Belmont Village San Jose

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced case management visit. LPA met with Director of Resident Care Services/Administrator Gilda Deocares. The purpose of today's visit is follow up on a recent facility fire clearance inspection. On August 8th, 2026, the Department requested a new fire clearance inspection for the facility for the conversion of three rooms on the 3rd floor in Memory Care, with each room accommodating two residents. On August 26th, 2026 the Department received the approved fire clearance dated 8/19/2026, to include the approval of three rooms on the 3rd floor in Memory Care to accommodate two residents. During today's visit, LPA toured the three converted resident rooms. There is no change to the facility approved capacity or ambulatory/non-ambulatory/bedridden status. No deficiencies cited during today's visit per California Code of Regulations, Title 22. This report was reviewed with Resident Care Services/Administrator Gilda Deocares. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 31, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit and met with Executive Director (ED) Rachel Brown. The facility is a 7 stories building. LPA toured with ED at the 7th floor. 7th floor is assisted living unit. LPA toured the 2 terrace garden, activity room, mailbox room, laundry room. Chemical room was observed locked. Evacuation chairs were observed a 2 stairs. 2 elevators were observed functional. 6th floor is assisted living unit. LPA toured the activity room, art studio, common restrooms and resident rooms. 5th floor is assisted living unit. LPA toured the screen room, salon room and resident rooms. 4th floor is assisted living unit. LPA toured the AL Med room, fitness room and resident rooms. 3rd floor is the memory care unit. LPA toured the laundry room, dining room, and resident rooms. LPA tested 2 delayed opening exit doors and they were functional. Med Carts were observed locked. 2nd floor is assisted living unit. LPA toured the activity rooms, common restroom and resident rooms. LPA toured the 1st floor memory care unit. LPA toured the resident rooms. LPA tested the 4 delayed opening exit doors and they were functional. LPA tested the 2 delayed opening exit gates of the court yard and they were functional. Continue on *09-C. page 1 of 2. LPA toured the lobby and reception area. Facility license, personal right posters and ADM certificate were observed in the facility. Room temperature was observed at 75 degree F. LPA toured the kitchen. Hot water was measured at 112 degree F in resident room. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Carbon monoxide detectors were tested and they were working. The temperature of the freezer was measured at 0 degree F, and the temperature of the refrigerator was measured at 37 degree F. 2 days perishable food supplies and 7 days nonperishable food supplies were observed sufficient. Fire extinguisher was serviced on 2/18/2026. The last time the facility conducted the emergency drill was on 5/26/2026. ED provided the fire alarm system inspection report dated 1/22/2026. LPA review 5 resident files and 5 staff files. No citation noted today. Exit interview was conducted with ED. The report was provided to ED for review and for signature.the state’s words, verbatim · CDSS document, Jun 22, 2026

Allegation investigated: Staff hit resident

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Rachel Brown. On September 3, 2025 the Department received a complaint alleging Staff hit resident. It has been alleged staff S1 hit resident R1. On September 9, 2025, LPA Monter conducted the initial complaint investigation visit. LPA attempted to interview resident R1. R1 stated he/she declined to be interviewed. Page 1 Out of 4. Unsubstantiated LPA interviewed staff S2-S4. S2 stated on September 1, 2025, he/she was preparing breakfast in the kitchen area of the dining room. S2 stated he/she noticed that they needed another meal made because one was missing and he/she asked S1 to contact the kitchen. S2 stated R1 was sitting on a wheel chair close to the telephone, S1 moved R1. S2 stated he/she observed R1 elbow staff S1 and saw R1 roll his/her wheel chair back hitting against S1. S2 stated as he/she saw this, he/she saw S1 then hit R1's right forearm with his/her right hand. S2 stated it was kind of like a reaction. S2 stated he/she asked S1 why he/she did that and S1 apologized. LPA requested S2 re-enact the hit on LPA's arm. S2's re-enactment was a slap, open handed, swinging the forearm downwards. S2 stated it made a slapping sound. S2 stated it wasn't a full swing. Staff S3 stated the day of the event, he/she was in his/her office. S3 stated S1 arrived to his/her office. S3 stated staff S1 said, he/she did hit R1. S1 said he/she tried to make a call and R1 hit S1. S1 stated he/she tried to get R1 to stop, and he/she reacted. Staff S4 stated he/she did work on September 1, 2025, but doesn’t remember where he/she was when the incident occurred. S4 stated he/she didn’t see the incident take place. On September 1, 2025, local law enforcement (LLE) interviewed resident R1, who did not recall the incident and had no complaint of pain. LLE did not observe any visible injury on R1. LLE interviewed staff S3. S3 stated at approximately 12:30pm, S1 was using the phone in the dinning hall when R1 came up to S1 and hit S1 repeatedly. S1 hit R1 back with an open hand one time causing R1 to stop. S1 reported the incident to S3. Page 2 Out of 4. On October 31, 2025, LPA Manuel Monter interviewed Staff S1. S1 stated the day in question, he/she was working in the memory care unit. S1 stated it was around lunch time. S1 stated there was a meal missing for a resident. S1 stated he/she needed to make a call to the kitchen to get that additional meal. S1 stated the phone is dining room next to dinning room table, directly across from the entrance doorway. S1 stated as he/she was reaching for the phone, R1 tried to hit him/her. S1 stated as he/she was being stuck, he/she redirected R1’s hand. S1 stated he/she had not been hit by R1 before and was shocked. S1 stated he/she didn’t hit R1, and he/she only put R1’s hand down. S1 stated he/she thinks, he/she may have accidentally scared R1 when he/she reached for the phone. S1 stated he/she doesn’t remember which hand he/she put down. S1 stated after putting R1’s hand down, staff S2 told him/her not to hit R1. S1 stated he/she then walked away. S1 stated he/she told the staff S3, that he/she had hit R1. S1 stated he/she had used the wrong term when she told S3 that he/she hit R1. S1 reiterated that he/she didn’t hit R1 and only placed R1’s hand down. On November 20, 2025, LPA Manuel Monter interviewed staff S2-S9. 8 Out of 8 Staff (S2-S9) interviewed stated prior to the event that occurred between R1 and S1 on September 1, 2025, S1 was a kind person who has not had any issues with families, other staff or residents. Staff S3-S5 & S7-S9 stated they were working at the facility on September 1, 2025, but did not witness the incident between R1 and S1. Staff S6 stated he/she was not in the facility when the alleged incident occurred and did not witness the event. LPA Manuel Monter interviewed ADM. ADM stated that Staff S1 is a mild mannered person. ADM stated S1 prior to the event in question, S1 has not had any issues with families, other staff or residents. On December 1, 2025, LPA Manuel Monter interviewed Staff S10-S12. Staff S10-S12 stated they were working at the facility when the alleged incident occurred on September 1, 2025. Staff S10 and S11 stated they were not in the dinning area and did not observe the event. 3 Out of 3 staff (S10-S12) stated S1 has not had any issues with staff, residents or families. Page 3 Out of 4. Staff S12 stated he/she was in the dinning room, located close to the entrance, when the alleged incident occurred. S12 stated he/she was serving food, he/she heard R1 was hitting S1. S12 stated he/she heard staff S1 say, “don’t hit me, don’t hit me.” S12 stated when he/she heard this, he/she turned around to see what was happening. S12 stated as he/she turned, he/she saw S1 moving R1’s wheel chair back. S12 stated he/she didn’t’ see anything else. S12 stated S2 went and asked what had happened. S12 stated S1, had said, R1 was hitting him/her. S12 stated, S2 responded that he/she would need to report it. S12 stated he/she did not observe staff S1 hit or touch R1. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. Page 4 Out of 4. END OF REPORT.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 26-AS-20250903112859

Allegation investigated: Facility staff had inappropriate behavior with a resident

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding for the above allegation. LPA met with Executive Director, Rachel Brown. On 03/11/2025, the Department received the complaint. On 03/12/2025, the initial complaint investigation was conducted. Documents were obtained to include 5 residents physician's report, service plan, progress notes from February - March 2025, resident roster, staff schedule, and police report. It was alleged that a staff had inappropriate behavior with a resident (R1). Another resident (R2) was the first person to have reported the information to the staff. R2 reported that a staff was having inappropriate behavior with R1. R2 could not provide a name of the staff who had inappropriate behavior with R1 but provided a description of the staff. R2 states that the inappropriate behavior was consensual per R1. Page 1 of 2. Unsubstantiated Based on review of the police report, the report was written for information purposes. It’s indicated that R1 stated to have been kissing a staff member, but the kissing was consensual. R1 did not remember the staff member’s name. The facility’s Executive Director advised that R1 suffers from a neurocognitive disorder but can still make decisions for him/herself. Based on the description that was provided of the staff member, it did not match any of the facility staff members on site. R1 was interviewed. Based on interview, R1 made inconsistent statements to the Department, local police officers and facility staff regarding the alleged incident that was reported by R2. The review of records shows that R1 has a diagnosis of a neurocognitive disorder and history of forgetfulness. Facility staff were interviewed. Based on interview, there were no facility staff who fit the description that was provided by R2. 7 out of 7 staff members interviewed denied the observation of any staff conducting inappropriate behavior with any resident, including R1. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the allegation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Rachel Brown and a copy of the report was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 26-AS-20250311090818

Allegation investigated: Staff inappropriately restrained a resident while in care

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to deliver the finding for the above allegation. LPA met with Executive Director, Rachel Brown. On 03/24/2025, the Department received the complaint. On 04/03/2025, the initial complaint investigation was conducted. The following documents were obtained to include a resident’s physician’s report, service plan, progress notes, resident roster and police report. It was alleged that on 10/27/2024 a staff member (S1) held the wrist down of a resident (R1) for about 15 seconds in order to “check his/her strength”. It was reported that R1 attempted to get his/her wrist away from S1 but was unable to do so. The incident was observed by a staff (S2) who stopped the incident. R1 did not sustain any injuries and did not recall the event due to his/her diagnosis of a neurological condition. Page 1 of 3. Substantiated On 11/06/2024, the Department conducted a case management visit to follow-up on this incident after receiving a self-reported SOC-341 from the facility. See case management on 11/06/2024. During this visit, R1 was interviewed and was unable to recall the incident occurring. R1’s family member was informed of the incident. The Executive Director (ED) stated that based on their internal investigation, S1 stated that he/she does this with R1 in a joking way where sometimes S1 would test R1’s strength. At the time of the interaction, R1 was not participating in the joke and seemed startled. S1 was terminated following the incident for inappropriate behavior with the resident. The local police department was notified and responded to the incident on 10/27/2024. Based on record review, R1 did not sustain any injuries and did not recall the event. The police obtained information of S1 and was identified and outstanding at time of the event. On 03/24/2025, the Department received a cross-report of the same incident and generated a complaint investigation. On 04/03/2025, 4 additional staff members were interviewed for the complaint investigation. Based on staff interview, it was stated that R1 was restrained by S1 and verbally challenged to attempt to raise his/her arm as an exhibition of strength. When the Executive Director (ED) interviewed S1 following the incident, S1 stated the incident was only a playful interaction with R1. The incident was witnessed by a staff (S2) who immediately stopped the interaction. Based on interview with S2, it was stated that S1 approached R1 from behind and held R1’s wrist on the side of his/her chair restricting R1’s movement. S2 stated that R1 had a distress look on his/her face during the interaction. S2 stated to have immediately called out S1’s name who immediately released R1’s wrist and reported to S2. S2 reminded S1 to not interact with the residents in that manner and to be careful of his/her action. The observation was then reported to management. The Department has investigated the above allegation. Based on interview and record review the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Rachel Brown and a copy of the report and appeal rights were provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 26-AS-20250324143221

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jul 23, 2025

(a) Residents in all residential care facilities for the elderly shall have all of 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 interview and record review, the licensee did not ensure that resident (R1) was accorded dignity in his/her relationship with S1, as S1 was observed to restrain R1’s wrist down which poses an immediate health, safety, and personal rights risk to person in care.the state’s words, verbatim · CDSS document, Jul 22, 2025

Plan of correction: Licensee immediately conducted an internal investigation after being notified of the incident and terminated S1. Licensee completes annual and in-service training on personal rights. Copies of the training records was provided to LPA Kabariti. Deficiency was cleared during visit.

Type of visit: Required - 1 Year

On 6/25/2025, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator, Rachel Brown. LPA explained the purpose of the visit. LPA toured the facility including a random sample of resident rooms, common areas, activity rooms and kitchen area. LPA observed some residents were at different activity rooms. While touring the facility it was observed that the temperature was at 74 deg F. Hot water was also tested in the resident rooms and the temperature was at 110 deg F. All personal belongings are intact inside residents rooms. Facility has sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. Resident call buttons were checked and functioning. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are done every month. Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA received the following documents, LIC610D and copy of Administrator Certificate. No deficiencies are cited at this time. Report is reviewed and a copy is provided.the state’s words, verbatim · CDSS document, Jun 25, 2025

Type of visit: Case Management - Incident

On April 16, 2025, Licensing Program Analyst Manuel Monter conducted a case Management Incident visit regarding an incident report the Department received, stating there was a water leak at the facility. On April 15, 2025, the Department received an incident report that stated, " On 04/13/25 around 10:59 AM, a leak was observed in the elevators. Staff alerted ... Executive Director, Rachel Brown. Elevators stopped on the nearest floor and opened, and were shut down. A plumber, elevator technician, and two water removal/remediation crews were brought on site. The source of the leak was found to be a water holding tank for the boiler, located on the roof. Water flooded into laundry rooms on floors 2-7 and traveled from laundry rooms into elevator doors and 11 resident apartments total, across floors 2-7. Water also impacted the 1st Floor lobby.... Executive Director, who called vendors for urgent assistance. LVN on Duty turned off main water. Vendors stopped flooding, removed water, and worked on drying wet surfaces. Elevator tech assessed elevator operations. Executive Director informed all responsible parties via email and called responsible parties of impacted apartments. Staff transported residents who were in programs back to their apartments via stairs, as directed by LVN on Duty. After removing water, remedial on crews placed fans & dehumidifiers in affected common areas and apartments on 4/13125,Remediation crews will check progress daily until areas are dry" Page 1 Out of 2. On April 16, 2025, Licensing Program Analyst Manuel Monter toured the facility 1-7 floors. LPA observed the areas that were affected by the water leak, which was areas directly next to the laundry rooms on floors 2-7. This water that leaked, traveled from laundry rooms into elevator doors and 11 resident apartments total, across floors 2-7. During the tour, LPA observed fans and dehumidifiers in each floor, and noted there was no smell or current sign of wetness during the tour. LPA interviewed facility Administrator. ADM stated 3 residents who were residing near the area, where the water leaked, moved to different apartments. ADM stated she has been talking to the residents to ensure they are doing well. ADM stated no resident was physically impacted by the water leak. ADM stated the Fans and dehumidifiers will continue to run until the moisture is gone, but stated vendors estimate the completion date by Friday. ADM also stated the water leak effected the elevators control panels. ADM stated the elevators still work, but need to operate manually. ADM stated the control panels for the elevator have been ordered and should arrive at the facility by Saturday, and installed by this Sunday. ADM stated the facility is assisting residents go down the to first floor by; the facility will manually operate the elevator, via the key and will escort residents down. ADM stated because the panels on the elevator are not functioning, they need to use a key to manually operate it. ADM stated her plan of action to address the leak and wet areas is the facility will be evaluating the tank. ADM stated they will assess the tank to see if they can reinforce the tank, as a temporary measure to ensure a leak does not re occur in the short term. ADM stated the facility is planing on replacing both hot water tanks. ADM stated her plan of action to ensure the health and safety of residents in care, is to continue to deliver meals. ADM stated once the elevator panel is fixed sometime this weekend, dinning can open for residents in the weekend. ADM stated she is staying in contact with the residents, asking how they are doing and family's to keep them updated on the ongoing process. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Rachel Brown and a copy of the report was provided. Page 2 Out of 2.the state’s words, verbatim · CDSS document, Apr 16, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. LPA met with Executive Director, Rachel Brown. The purpose of the visit is to follow-up on an incident report the Department received regarding a resident (R1) who exited the memory care unit through a delayed egress door and was found at the facility’s driveway. Based on the incident report, it was stated that a visitor observed the resident on the driveway and informed the concierge through the driveway intercom a minute after the resident had exited. The visitor immediately escorted the resident back to memory care. No injuries were noted, and resident’s condition was at baseline. Based on interview with the ED, it was stated that because R1 was attempting to exit seek throughout the day, the staff was turning the delayed egress door alarm on/off throughout the day. After R1's previous attempt to exit seek, the staff mistakenly did not reset the delayed egress door alarm resulting in R1 being able to exit seek without staff's knowledge. LPA observed that R1's bedroom is located near the exit door. ED states that R1 was not able to get past the gate alone as R1 was found by a visitor who was entering into the community, who then escorted R1 back to memory care. After the incident, resident was placed on monitoring for 72 hours, facility staff reached out to R1's doctor regarding possible medication changes, informed R1's authorized representative, and updated R1's care plan. All staff was retrained on elopement prevention, including management of wandering behavior and delayed egress doors. The facility also has on-going elopement drills. Page 1 of 2. The facility plans to change their delayed egress door alarm from a key to a number pad to help prevent the same incident going forward. During visit, LPA obtained R1's physician's report, service plans, progress notes, and staff training records. Based on record review, the facility completed an updated service plan dated 03/07/25 which includes interventions in place for R1's exit seeking to include accompanying R1 to activities and meals, and notifying the nurse when R1 exit seeks. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Rachel Brown and a copy of the report was provided. Page 2 of 2.the state’s words, verbatim · CDSS document, Mar 12, 2025

Allegation investigated: - Facility is not kept clean - Dishes to serve residents food are dirty

On 02/05/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver the findings regarding the received allegations. LPA met with executive director Rachel Brown and explained the purpose of today's visit. During the course of the investigation interviews were conducted, observations were made, and documents were received. Based on the information provided there are dishwashers present at the facility and substantial food supply observed. Per interviews any dishes that do not meet standards are usually replaced with new or cleaner dishes. Some cutlery and mugs were observed to have staining but this was not apparent on all mugs, cups, dishes, and cutlery. These allegations are unsubstantiated based on the totality of observations made and investigation conducted. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with Rachel Brown and a copy is provided on this day. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 5, 2025 · control 26-AS-20230313164543

Allegation investigated: - Facility does not respond to emergency pull cord signals in a timely manner. - Facility not providing medications to resident when requested - Facility is not providing contracted services - Facility is not changing resident's urine bag

On 02/05/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver the findings regarding the recieved allegations. LPA met with executive director Rachel Brown and explained the purpose of today's visit. During the course of the investigation interviews were conducted, observations were made, and documents were received. Call logs show a pattern of responsiveness that were best met by time and staff on hand to be resonable depending on the service needed. Medication records observed and interviews show that all prescribed medications were given as prescribed and directed, this would include the changing of the resident's urine bag. When alerted staff would respond based on the demand of staffing and business of the facility. Staff are not informed of the type of service needed when called upon but do respond based on the records reviewed. The resident did not have one on one caregiving. All services were met by the facility to the best of their abilities at the time. These allegations are unsubstantiated based on the totality of observations made and investigation conducted. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with Rachel Brown and a copy is provided on this day. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 5, 2025 · control 26-AS-20240304153845

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Christine Dolores and Santino Fortes arrived unannounced to conduct a case management – incident visit. LPA met with Executive Director, Rachel Brown. The purpose of the visit is to follow-up with a SOC341 the Department received on 10/28/2024, based on an incident that occurred with resident (R1) and 10/27/2024. On 10/27/2024, it was reported that during breakfast a staff (S2) exited the dining room area and observation an interaction with S1 and R1. It was observed that S1 approached R1 from behind and grabbed R1's arms by the wrist for approximately 15 seconds. R1 was observed struggling against S1. S2 called S1 over and the interaction ended. R1 was assessed and R1 did not show any signs of injury to include bruising around the area. R1 was unable to recall the incident. During visit, LPAs interviewed the ED and R1. Based on interview with the ED, S1 was terminated following the incident. R1's family members were informed of the incident and police was notified the following day. Based on interview with R1, R1 states all the staff treats the resident nicely and denied a staff hurting the resident. Documents were obtained to include the staff schedule for 11/06/2024 and 10/27/2024, R1's physician's report and service plan, S1's job application, annual confirmation statement, training and the police report number. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Rachel Brown and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 6, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Executive Director, Rachel Brown. The purpose of the visit is to deliver an immediate exclusion letter for staff (S1). LPA explained the purpose of the letter. ED confirmed S1 is not an employee of the facility. The immediate exclusion letter was handed to ED. No deficiencies were cited today per California Code of Regulations, Title 22. This report was reviewed with Executive Director Rachel Brown and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 27, 2024

Type of visit: Required - 1 Year

On 6/26/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator, Rachel Brown. LPA explained the purpose of the visit. LPA & LPM toured the facility inside and a random sample of resident rooms, common areas, and kitchen area. LPA observed some residents were at different activity rooms. While touring the facility it was observed that the temperature was at 74 deg F. Hot water was also tested in the resident rooms and the temperature was at 112 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Facility has sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. Resident call buttons were checked and functioning except for one random room that was checked. It was fixed right away. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are done every month. Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Facility accepts hospice residents and are in compliance with the required waiver requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA interviewed four residents and four staff. LPA received the following documents, Certificate of Liability Insurance & LIC500. No deficiencies are cited at this time. Report is reviewed and a copy is provided.the state’s words, verbatim · CDSS document, Jun 26, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA met with Executive Director (ED) Rachel Brown. On 05/30/2024, the Department was notified of a serious incident that occurred with resident (R1) and staff (S1). On 05/29/2024 around 9PM, the facility received an alert from their fall detection system from R1's bedroom. The review of the video showed a staff (S1) assisting R1 back to bed in a rough manner. The Executive Director was notified of the incident immediately and S1 was escorted out of the building. Staff was immediately suspended and did not return to work after the incident. After the incident, staff assessed R1 and observed redness on R1's left cheek and scratches on the forehead. Emergency services were not contacted as R1 did not complain of any unusual pain. The facility notified R1's family, Ombudsman, and local law enforcement. On 05/30/2024, in-service training was conducted with staff to include the topics of elder abuse, mandated reporting, and R1's care plan. During visit, LPA interviewed 2 staff members and R1. LPA reviewed the video with ED and recorded part of the video using LPA's state issued cellular device. LPA requested the video footage from the facility's fall detection system to be sent via email. Documents were obtained to include the law enforcement case number, in-service training records, and S1's personnel file. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Rachel Brown and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 31, 2024

Allegation investigated: Resident's hygiene needs not being met. Medications not given to resident according to physician's instructions. Lack of supervision resulting in resident wandering from the facility. Facility is charging for services not provided.

Licensing Program Analyst (LPA) Steve Chang conducted a complaint investigation visit to deliver investigation findings and met with Memory Program Coordinator (MPC) Allyson Fuji. On 08/16/2021, the Department received a complaint of the above allegations. On 8/20/2021, an initial complaint investigation visit was conducted. LPA interviewed ED and two staff (S1, S2). Residents Physician reports, medical records, Appraisal Needs and Services Plan of Residents, Admission Agreement, And the facility Activity Programs documents were obtained. . Continued on LIC9099-C. page 1 of 4 Unsubstantiated Resident's hygiene needs not being met: On 8/19/2021, the Department interviewed R1's family member (FM). FM stated R1 was not incontinent. FM stated he/she wanted R1 to wear fresh/clean undergarments daily, so he/she brought a lot of diapers in R1's bedroom, and he/she changed R1's diaper whenever he/she met R1. FM stated most of time he/she found R1 wore soiled diaper whenever he/she visited R1. FM stated he/she found caregivers did not change R1's diaper often. FM stated the resident bedroom trash bags were changed 2 or 3 times per day, why the facility was unable to change R1's diapers at least 3 times per day. FM admitted R1 did not participate in the facility changing diaper program, because R1 did not need to change diaper every two hours. On 8/20/2021, LPA interviewed Executive Director (ED). ED stated that upon admission, residents were assessed if the residents need the toilet remind or need physical hands-on changing diaper. If there was no need for the service, then the facility will not check or change the residents diapers. ED stated if the assessment shows the resident needs the service, then the resident needs to pay either $400/month fee for toilet remind service or $900/month fee for hands on diaper changing service. ED stated the facility will check resident diaper every two hours for the services. ED stated R1 was not diagnosed as incontinent and was not evaluated as toilet reminding needed or diaper changing needed. ED stated R1 did not have toilet reminding or diaper changing in R1's care plan. ED stated caregivers provide care service according to care plan, so R1 did not receive the service of diaper changing. ED stated caregivers changed R1's soiled diaper when caregivers found R1's diapers needed to be changed. ED stated residents can participate in the toilet reminding or diaper changing programs voluntarily if they pay the fee. ED stated the facility communicated with R1's family member to have R1 participate in the changing diaper program, but R1's family disagreed to pay $900 per month. ED stated housekeepers cannot change residents' diapers. Reviewing R1's medical documents, R1 was not diagnosed incontinent and R1 was not evaluated to have toilet reminding or diaper changing service. FM found the diaper supplies he/she put in R1's bedroom decreased but did not decrease as much as expected that means caregivers changed diapers for R1 but not as often as needed. FM did not pay the monthly fee for the changing diaper program. The facility suggested R1 to participate in the changing diaper program, but FM disagreed. Continue on LIC9099-C. Page 2 of 4 Medications not given to resident according to physician's instructions: On 8/19/2021, the Department interviewed R1's family member (FM). FM stated R1 had doctor's prescription medications to be administered twice per day, but the facility administered R1's medications to R1 at 8:00AM and 4:00PM. FM stated the medications should be administered between 12 hours if the prescription specified twice per day. On 8/20/2021, LPA interviewed Director of Resident Care Service (DRS). DRS stated caregivers were not allowed to administer medications to residents; only Med Tech or Nurses can administer medications to residents. DRS stated the operation hours of the medication rooms to administer medications to residents were 6:00AM - 8:00AM and 4:00PM - 6:00PM, so the medications will be administered to residents during these time period windows except doctor prescriptions specified the time. DRS stated one of the residents had a doctor prescription specified bedtime 9:00PM, and the facility administered the medications at 9:00PM to resident. DRS stated the facility communicated with R1's family member (FM) to have the doctor to specify the exact time for the medications in the prescription, but the facility did not receive the updated prescription. Based on the interviews conducted, the facility administered the medications according to doctors' prescriptions. The facility did not receive an updated prescription from the doctor, and the facility followed the facility policy to administer medications to residents. Lack of supervision resulting in resident wandering from the facility: On 8/19/2021, the Department interviewed R1's family member (FM). FM stated on 6/13/2021, at 9:00PM, he/she received a phone call from the facility that R1 eloped from the building but was found by staff in facility campus. On 8/20/2021, LPA interviewed ED. ED stated couple months ago, R1 walked out for fresh air without wearing pendant alarm. ED stated facility staff found R1 disappeared and reported to the facility immediately. ED stated facility staff all searched around and found R1 outside the building but still in the facility campus. Staff took R1 back to building immediately and notified FM. ED stated the facility implemented an action plan to prevent the situation to occur again and sent the action plan to FM. ED stated the facility tried to communicate with FM to discuss how the facility should improve to help residents, but the facility did not receive any response from FM. Continue on LIC9099-C. Page 3 of 4. Based on the interviews conducted, R1 eloped from the facility building without wearing Pendant alarm ring that was the reason why the pendant alarm did not sound. Staff found R1 had disappeared and immediately reported to the facility. The facility immediately had facility staff to search for R1 and found R1 outside the building but still in facility campus. The facility implemented an action plan to prevent similar incidents to occur again. Facility is charging for services not provided: On 8/19/2021, the Department interviewed R1's family member (FM). FM stated he/she enrolled R1 into an activity program and paid the monthly fee. FM stated most of the time the facility activities were not provided. FM stated the facility did not refund the fee. On 8/20/2021, LPA interviewed ED. ED stated the facility provided many activity programs to residents, but due to the COVID pandemic, there were many programs that had to change the content of the activities. ED stated the facility follows the CDC and local health department guidelines to change the activity. ED stated the purpose of the changes is to keep the residents and staff healthy and safety. ED stated the facility did not refund the fee for activity because the corporate was discussing how to handle it. On the same day, LPA interviewed Memory Program Coordinator (MPC) for the program activity during pandemic. MPC stated the facility activities made some changes due to COVID pandemic, but none of residents complained about the activity of the programs. MPC stated the activity staff, and the residents all wanted the activity to continue. Based on the interviews conducted, the facility provided the activities to residents, but due to the COVID pandemic, the facility activity programs were changed to follow CDC and local health department guidelines. The Department has investigated the above allegations. Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No citations cited under California Code of Regulations Title 22. Exit interview conducted with MPC. The report was provided to MPC for signature. A copy of the report was provided to MPC. Page 4 of 4.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 26-AS-20210816084035