed and fractured hip. On 8/15/25, the Department received an incident report of R8 found on the floor due to an unwitnessed fall. The resident was transported to hospital via EMS and returned with a splint and sling due to a fracture of her arm. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of lack of supervision resulted in residents sustaining multiple falls is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities is being cited on the attached LIC 9099D. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility. Allegation: Facility staff are not properly addressing pests in the facility LPA Lindstrom toured the facility on 5/5/25, 5/28/25, 6/9/25 and 8/4/25 and interviewed a total of fifteen staff, ten residents, and four family members. 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 was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 27-AS-20250528150925

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 3, 2025

87468.2 Additional Personal Rights of Residents...(a) Residents shall have…the...rights (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers... This requirement is not met as evidenced by: Based on interview with R6 and R7, incident reports of 12 unwitnessed falls with four serious injuries, and staff schedule review, adequte care and supervision is not being met. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Administrator refused to participate in developing a plan of correction. The licensee will provide to the Department their plan to meet the regulation by the POC date

Allegation investigated: Facility staff does not answer pendant calls in a timely manner.

On 9/03/2025, Licensing Program Analysts (LPA) Triel Ellen Lindstrom and Arielle Pascua arrived unannounced at the facility to deliver the findings on a complaint received on 5/1/2025. The LPA met with Administrator Lacy Vincent and explained the purpose of the visit. LPA Lindstrom had toured and made observations at the facility, reviewed records and work schedules, and interviewed residents, staff, and family members. This investigation was conducted during site visits on 5/5/25, 5/28/25, 6/9/2025 and 8/4/2025. Allegation: Facility staff does not answer pendant calls in a timely manner On 5/5/25, LPA Pascua interviewed S7, who stated that the expectation regarding response time to pendant calls was 10 minutes. An analysis of the pendant log for April 2025 showed that the wait 11-20 minutes 21% of the time, 21 to 30 minutes 5% of the time, and over 30 minutes 3% of the time. LPA Lindstrom interviewed a resident R6, who stated that when the facility is not sufficiently staffed, it can take (Continued on 9099-D) Substantiated staff up to an hour to respond to calls for help, often times leaving R6 screaming as they cannot reach the call button. R7 stated that staff response time to her call button is usually around 15-20 minutes, although has taken up to 30 to 45 minutes. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that staff did not answer resident's call button in a timely manner, therefore the allegation of is SUBSTANTIATED. No deficiencies are being cited as this regulation is being cited today under complaint control # 27-AS-20250501155055. An exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 27-AS-20250521081550

Allegation investigated: Staff do not ensure that residents' incontinence needs are met. Staff speak inappropriately to residents. Staff do not distribute resident's medication as prescribed. Staff did not ensure resident's dietary needs were met. Staff did not answer resident's call button in a timely manner.

On 9/03/2025, Licensing Program Analysts (LPA) Triel Ellen Lindstrom and Arielle Pascua arrived unannounced at the facility to deliver the findings on a complaint received on 5/1/2025. The LPAs met with Administrator Lacy Vincent and explained the purpose of the visit. LPA Lindstrom had toured and made observations at the facility, reviewed records and work schedules, and interviewed residents, staff, and family members. This investigation was conducted during site visits on 5/5/25, 5/28/25, 6/9/2025 and 8/4/2025. Allegation: Staff do not ensure that residents' incontinence needs are met A family member (F1) of a resident (R1) was interviewed and stated that R1 had had two occurrences when incontinence care was not met. On 8/4/25, F1 discovered R1 still in bed at 8:20 AM. F1 walked into R1’s bedroom and found R1 lying in bed with soaked briefs and bed pads. In another occurrence, F1 looked throughout the unit for a caregiver to help R1 toilet and could find none. R1 subsequently got (Continued on 9099-C) Substantiated feces all over themselves. A review of R1’s 602 physician’s report states that R1 needs assistance with toileting, bathing and grooming. A review of the facility’s August work schedule shows that only two caregivers were working in the memory care unit with 28 residents on the AM shift on 8/4/25. S1 stated that they often find all residents’ briefs soaked at the beginning of an AM shift in the Memory Care unit. S2 stated that a couple of times they had discovered residents with dried feces on their buttocks at the beginning of the AM shift, which S2 said was a sign that caregivers had not changed their briefs in a while. S5 stated that sometimes when the facility was not sufficiently staffed and staff could not respond to call buttons within 10 minutes in Assisted Living, residents had accidents that resulted in soaking through their briefs and bedding. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of staff do not ensure that residents' incontinence needs are met is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87625(b)(3) Managed Incontinences being cited on the attached LIC 9099D. Allegation: Staff speak inappropriately to residents On 5/29/2025 and 6/09/2025, LPA Lindstrom conducted interviews with two staff members, S10 and S12 respectively. Both staff members stated that S9 was very verbally abusive to residents, used bad words, and was aggressive. S10 stated that S9 told resident R2 to go in their f’ing room when R2 would come out at the beginning of S9’s shift. S12 stated that S9 is rude to everyone and calls people retards. On 8/4/25, LPA Lindstrom interviewed F1, who stated that she heard S9 cuss, be vulgar, and tease residents, including saying, “What the f’ are you doing?” to a resident. A review of S9’s file shows that S9 had a history of speaking inappropriately and loudly to residents and to other staff in the presence of residents and their family. Disciplinary records show that management had been meeting with and writing up S9 for at least 8 months. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of staff speak inappropriately to residents is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468(a)(1) Personal Rights is being cited on the attached LIC 9099D. (Continued on 9099-C) Allegation: Staff do not distribute resident's medication as prescribed On 8/4/25, a Medication Administration Report (MAR) for R1 shows that R1 was taking 10 daily medications. The MAR for July shows that medications were not documented as being given on 7/10, 7/11,7/25, and 7/26. R1 is unable to neither confirm nor deny if he received their medications on these days. S4 stated that they had observed empty medicine bottles in the medicine cart that had not been refilled. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of Staff do not distribute resident's medication as prescribed, therefore the allegation is SUBSTANTIATED.California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87465(a)(4) Incidental Medical and Dental Care is being cited on the attached LIC 9099D. Staff did not ensure resident's dietary needs were met LPA Lindstrom toured the facility on 5/5/25, 5/28/25, 6/9/25 and 8/4/25 and interviewed a total of fifteen staff, ten residents, and four family members. S5 stated that when the facility is not sufficiently staffed, new staff forget to order residents’ meals. F1 stated that R1 was getting their food pureed when first admitted and that R1 started to lose weight after admission. R1’s 602 states that R1 only needs their food to be easy to chew. S1 stated that staff did not meet the dietary needs of R2, who is bedridden. There have been times when R1 was hallucinating due to a side effect of medication and could not eat when his room tray was delivered. Staff put his meal in the microwave and forgot it there. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that staff did not ensure resident’s dietary needs were met, therefore the allegation is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87555(b)(1) General Food Service Requirement is being cited on the attached LIC 9099D. Staff did not answer resident's call button in a timely manner On 5/5/25, LPA Pascua interviewed S7, who stated that the expectation regarding response time to pendant calls was 10 minutes. An analysis of the pendant log for April 2025 showed that the wait 11-20 minutes 21% of the time, 21 to 30 minutes 5% of the time, and over 30 minutes 3% of the time. LPA Lindstrom interviewed a resident R6, who stated that when the facility is not sufficiently staffed, it can take staff up to an hour to respond to calls for help, often times leaving R6 screaming as they cannot reach the call button. R7 stated that staff response time to her call button is usually around 15-20 minutes, although has taken up to 30 to 45 minutes. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that staff did not answer resident's call button in a timely manner, therefore the allegation of is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87464(f)(1) Basic Services is being cited on the attached LIC 9099D. An exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 27-AS-20250501155055

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 11, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on review of medication administration records, R1 did not receive all required daily medications, This poses an immeidate risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Administrator refused to participate in developing plan of correction. The licensee will provide to the Department their plan to meet the regulation by the POC date

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

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision... This requirement is not met as evidenced by: Based on an interview with S7, the expected staff response time to call buttons is ten minutes. Review of pendant logs show that 29% of call buttons are answered in more than ten minutes. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Administrator refused to participate in developing plan of correction. The licensee will provide to the Department their plan to meet the regulation by the POC date The licensee will provide to the Department their plan to meet the regulation by the POC date

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(1) · Plan of correction due date: Sep 11, 2025

87555 General Food Service Requirements (b)The following...shall apply: (1) Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day. The requirement is not met as evidenced by: Based on interviews with F1 and S5 and review of R1's LIC602, modifications were made to R1’s diet that were not required by the doctor, and that when not sufficiently staffed, R2 missed his meal. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Administrator refused to participate in developing plan of correction. The licensee will provide to the Department their plan to meet the regulation by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Oct 3, 2025

87625 Managed Incontinence (b)…the licensee shall be responsible for...(3) Ensuring that incontinent residents are kept clean and dry... This requirement is not met as evidenced by: Based on interview with F1, R1 was found on 8/4/25 with soaked briefs and bedpads. According to R1's LIC 602, resident is not ambulatory and requires assistance for toileting needs.This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Administrator refused to participate in developing plan of correction. The licensee will provide to the Department their plan to meet the regulation by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(1) · Plan of correction due date: Sep 11, 2025

87468 Personal Rights (a) Residents…shall have…the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced. by: Based on a review of S9’s disciplinary records and interviews with F1, S10, and S12, which showed that S9 did not treat residents in care with dignity by using curse words when speaking to them. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Administrator refused to participate in developing plan of correction. The licensee will provide to the Department their plan to meet the regulation by the POC date

Type of visit: Case Management - Deficiencies

On 9/03/2025, Licensing Program Analysts (LPA) Triel Ellen Lindstrom and Arielle Pascua arrived unannounced at the facility to deliver a case management deficiency. The LPAs met with Administrator Lacy Vincent (S1) and explained the purpose of the visit. The department has recently conducted five visits to the facility on 5/5/25, 5/28/25, 6/9/25, 8/4/25 and 8/7/25. LPA’s Pascua and Lindstrom conducted interviews with fifteen staff, ten residents, and four family members. LPA Lindstrom interviewed S1 on 8/04/2025. During that interview, S1 stated that stafffing levels at the facility are based on the needs of the resident. S1 stated that the staffing ratio in Memory Care is one staff for every seven residents. F1 stated that on 8/4/25, there was only one caregiver working in memory care with 28 residents and R1 was soaking wet in the bed. S2 and S5 state that when they are not sufficiently staffed, they are unable to give residents showers. R6 states that when the facility is not sufficiently staffed, it can take an hour for someone to respond to her when screaming and unable to reach her call button. R7 states that the facility is often not sufficiently staffed and that staff have to work overtime. R7 states that on 6/9/25, a resident had to go to the hospital and there was a delayed response to call pendants. R7 also stated that due to insufficient staffing, the staff don’t “spot” her when walking. On 5/29/25, S10 stated she was the only one working in memory care. The facility’s August work schedule shows that only 2 caregivers were working memory care in the AM shift on August 4th,28th and 31st and that there was only one caregiver in the AM shift on August 7th, 13th, 14th, 19th, 20th, 25th, and 26th. Text messages from S7 stated that hiring more staff doesn’t happen overnight and that no one should tell Licensing that they are short staffed. The following Type A deficiency is cited per California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87411(a). 87411 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. Additional staff shall be employed as necessary……for cooking, house cleaning, laundering…. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. An exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 3, 2025

87411 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... This requirement is not met as evidenced by: Based on interviews with residents and staff, records review, and observations made, the Memory Care facility has less than the 1:7 ratio the Administrator said is needed to meet the residents' needs.This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Administrator refused to partipate in developing plan of correction. The licensee will provide to the Department their plan to meet the regulation by the POC date

Type of visit: Case Management - Deficiencies

On 09/03/2025, Licensing Program Analysts (LPAs) Arielle Pascua and Triel Ellen Lindstrom arrived unannounced to this facility to conduct a case management visit. LPAs met with Facility Designated Administrator (FDA), Lacy Vincent and explained the purpose of the visit. The purpose of this visit was in response to LPA observations made during a subsequent complaint and case management visit dated September 3, 2025. Current census was 83. During the course of this visit, LPA toured the Memory Care building and the Assisted Living building. LPA confirmed with facility staff and a resident roster that there are currently 57 residents in Assisted Living and 26 in Memory Care. There are current 2 residents from Memory Care out of the facility at this time. During the visit, LPA observed one caregiver and one medication technician on duty, with one caregiver on a lunch break. Four residents were observed in the dining area, and five were in the living area watching TV. All other residents were in their respective bedrooms. During a walk-through of the Memory Care unit, LPA observed one resident (R1) in a bedroom with a mesh bed rail with the words "HOMEAL" installed along the full length of the bed. A review of R1’s facility records revealed no physician’s order for the use of a full bed rail, nor is R1 currently on hospice. Staff interviews indicated that the bed rail was installed at the request of a family member concerned about potential falls. LPA Pascua informed staff that a physician's order is required for the use of a bed rail that reaches the full length of the bed. LPA also toured the Assisted Living section, including two resident floors. During this tour, LPA observed three caregivers and one medication technician providing care and supervision to residents. As a result, the following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was attempted with FDA Vincent and a copy of this report was provided to the facility. A copy of this report will be sent to the Licensee and facility email addresses confirming delivery and read receipt.the state’s words, verbatim · CDSS document, Sep 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Sep 4, 2025

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This is not met as evidenced by: Based on observation, record review, and interview, the licensee did not ensure that that resident did not have a full length bedrail with a doctors order, which prohibited the resident from movely freely off of their bed. This poses an immediate health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Administrator was unable to collorborate with the LPA to arrange Plan of Correction.

Type of visit: Case Management - Legal/Non-compliance

A Noncompliance Conference (NCC) was conducted today on August, 19,2025, via Microsoft Teams. The purpose of the NCC was to discuss the complaints since licensure. Present at today’s NCC were the Sacramento South Regional Office Adult and Senior Staff, Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Lisa Rios, Licensing Program Analysts (LPAs) Ellen Lindstrom and Arielle Pascua. Present from One Life Senior Living Management Company, Chief Executive Officer, Dan Williams, Senior Vice President of Operations, Laurie McConnell, Senior Vice President of Health and Wellness, Cyndie Bryant, and Regional Director of Operations, Laura Schutt. Present for the facility was, Facility Designated Administrator (FDA), Lacy Vincent, Health and Wellness Director, Kurtis Woody and Licensee's Patrick Corrigan and Austin Corrigan. The non-compliance conference process was explained during this meeting to include the Administrative process. The NCC is being held due to non-compliance. Since facility licensure on 11/04/2022 the facility has a total of 13 complaints along with 10 Type A citations and 9 Type B citations. The deficiencies noted are: Deficiencies: Incidental and Medical, Reporting Requirements, Managed Incontinence, Basic Services Requirements, Personal Rights, Personnel Requirements, Resident Records, Infection Control, Care of Persons with Dementia, Buildings and Grounds, Care and Supervision, and Food Service. Issues discussed during the Non-Compliance Conference were: Facility staffing Care and supervision Reporting Requirements Seeking timely medical attention Care Plans and Fall Prevention Plan The facility has stated they will do the following to achieve continued and substantial compliance: Increase staffing Email a copy of August Payroll Update LIC 500 Personnel Report and provide form to Community Care Licensing Department (CCLD) indicating lead staff Assign and hire a Memory Care Director by 09/30/2025 Provide and conduct staff training regarding the topics discussed Continue conducting on-site random visits from facility management Facility staff will email CCLD facility plans to achieve compliance by 08/29/2025 5:00 PM. In addition, all requested above documents shall be emailed to CCLD by 08/29//2025 5:00 PM. In addition, at this meeting the notified Licensee/Administrator was advised future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and further potential administrative action. Community Care Licensing Department (CCLD) will do the following: Increase Monitoring to quarterly visits. TSP Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager. Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited during this visit. An exit interview was conducted and copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.the state’s words, verbatim · CDSS document, Aug 19, 2025

Type of visit: POC

On 8/7/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived unannounced at the facility to to conduct a Plan of Correction (POC) case management site visit. The LPA met with the Administrator and explained the purpose of the visit. The purpose of the visit was to discuss the Plan of Correction developed by the Administrator and the Department during a 12/26/2024 complaint site visit. The Administrator stated that she sent the POC documentation to the previous LPA. The Administrator will resend this to LPA Lindstrom by 08/15/2025. No deficiencies were noted or cited during today's site visit. The Department will follow-up at a later date. An exit interview with the Administrator was conducted and a copy of this report was provided to her.the state’s words, verbatim · CDSS document, Aug 7, 2025

Type of visit: Case Management - Other

On 6/9/2025, Licensing Program Analysts (LPAs) Triel Ellen Lindstrom and Arielle Pascua arrived announced for a case management visit to tour the Memory Care unit. The facility has requested an increase in their capacity from five to fourteen bedridden residents. The Department has received the facility's updated Plan of Operations, which incorporates the required language about dementia care, a signed LIC 200, a completed STD 850, and a new facility sketch that designates bedridden rooms. The LPAs met with Designated Facility Administrator (DFA) Lacy Vincent, who gave them a tour of the new Memory Care unit. On the tour of the Memory Care unit, the LPAs viewed the common areas, two resident bedrooms, two laundry rooms, a storage area, the kitchenette, the reception area, two interior courtyards, and an enclosed outside paved walkway and garden. The current capacity of the unit is 22 residents. The unit is clean and the rooms contain the required furnishings. The LPAs observed residents gathered around a large table with the Activity Director and her assistant doing a painting project. The outdoor area with a walkway is located in the front of the building between it and the parking lot. It is enclosed with a tall metal perimeter fence. The gate leading out of this area is currently unlocked. Because of this, residents are accompanied one-on-one with a caregiver when in this area. A technician has been scheduled to install a delayed egress on the gate in mid-June. The new Memory Care unit contains six rooms that have been cleared for bedridden residents. These six rooms are Rooms # 501, 504, 505, 520, 524, and 525. These rooms are identical to every other room in the unit. The rooms designated as bedridden rooms on the new facility sketch are all located near the corners of hallways. DFA Vincent stated that this location will make it easier for staff to evacuate residents in the case of an emergency, as there is an exit door at each corner. The unit has an approved capacity of forty-two residents. DFA Vincent stated that she recently sent a revised occupancy plan to management, reducing the number of rooms designated for double occupancy from sixteen to eight. This would cap the total occupancy at thirty-six residents maximum. This site visit concludes the Department's approval of the six new bedridden rooms in the facility's Memory Care Unit, increasing the capacity from five to fourteen bedridden residents in the facility. Based on observation and records review made during this site visit, there were no deficiencies observed or cited during today's case management visit. A brief exit interview was conducted with DFA Vincent and a copy of this report was provided to the DFA.the state’s words, verbatim · CDSS document, Jun 9, 2025

Type of visit: Office

A virtual informal conference - office meeting was held via Microsoft Teams to discuss compliance issues presented throughout the last 12 months. Present in today's meeting was Licensing Program Analyst (LPA) Arielle Pascua, Licensing Program Manager (LPM) Lisa Rios, and Facility Designated Administrator (FDA), Lacy Vincent. The following topics were discussed during the informal conference: Waivers and Exceptions Hospice Staffing The facility will do the following to achieve compliance: Continue to provide care and supervision to the residents within allotted hospice waiver allowance Facility will provide the department a request for hospice increase Facility will follow up on capacity changes and provide new fire clearance The regional office will do the following: Continue to collaborate and provide assistance to licensee as needed Per California Code of Regulations (CCR) - Title 22 - no deficiencies are being cited. An exit interview was held, and a copy of the report was sent via email. Licensee to send a signed copy to LPA Pascua.the state’s words, verbatim · CDSS document, Jan 22, 2025

Allegation investigated: Staff did not seek medical attention to resident in a timely manner. Staff did not notify CCL of incidents

On 12/30/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Lacy Vincent and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current census was 87. A brief interview with FDA Vincent was conducted. Allegation: Staff did not seek medication attention to resident in a timely manner It was alleged that the staff did not seek medication attention to a resident in a timely manner. During the course of this investigation, interviews were conducted, and facility records were reviewed. Based on interviews conducted it was learned that on 07/26/2024 R1 was found on the floor next to their bed by staff. It was stated by staff that they were unsure how long R1 was on the floor for and upon assessment the facility asked if R1 they wanted to get assessed by emergency services however reminded R1 that they could refuse to medical attention. Substantiated It was also stated that it was observed that R1 was not at their baseline of consciousness as they were unsure of how they fell and stated they were in a different town other than where they currently resided. It was learned that R1 has a diagnosis in which can impede in the resident’s decision making. After 20 minutes passed, facility staff contacted R1’s responsible party and notified them that R1 fell however will not be sending because of R1’s refusal. R1’s responsible party asked why the facility was not sending out R1 and staff stated that R1 could refuse medical emergency regardless of the resident’s current state. After 20 minutes, R1’s responsible party persuaded R1 to go to the hospital to obtain medication attention. A review of the facilities plan of operation was conducted. It states that under medical emergencies that if a resident show any sign or symptom of distress including but not limited to shortness of breath, chest pain or change of level of consciousness, emergency medication services will immediately be summoned. Based on the information gathered, the facility staff did not seek medical attention to a resident in a timely manner. Allegation: Staff did not notify CCL of incidents It was alleged that the staff did not notify CCL of incidents. During the course of this investigation, interviews were conducted and facility records were reviewed. Based on interviews conducted it was learned that R1 fell on 06/18/2024 and was sent out to the hospital and diagnosed with a hip fracture. Subsequently, on 07/26/2024, the R1 fell a second time and was sent out of the facility after R1’s responsible party convinced for the resident to go obtain medical services. An interview with the facilities Health and Wellness Director was conducted and it was learned that the facility was unsure when to send out incident reports when a resident frequently falls. LPA was able to obtain an incident report for the fall on 06/18/2024 and 07/26/2024 from the facility on 08/13/2024, however did not have an attached fax confirmation sheet. The facility was unable to provide proof that this incident report was sent via email or fax. A review of the departments facility records do not have any incident reports regarding any type of incident regarding R1 within the months of June and July 2024. In addition, a review of the R1’s care notes do not have documented falls within the months of March 2024-August 2024. Based on the information gathered, the facility staff did not notify CCL of incidents. Based on the information gathered, the facility staff did not notify CCL of incidents. Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANTIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged. Citations are being issued pursuant to the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report, appeal rights and a confidential names list was provided. Based on the information gathered, it is unclear if the resident developed a UTI while in care. Based on the interviews conducted and a lack of documentation with law enforcement of a missing person the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report, a confidential names list and appeal rights were given.the state’s words, verbatim · CDSS document, Dec 30, 2024 · control 27-AS-20240807121831

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Dec 31, 2024

87465(g) Incidental Medical and Dental Care The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health...This requirement was not met as evidence by. Based on file review and interviews, The Licensee did not ensure to seek timely medical attention for R1. R1 was not provided timely medical attention due to stating that R1 had the option of refusal of medical services. However, based on facility records staff are to call 911 if they R1 was not at their level of consciousness. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Dec 30, 2024

Plan of correction: A statement of correction and acknowledgement shall be provided to the LPA by POC date 12/31/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1) · Plan of correction due date: Dec 31, 2024

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.This requirement was not met as evidenced by: Based on file review and interview, The licensee did not ensure that facility reported R1's falls that occured on 06/18/2024 and 07/26/2024 were reported to the department. LPA reviewed facility records and found that there were no reported incidents regarding falls or R1 within the months of March 2024-August 2024. This poses an immediate health,safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Dec 30, 2024

Plan of correction: A statement of correction and acknowledgement shall be provided to the LPA by POC date 12/31/2024.

Allegation investigated: Staff do not keep the facility free from scabies Staff behavior poses as a risk the residents

On 12/26/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with Executive Director Lacey Vincent and explained the purpose of today's visit. During the course of this investigation LPA Jensen conducted site visits on 3 separate occasions. LPA Jensen also interviewed 7 current staff members, 1 former staff member, 3 family members of residents and 1 external contractor paid to provide ancillary services to a resident. LPA Jensen also reviewed the infection control plan and resident records. Allegation 1: Staff do not keep the facility free from scabies The facility has an infection control plan that is adequate. During the course of the site visits LPA Jensen observed staff practicing appropriate infection control measures. The parties interviewed stated that the scabies outbreak was handled in a timely and appropriate manner. Unsubstantiated While the facility did have a scabies outbreak there is insufficient evidence to suggest staff negligence caused the outbreak therefore the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Allegation 2: Staff behavior poses as a risk the residents In the fall of 2024 (approximately October 2024), the facility underwent a change in leadership and management companies. During the course of interviews a former staff member and current staff member stated that one of the prior directors would routinely give false information to the department when complaints were being investigated. Another staff member said that a previous director gave staff insufficient information about resident needs. While these allegations are concerning and could pose a risk to residents in care there is insufficient evidence to support the allegation. The allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Technical assistance was provided on inimical conduct. An exit interview was conducted and a copy of this report was provided. While the facility states they began calling responsible parties to notify them of scabies in the facility this is not documented. During the course of interviews conducted, 2 family members advised they were made aware that there was scabies in the facility by a personal acquaintance that had been at the facility a week prior to receiving a formal phone call from staff. The allegation of "staff are not properly reporting incidents involving the residents" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were given.the state’s words, verbatim · CDSS document, Dec 26, 2024 · control 27-AS-20241023142247

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Dec 27, 2024

Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Occurrences...which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours ... This requirement was not met as evidenced by LPA Jensen's verification that the Department and responsible parties were not notified with 24 hours. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Dec 26, 2024

Plan of correction: The Licensee agrees to submit a signed attestation that CCR 87211 has been read, understood and will be complied with in it's entirety.

Allegation investigated: Staff did not prevent a resident from dragging another resident

On 12/26/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with Executive Director Lacey Vincent and explained the purpose of today's visit. During the course of this investigation LPA Jensen interviewed 4 current staff members, 1 former staff member, 3 family members of residents and 1 external contractor paid to provide ancillary services to a resident. LPA Jensen also reviewed resident records. Based on the records reviewed and interviews conducted the facility was hosting a regularly scheduled happy hour. Resident 2 (R2) had placed her belongings on a chair and left her seat to dance. Resident 3 (R3) attempted to take over the already occupied seat and a disagreement ensued with R3 attempting to physically assault R2. Staff were within approximately 5 feet of the residents when this incident occurred. Unsubstantiated Additional staff promptly arrived to assist including 2 other care staff, the business manager and the Health and Wellness Director. Due to the fact that the event was appropriately staffed and resident behaviors can be highly unpredictable the allegation of "staff did not prevent a resident from dragging another resident" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened the preponderance of evidence does not prove it. Since this incident the facility has called a care conference with the family of R3 and are working with R3's physician to determine if medication adjustments are in order. An exit interview was conducted a copy of this report was given. A staff member from an outside agency reported their client has been receiving their meals late. A responsible party stated that their family member has 2-3 altercations with another resident. A different responsible party stated that their family sustained fracture to the spine and hit their head as a result of staff not being adequately trained. Based on records reviewed and interviews conducted with current staff, former staff, outside agency staff and family members the allegation of "staff is unable to meet the needs of the residents while in care" is SUBSTANTIATED. A finding of substantiated means the preponderance of evidence standard has been met. The consensus amongst interviewees is that the facility was understaffed for a period of time which resulted in residents not receiving adequate care and supervision. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights was provided.the state’s words, verbatim · CDSS document, Dec 26, 2024 · control 27-AS-20241108155944

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411 · Plan of correction due date: Dec 31, 2024

Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement was not met as evidenced by: This requirement was not met based on staff and family interviews as well as incident reports sent to the Department. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Dec 26, 2024

Plan of correction: The Licensee agrees to submit a plan to the Department outlining what measures will be taken to ensure resident needs are being met.

Type of visit: Required - 1 Year

On 9/30/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with the Director of Health ad Wellness and explained the purpose of today's visit. LPA Jensen toured the exterior and observed all paths to be free of obstruction. The facility property also has independent living suites on site and a swimming pool. The swimming pool was area was verified to be locked. There are shaded areas and outdoor furniture available for resident use. The facility has numerous activities available for resident engagement. An independent living suite was toured. LPA Jensen toured the interior of the facility including the dining room, hair salon, gym and several gathering areas. The common areas contained adequate furniture and lighting. The kitchen was observed to have a 2 day supply of perishable food and a 7 day supply of non-perishable food. The lunch service accurately reflected what was listed on the menu. The fire extinguisher and Ansul system was last serviced in August of 2024 and is in compliance. The stairways are equipped with evacuation chairs. LPA Jensen toured the resident rooms in assisted living and memory care. LPA Jensen observed a cabinet that had a pillow with a plastic covering that had writing which said for use to cover incontinence stains on upholstered chair. The chair in the room was observed to be stained. LPA Jensen tested the call signal system and care staff responded in a timely manner. The facility currently has 8 residents on hospice. Hospice care plans were on file for all 8 residents. A signed agreement was observed to be on file for a resident sharing a room with a resident on hospice. LPA Jensen conducted interviews with staff members and residents. LPA Jensen reviewed 5 resident files. The physician's report was outdated in 2 of 5 files. Furthermore, the needs and service plans did not accurately reflect the needs of 2 of residents. The facility has 2 residents that have insulin dependent diabetes. 1 of 2 residents that has insulin dependent diabetes has a physician report that makes no mention of this condition. The second resident with insulin dependent diabetes has a physician order stating they are unable to handle their own injections. Both residents with diabetes have a needs and service plan that says med techs will assist with insulin administration. 2 of 5 residents files showed multiple documented falls resulting in serious injury yet no fall mitigation plans put in to place. Deficiencies are being cited and technical assistance is being provided. Failure to correct deficiencies may result in the assessment of civil penalties. LPA Jensen reviewed 4 staff files and found them to be complete with 1st aid certifications, all required training documented, criminal background clearance and health screens. LPA Jensen is requesting the facility provide the following by 10/7/24: Liability insurance LIC 500 Dementia Care Plan Diabetes Care Plan Incontinence Care Plan The facility has an infection control plan and a disaster plan readily available. An exit interview was conducted and a copy of this report was given.the state’s words, verbatim · CDSS document, Sep 30, 2024

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not order resident's medication refills in a timely manner

On 9/24/24 LPA Jensen arrived at the facility unannounced to continue a compliant investigation in to the above listed allegation. LPA Jensen met with Business Office Manager Desiree Soria and explained the purpose of today's visit. LPA Jensen conducted interviews with staff 1 (S1), staff 2 (S2), staff 3 (S3) and Resident 1 (R1). LPA Jensen also reviewed the Centrally Stored Medication and Destruction Record (CSMDR) and Medication Administration Record (MAR) for R1 and progress notes. Based on the CSMDR R1 had a 30 day supply of medications. The CSMDR revealed that multiple prescription medication orders were filled after the 30 day mark. The MAR shows that 5 seperate medications "on hold until the medication is available". LPA Jensen interviewed R1 who stated that she had previously had a problem with getting medication refills but the problem has been resolved since she has been assigned a new medication technician. Substantiated Statements provided by 2 staff members corroborate that medication refills for R1 were not ordered in a timely manner in or around the month of July 2024. Based on the interviews conducted and the records reviewed the allegation of "Staff did not order resident's medication refills in a timely manner" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.the state’s words, verbatim · CDSS document, Sep 24, 2024 · control 27-AS-20240712161154

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 25, 2024

Incidental Medical and Dental Care ....The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed facility staff did not order refills of a resident's medication in a timely manner.the state’s words, verbatim · CDSS document, Sep 24, 2024

Plan of correction: The Licensee will email a plan to LPA Jensen for auditing medication administration and taking action as appropriate based on audit findings within 24 hours.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to complete a complaint investigation. During the course of that visit it was learned that Administrator Cindy Lichtenhan is no longer in this position. LPA Jensen met with Business Office Manager Desiree Soria and explained the purpose of the visit. LPA Jensen was informed that Cindy Lichtenhan's final day of employment was 9/13/24 and that the facility is actively recruiting for a new Administrator. LPA Jensen provided technical assistance on reporting requirements and requested the following for a change in Administrator: -A letter from the board appointing the new Administrator -The applicant's current Administrator's Certificate -Evidence that the applicant meets the Administrator Qualifications as outlined in CCR 87405 -An updated LIC 500 -An updated LIC 308 -An LIC 501 -An updated LIC 200 LPA Jensen advised the facility has 30 days to appoint a new or an interim Administrator. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 24, 2024

Allegation investigated: Staff did not seek medical attention for residents in a timely manner Resident wandered away from the facility due to lack of care from staff

On 7/5/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a compliant investigation in to the above listed allegations. LPA Jensen met with Health and Wellness Director Teri Ford and explained the purpose of today's visit. Allegation 1: Staff did not seek medical attention for residents in a timely manner During the course of the investigation LPA Jensen reviewed the resident file for resident 1 (R1), interviewed 7 staff members and 3 residents. Based on the interviews conducted R1 experienced a change in condition around March of 2024. All staff interviews conducted and records reviewed appear to indicate that staff notified R1's medical providers and treatment was sought in a timely manner. During the course of the interviews conducted 3 of 3 residents interviewed agreed that staff seek medical attention for them in a timely manner when needed. While it was difficult to ascertain precisely when R1's change in condition presented itself there was no evidence to support that it was not addressed timely therefore the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened Unsubstantiated the preponderance of evidence does not prove it. Allegation 2: Resident wandered away from the facility due to lack of care from staff LPA Jensen interviewed 6 staff members during the course of this investigation. None of the 6 staff members recall an incident wherein a resident wandered off without staff knowledge during the year 2024. LPA Jensen contacted law enforcement and no report for a missing person was found. It is difficult to ascertain whether there could have been a missing person instance that was resolved. Based on the interviews conducted and a lack of documentation with law enforcement of a missing person the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report, a confidential names list and appeal rights were given.the state’s words, verbatim · CDSS document, Jul 5, 2024 · control 27-AS-20240408103523

Type of visit: Case Management - Other

On 7/5/24 Licensing Program Analyst (LPA) Maja Jensen arrived unannounced at facility to conduct a complaint investigation. LPA Jensen met with Health and Wellness Director Teri Ford and explained the purpose of the visit. During the course of the investigation LPA Jensen reviewed the file for resident 1 (R1). There were 2 LIC 602's in file both from February of 2023. LPA Jensen interviewed the Health and Wellness Director who stated that R1 has been determined to have a systemic health condition that has resulted in a recurring skin condition. Both LIC 602's state the resident has no history of skin conditions. Technical assistance is being provided to ensure that residents receive an updated physician's report at least every 12 months or whenever a change in condition is identified. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 5, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jason Lund arrived at the facility unannounced to conduct a case management visit. LPA Lund met with Executive Director Cindy Lichtenhan and explained reason for the visit. On 6/6/2024 LPA Lund observed seven (7) residents on hospice, none of the residents were bedridden at this time. The facility a clearance for five (5) bedridden residents and currently has no bedridden residents. No deficiencies were observed during this visit. An exit interview was conducted, and a copy of report left.the state’s words, verbatim · CDSS document, Jun 6, 2024

Allegation investigated: Staff do not meet resident's needs

On 4/12/24 at approximately 3:15 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open an investigation in to the above listed allegations. LPA Jensen met with Executive Director Cindy Lichtenhahn and explained the purpose of today's visit. LPA Jensen requested and received a staff roster with contact information and signal system activation logs for April 5th through April 12th. LPA Jensen also toured the memory care unit. In the memory care unit 3 rooms were inspected and interviews were conducted with 3 residents. LPA Jensen observed soiled under garments and soiled briefs on a bathroom vanity counter in 1 room. LPA Jensen observed soiled undergarments in the shower of a second bathroom. LPA Jensen reviewed the call signal activation logs which show that in a course of a week it took 20 minutes or more to respond when a resident activated their call signal 60 times. Substantiated LPA Jensen observed a resident with wounds in the memory care unit. LPA Jensen interviewed Staff 1 (S1) and asked what stage resident 1's (R1's) wounds are. S1 advised that R1's home health nurse stated the wounds are unstageable. During the course of an interview with R1, LPA Jensen asked if he was in pain and R1 confirmed he was. LPA Jensen asked if he would like pain medication and he confirmed he would. LPA Jensen reviewed the MAR for R1 and observed that he had a PRN for pain medication that was last administered on 4/4/24 and documented as being "somewhat effective". S1 also confirmed that R1's physician was not contacted to seek more effective pain medication. Technical assistance was provided on Prohibited Health Conditions. The Executive Director agreed that on this day R1 will be sent out for medical attention as he requires a higher level of care for wounds. Based on the LPA Jensen's observation of a resident with a prohibited health condition, soiled undergarments and briefs in resident rooms, call signal logs and a lack of follow up regarding a PRN medication that did not achieve the desired outcome in effectiveness, the allegation of "Staff do not meet resident's needs" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Citations are being issued pursuant to the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report, appeal rights and a confidential names list was provided.the state’s words, verbatim · CDSS document, Apr 12, 2024 · control 27-AS-20240408103523

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87564(f)(1) · Plan of correction due date: Apr 13, 2024

Basic Services Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interviews conducted with staff, residents and LPA Jensen's observation of unsanitary conditions in a resident room, R1 was not receiving the care needed. This poses an immediate risk to the health, safety and personal rights or residents in care. bthe state’s words, verbatim · CDSS document, Apr 12, 2024

Plan of correction: The Executive Director has agreed to seek a higher level of care for R1 as of this day. The facility is also setting up the call signal system to notify the Wellness Director and Executive Director when signals are not responded to promptly starting 4/15/24.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 1/25/24 at approximately 3:15pm Licensing Program Analyst (LPA) Maja Jensen arrived at the facility unannounced to conduct a case management. LPA Jensen met Executive Wellness Director Teri Ford and explained the purpose of today's visit. On 1/5/24 Teri Ford emailed an inquiry to LPA Jensen regarding acceptance of resident with a potentially restricted/prohibited condition who was returning from a skilled nursing facility with a higher level of care needed. LPA Jensen provided technical assistance in the areas of restricted health conditions, prohibited health conditions and indwelling urinary catheters. No deficiencies were cited as a result of this visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 25, 2024

Allegation investigated: Staff are not addressing a scabies outbreak

On 12/29/23 at approximately 10:30am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unanounced to continue a complaint onvestigation in to the above listed allegation. LPA Jensen met with the Executive Director Cindy Lichtenhan and Nurisng Director Teri Ford. During the course of the investigation LPA Jensen conducted interviews with 4 staff members. 2 of the 4 staff members were directly responsible for resident care and 2 staff mebers were responsible for providing ancillary services. 3 of 4 staff members stated they were not informed of potential scabies exposure amongst the residents or staff in the facility. LPA Jensen reviewed records that included "Move In & Routine Skin Assessment" for 4 residents and "Post Skin Concern Investigation/Assessments" for 12 residents. The Post Skin Concern Assessments were dated from 10/17/23 through 10/26/23. Unsubstantiated LPA Jensen reviewed the Electronic Medical Records online with LVN Teri Ford and observed that residents were being treated for potential exposure to scabies in October of 2023 in a designated unit of the facility which corresponds to Post Skin Assessment records. LPA Jensen also reviewed Physician Communication forms for 16 residents requesting an order for scabicides as a precautionary measure. In-service training documents show that Management conducted a training on Scabies Prevention and Control on October 20, 2023. Based on the interviews conducted and the records reviewed, the allegation of Staff are not addressing a scabies outbreak is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report, appeal rights and confidential names list was provided.the state’s words, verbatim · CDSS document, Dec 29, 2023 · control 27-AS-20231020101853

Type of visit: Case Management - Annual Continuation

On 11/30/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a required 1 year annual inspection. LPA Jensen met with Health and Wellness Director Teri Ford and explained the purpose of today's visit. Grounds The grounds were observed to be maintained and all paths were free of obstruction. The facility maintains adequate outdoor furniture. There are shaded areas for the clients to enjoy outdoor activities. The facility maintains outdoor water fountains that have determined to be in compliance. Physical Plant The physical plant was observed to be sanitary and free of odor. The facility temperature was 77 degrees for the comfort of the residents which falls between the required regulatory range of 68-85 degrees Fahrenheit. The fire extinguisher was last serviced in August of 2023 and is in compliance. The smoke detectors and carbon monoxide detectors were observed to be in good working order. The disaster plan was reviewed and is in compliance. The facility furniture and equipment were determined to be in good repair. The common area bathrooms were observed to have open top waste disposal cans. Technical assistance was provided. LPA Jensen toured 6 resident rooms. LPA Jensen observed numerous of bottles of prescription medications, PRN medications and cleaning chemicals such as bleach stored with food throughout the living area for resident 2 (R2). LPA Jensen reviewed the physician's report for R2 and confirmed that R2 is responsible for their own medication administration however the facility is taking no precautions in order to secure the medications and toxins from other residents with restrictions that can freely enter the room. Technical assistance was provided. LPA Jensen tested the water temperature in resident rooms and observed the temperature to range between 106 and 108 degrees Fahrenheit which falls within the required regulatory range of 105-120 degrees Fahrenheit. The facility maintains an adequate supply of linens. The resident units are adequately furnished with beds, night stands, dresser and lamps. Physical Plant LPA Jensen observed the elevators to be in good working order. The facility maintains an evacuation chair at the stair well. All required postings were observed in the correct format and size. LPA Jensen observed a variety of activities available for client engagement including but not limited a full exercise gym, poker tables, shuffle board tables. LPA Jensen toured the kitchen and the dining area. LPA Jensen observed the refrigerator and freezer temperatures to be in compliance. The Ansul system was last served in August of 2023 and is in compliance. There was a 7 day supply of non-perishable food and 2 day supply of perishable food available. LPA Jensen observed lunch service. The facility menu stated that lunch service would consist of a choice between white wine and mushroom chicken or hamburger steak and onions, salad, cheesy mashed potatoes, baked roll, green beans and blonde brownies with nuts. The facility did not have potatoes on hand and made an impromptu substitution with mashed sweet potatoes. Technical assistance was provided. Medication LPA Jensen inspected the medication room in the memory care unit and interviewed a medication technician, staff 1 (S1) and the Resident Care Director, staff 2 (S2). LPA Jensen reviewed medication for resident 3 (R3) and resident 4 (R4). 2 of 2 residents had a medication count under the amount reflected on the Medication Administration Record (MAR). LPA Jensen interviewed S1 and S2 regarding the discrepancy. S1 indicated the facility received the wrong amount of medication from the pharmacy and S2 was unable to explain the discrepancy. The Health and Wellness Director was notified of the discrepancy and she was able to show LPA Jensen that according to the Centrally Stored Medication and Destruction Record (CSMDR) the 2 residents were admitted to the facility with partial prescriptions and all medication was accounted for. In addition, the facility utilizes an electronic Medication Administration Record (MAR). Technical assistance was provided. File Reviews On 11/21/23, LPA Pascua reviewed 7 staff files. 7 of 7 staff files were either missing first aid certifications or the certification was expired. LPA Pascua reviewed 12 resident files, 7 from memory care and 5 from assisted living. 11 of 12 resident files had service need assessments that were either missing or incomplete due to missing signatures. 2 of 12 resident files did not have current Physician Reports. 4 of 11 files did not have a completed property inventory list. LPA Jensen conducted interviews with 3 staff members and 3 residents. Residents interviewed expressed satisfaction with quality of care. Staff interviews revealed opportunity for training enhancement. LPA Jensen requested current copies of: The infection control plan LIC 500 LIC 308 Liability Insurance The documents will be emailed by 12/6/23 Deficiencies are being cited pursuant to the California Code of Regulations (CCR) and/or Health and Safety Code (HSC). Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report, appeal rights and a confidential names list was provided.the state’s words, verbatim · CDSS document, Nov 30, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(c)(1) · Plan of correction due date: Dec 1, 2023

Personnel Requirements - General Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met based on: LPA Pascua's review of 7 staff files, 7 of 7 files were missing first aid certificates or had expired first aid certificates. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Nov 30, 2023

Plan of correction: The Director agrees to send an attestation to maja.jensen@dss.ca.gov that all staff will be enrolled in and complete first aid training by 01/15/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87506(a) · Plan of correction due date: Dec 1, 2023

Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident...This requirement was not met as evidenced by: Based on LPA Pascua's resident record review 11 out of 12 resident records were incomplete to a varying degree-please refer to LIC 809C for specifics. This poses an immediate risk to the health, safety and personal rights of reisdents in care.the state’s words, verbatim · CDSS document, Nov 30, 2023

Plan of correction: The Director agrees to send an attestation to maja.jensen@dss.ca.gov that all resident records will be updated and complete by 01/15/24

Type of visit: Required - 1 Year

On 11/21/23 at approximately 10am Licensing Program Analysts (LPAs) Maja Jensen and Arielle Pascua arrived at facility unannounced to conduct a required 1 year annual. LPAs Jensen and Pascua met with Executive Director Cindy Lichtenhan and explained the purpose of today's visit. During the course of the visit LPA's Jensen and Pascua toured the interior of the facility including common areas, bathrooms, kitchen and 6 resident rooms. LPAs reviewed 10 resident files and 7 staff files. 2 staff members and 2 residents were interviewed. A random audit of the medication room was conducted. The inspection tool was used during this visit. Due to time constraints this required 1 year annual will be continued at a later date. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 21, 2023

Allegation investigated: Licensee does not ensure staff properly respond to call button system for residents

On 10/26/23 at approximately 3pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to deliver findings related to a compliant investigation for the above listed allegations. LPA Jensen met with Health and Wellness Director, Teri Ford, and explained the purpose of todays visit. During the course of the investigation LPA Jensen conducted in person interviews with 3 residents. 3 of 3 residents indicated there have been occasions when staff are too busy to respond in a timely manner. LPA Jensen also reviewed the Signal System Response Time Report for the period of September 22, 2023 through October 2, 2023. According to the report provided to the Department, the signal system was activated 797 times during the selected period. The response times were as follows: Response time between 0-10 minutes - 449 activations (56%) Response time between 11-29 minutes - 262 activations (33%) Response time between 30-56 minutes - 86 activations (11%) Substantiated Facility staff required longer than 10 minutes to respond to the signal system 44% of the time it was activated. Based on the interviews conducted and the signal system response time report, the allegation of Licensee does not ensure staff properly respond to call button system for residents is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report, an LIC 811 and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 26, 2023 · control 27-AS-20231002135058

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 9, 2023

Personnel Requirements Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....This requirement was not met as evidenced by: Based on interviews conducted and the signal system response time report, staff took more than ten minutes to respond to the signal system 44% of the time during the course of a randomly selected 10 day period. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2023

Plan of correction: The Health and Wellness Director agrees to conduct an in-service training and weekly audits for one month. Proof of completion of the plan of correction will be emailed to maja.jensen@dss.ca.gov by the due date.