Belmont Village Sunnyvale

Type of visit: Case Management - Annual Continuation

To complete annual inspection of 4/6/26, LPA Jeung reviewed random staff files and random Centrally Stored Medications Records. Deficiencies of the California Code of Regulations, Title 22, are cited, based on observations made on 4/6/26 and today. See also Technical Advisory Notes--4 pages.the state’s words, verbatim · CDSS document, Apr 9, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Apr 23, 2026

POSTURAL SUPPORTS A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement is not met, as MD orders are not maintained for half bed rails for clients #1, #2, #5, #7, and residents in rooms #408, #342, #223, #203, #207, #125, #102. Licensee failed to ensure that MD orders are maintained for residents who use half bed rails, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Written MD orders for half bed rails for referenced clients shall be obtained and copies shall be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1(a)(13) · Plan of correction due date: Apr 23, 2026

PERSONAL RIGHTS Residents in all residential care facilities for the elderly shall have ... the following personal rights... To have access to individual storage space for private use. This requirement is not met, as closets and/or storage spaces of residents #12 and #13--in rooms 203 and 207 respectively--are locked and not accessible to residents as requested by clients' powers of attorney. Licensee failed to ensure that residents have access to their individual storage spaces, which poses a potential health, safety or personal rights violation.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Plan/proof of correction to be sent to CCLD BY DUE DATE, which may include exception requests with supportive documentation.

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility, which consists of 4 floors; assisted living residents reside on all floors. Memory care residents reside in 21 rooms on ground level and 20 rooms on second floor; both of these units are secured with egress alert devices and have a designated dining room. In addition, there are 7 designated rooms on fourth floor reserved for residents with severe dementia, as well as a separate dining room. Most units have wet bars with small refrigerators. All units have an emergency signal system which consists of pull cords in bathrooms and living areas, which sends an audible alert to staff on their cell phones. Operable carbon monoxide detectors are installed in each apartment. There are no accessible bodies of water or fire safety hazards observed. Emergency drills are conducted monthly and documented. Medications are stored in locked medication carts. A comfortable temperature is maintained, passageways are clear, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and there are benches installed in shower stalls. Hot water temperature tested in clients' bathrooms between 116 and 117 degrees. Fresh and non-perishable food supplies are maintained. Quarterly food and dietary audits are conducted and documented; copy of last audit by registered dietician dated 2/13/26 is provided. First-aid kit is inspected. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed Transcripts of staff training are provided today for review. Random client files are reviewed. Staff records--including training--will be reviewed at a later date. Executive director Tyler Manzo is a certified RCFE administrator (x 5/27) that oversees facility operations. The following information is provided to LPA today: • Proof of current liability insurance • Personnel Report (LIC500) • Facility Sketch • Emergency Disaster Plan (LIC610D) Deficiency of the California Code of Regulations, Title 22 is cited on following page.the state’s words, verbatim · CDSS document, Apr 6, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Apr 6, 2026

INCIDENTAL MEDICAL CARE Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met, as client #8 is not able to self store/admin medications, per MD, but Ibuprophen (2), Tylenol and Tumms are stored in bathroom. Licensee failed to ensure that medications are inaccessible to clients who cannot self store/admin meds, which poses an immediate health or safety risk to clients in care.the state’s words, verbatim · CDSS document, Apr 6, 2026

Plan of correction: Ibuprofen, Tylenol and Tumms were removed from client's bathroom in LPA's presence Deficiency corrected and cleared

Allegation investigated: -Staff mismanaged resident medication -Staff did not respond in a timely manner to resident's call for assistance -The facility call system is in disrepair

On 01/14/2026 Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced complaint inspection visit to deliver findings regarding the complaint allegations received. LPA met with administrator, Tyler Manzo, LPA explained the purpose of the visit. Regarding the allegation that staff mismanaged resident medication, the Department conducted an investigation that included a review of records, documentation, and interviews. The investigation determined that Resident R1 did not receive the prescribed morning dose of medication due to a depleted medication supply. The facility provided documentation indicating that measures were taken to address the depletion of the medication supply. The facility reported no incident in which Resident R1 was affected as a result of the depleted medication supply. continue to 9099-C Unsubstantiated Regarding the allegation that staff did not respond in a timely manner to the resident’s call for assistance, the Department conducted an investigation that included a review of records and interview. The LPA observed the Administrator and Director of Resident Services test the call buttons, bed sensor, and pull cords in different resident rooms in each floor of the facility. Caregiver staff responded to each activation within an appropriate time frame. The information obtained during the investigation was contradictory, and there was insufficient documentation and corroborating evidence to substantiate that staff failed to respond to the resident’s request for assistance in a timely manner during the investigation period. Regarding the allegation that the facility’s call system was in disrepair, the Department conducted an investigation that included a review of records and an interview with the resident R1. The LPA observed the Administrator and Director of Resident Services test the call buttons, bed sensor, and pull cords, confirming that activation generated timely alerts to staff. The information obtained during the investigation was contradictory, and there was insufficient documentation and corroborating evidence to substantiate that the call system was malfunctioning. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove whether the allegations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed and a copy of this report is provided to the administrator.the state’s words, verbatim · CDSS document, Jan 14, 2026 · control 26-AS-20251027221630

Type of visit: Case Management - Other

On 1/14/2026, Licensing Program Analysts (LPA) Yi Sam Jian arrived unannounced for the purpose of conducting a case management. The purpose of the case management is to address the corresponding complaint investigation report number 26-AS-20251027221630. LPA met with administrator, Tyler Manzo. LPA explained the purpose of the visit. Regarding the allegation that staff mismanaged resident medication, the Department conducted an investigation and determined that Resident R1 did not receive the prescribed morning dose of medication due to a depleted medication supply. Although the facility provided documentation indicating that measures were taken to address the depletion of the medication supply, the facility did not arrange, or assist in arranging, for medical care appropriate to the resident’s conditions and needs to prevent the medication from running out. This resulted in a technical violation. This report was reviewed with the administrator, and a copy was provided to the facility.the state’s words, verbatim · CDSS document, Jan 14, 2026

Allegation investigated: - Staff left resident in urine and feces for extended periods of time. - Staff are not repositioning resident resulting in worsening wounds.

Based on review of facility and home health care records and interviews with staff and witness, these allegations are determined to be unsubstantiated. Client #1 was admitted on 2/16/16 and was hospitalized on 9/14/23 for care and treatment of pressure injuries of buttocks, ankle and foot. Client was discharged from home health care on 9/7/23 because stage II pressure injuries of buttocks were responding well to wound care and healing. Stage I pressure injuries of ankle and foot were essentially closed and healed. Facility staff were provided detailed instructions for ongoing wound care by home health nurse on 9/7/23 upon home health discharge. Pressure injuries were observed and evaluated on 9/12/23 by home health nurse, necessitating resumption of home health nursing care for decubitus ulcers of ankle--stage III or IV--foot--stage I or unstageable--and buttocks--stage II. There was no evidence that the pressure wounds worsened because staff neglected to reposition client every 2 hours, nor that staff failed to change client's diapers and allow client to remain in soiled diapers for an extended period of time. Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 5, 2026 · control 26-AS-20230914081638

Allegation investigated: Resident was physically abused while in care

On 08/27/2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to deliver and discuss the findings of the Complaint allegations and investigation. Upon arrival, the LPA met with the Executive Director, Tyler Manzo, and disclosed the purpose of the visit. On 07/15/2025, the department received a complaint with one (1) allegation ‘Resident was physically abused while in care’. On 07/22/2025 and 08/22/2025, the department conducted initial investigations at the facility. Continued on LIC9099-C Unfounded On 07/23/2025 and 08/20/2025, LPA interviewed five (5) staff members (ED, S1-S4) and five (5) residents (R1-R5). ED stated that on 07/06/2025, R1 reported that a caregiver (S5) had entered their room and caused harm. R1’s family expressed concern, and S5 was suspended pending investigation. Law enforcement was contacted and interviewed R1 the same day. No injuries were observed, and accounts of the incident were inconsistent. S5 resigned the following morning. The facility completed an internal investigation, which concluded that no abuse or injuries occurred. R1’s family was satisfied with the facility’s response and requested that S5 no longer provide care to R1. S1 stated that R1 was observed to be anxious and shaken. Staff checked for injuries and none were found. S5 was suspended and later resigned. Hospice was notified and assessed R1, confirming that there were no injuries. R1 did not report the incident again, and R1’s family expressed that R1 was comfortable and that the staff were supportive. S2 stated that R1 had fragile skin and bruised easily. S2 stated that S2 used extra precautions when providing assistance to R1 and asking another staff member for help. S2 reported providing activities of daily living to R1, regularly checking for bruises, and stated that no injuries were observed after R1 reported the incident. R1’s family visited frequently and did not raise concerns. S3 stated that R1 preferred care from specific caregivers and bruised very easily, even with a light touch. S3 stated that hospice staff and caregivers regularly checked on R1 for bruises. R1 was handled carefully, and no injuries or physical abuse were observed. S4 stated that on 07/06/2025, staff reported that R1 appeared upset and faint bruises were observed on R1’s arm. The concern was reported to management, documented, and shared with R1’s family. Law enforcement was contacted and R1 was interviewed. R1 expressed not wanting to leave the facility. No further complaints were made by R1, and no prior history of rough handling was found in the S5’s file. S5 later resigned for other employment. R1 stated that R1 was satisfied with the care and services at the facility. R1 stated that a nighttime staff member had made them uncomfortable, expressing concerns about the staff member’s behavior, and was later terminated. Law enforcement was contacted in response to the concern. R1 expressed feeling comfortable with the current staff and reported no ongoing issues, and stated they were happy living at the facility. Continued on LIC9099-C R2 stated that R2 had not observed or received reports of staff being physically abusive toward residents. R2 further stated that staff were generally respectful and attentive, and that the only concerns raised by residents were related to food quality. R3 stated that R3 likes living at the facility and expressed satisfaction with the care and services provided. R3 further stated that R3 does not have any concerns about staff, describing them as calm, respectful, and helpful, and stated they had not observed or heard of any aggressive or abusive staff behavior. R4 stated that they were comfortable at the facility and stated that staff were polite, attentive, and respectful of individual preferences. R4 further stated that staff were careful when providing assistance and reported not witnessing or hearing of any physically aggressive staff behavior. R4 added that staff appeared well trained. R5 stated that the facility had a positive environment. R5 further stated that staff were gentle, attentive, and respectful, kept their room clean, and that they had not experienced or observed any aggressive behavior from the staff. On 07/22/2025, LPA obtained and reviewed SOC341 and LIC624 Incident Report, dated 07/06/2025, which showed that on 07/06/2025, the facility reported that R1 stated a caregiver had been rough while assisting them to bed and had struck R1’s arm. The concern was reported to management, and law enforcement was contacted the same day. A nurse assessed the resident and observed no injuries. The caregiver, S6, identified in the allegation, was immediately suspended pending investigation and denied that the incident occurred. On 07/22/2025, LPA obtained and reviewed the facility’s internal investigation Report, which stated that law enforcement found the R1’s statements to be inconsistent with the initial allegation. R1 later stated they had fought off attackers, but did not mention facility staff. The staff member, S6, named in the allegation, resigned shortly after the report, citing another job opportunity. Due to the inconsistent statements, absence of injuries, and the staff member’s denial of the allegation, the facility determined the claim of abuse to be unsubstantiated. On 07/22/2025, LPA obtained and reviewed R1’s Pre-Placement Appraisal, dated 09/02/2024, which stated R1 had multiple medical conditions and physical care needs. The record stated that R1 used a walker or wheelchair and required assistance with transferring, showering, dressing, toileting, and medication. Continued on LIC9099-C On 07/22/2025, LPA obtained and reviewed R1’s Physician’s Report, dated 7/14/2024, which didn’t state that R1 had Dementia. On 07/22/2025, LPA obtained and reviewed R1’s Montreal Cognitive Assessment (MOCA) record, dated 9/9/2024, with a score of 13 out of 30. On 07/22/2025, LPA obtained and reviewed R1’s Assessment and Service Plan, dated 07/07/2025, which listed R1’s multiple medical diagnoses. On 07/22/2025, LPA obtained and reviewed R1’s Hospice Notification Record, dated 04/08/2025, stating that hospice services for R1 had been initiated and were being provided by an outside hospice agency. On 08/20/2025, LPA obtained and reviewed a report for a Police complaint. The Law enforcement conducted an investigation following the allegation. The officer reported observing no visible injuries on R1 and found no signs of physical abuse. The case was later closed as inactive by the investigating agency. On 08/21/2025, during the facility visit, LPA observed R1 in the dining hall eating lunch. No visible bruises or injuries were observed on R1. R1 appeared cheerful and was interacting with other residents at the table. Based on observations, interviews, and records reviewed, there was insufficient evidence to support the allegation that a resident was physically abused while in care. 5 out of 5 staff members stated that no injuries were observed on R1 and 5 out of 5 residents stated that no abusive behavior by staff had been witnessed. Law enforcement conducted an investigation, observed no visible injuries, and later closed the case as inactive. The facility immediately suspended the staff member involved and completed an internal investigation, which concluded that the R1’s statements were inconsistent with the allegation and no abuse occurred. Hospice staff and caregivers regularly assessed R1, and no injuries were reported. R1 was observed to be cheerful, with no visible signs of abuse, and expressed satisfaction with care. Given the absence of injuries and corroborating interviews confirming no abuse occurred, the department has determined that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, the allegation is UNFOUNDED. No deficiencies were cited under the California Code of Regulations, Title 22. An exit interview was conducted with the Executive Director. A copy of this report was provided to the Executive Director, Tyler Manzo, whose signature on this form confirms receipt of the report.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 26-AS-20250715095200

Type of visit: Case Management - Incident

On May 27, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident inspection visit regarding a self-reported SOC 341 for the financial abuse incident. Upon arrival, the LPA was greeted by the Executive Director (ED), Tyler Manzo. The LPA disclosed the purpose of the visit. ED stated that on May 21, 2025, at approximately 11:00 AM, the daughter of resident R1 contacted the facility to report that R1 had been writing checks to their caregiver, staff member S1, at Belmont Village Sunnyvale. The family member (FM) provided copies of six (6) cashed checks dating back to August 26, 2024, totaling $6,850. R1 was his own financial power of attorney and resided in the Assisted Living unit of the community. S1 did not and would not have access to R1. The ED reported reviewing evidence showing that six checks were endorsed on the back and cashed by the facility employee, S1. As a result, S1 was terminated over the phone. The ED noted that there had been no prior concerns or complaints involving S1. The ED confirmed that the facility has a policy prohibiting employees from accepting gifts from residents or their family members. In cases where residents or families insist on giving a gift, the policy requires the employee to report it to the ED, who then contacts the power of attorney (POA) to determine proper handling. The ED further stated that on May 23, 2025, S1 returned to the facility and returned $5,000 in cash from the total $6,850 received from R1. S1 reportedly lacked the funds to return the remaining $1,850. The ED met with R1 and the FM at 2:30 PM to hand over the $5,000 returned by S1. The ED confirmed that S1 remained terminated from employment and that the partial repayment did not affect the termination decision. LPA conducted a wellness check on R1 by visiting their room. R1 stated that they were doing good and it was their judgement to write checks to S1, and no one forced R1 to write checks. Continued on LIC809-C R1 mentioned that they recently gave one check to S1 in the amount of $5000. Prior to that R1 had given checks in the amount of about $2000 as S1 was not paid when S1 was sick or taking care of their family. R1 stated that S1 never demanded any money and it was R1's impression that S1 needed help. R1 further stated that they still worry about S1 as it was their fault and hope the licensing department is not too tough on S1. LPA requested and received the following documents from the ED: 1) R1's admission agreement 2) R1's care plan 3) R1's LIC 602 Physician’s Report 4) Copies of the 6 checks (front and back) 5) Facility's Work Rules 6) Notes on the facility’s investigation and corrective action 7) S1's employee file 8) Staff schedule for the months when the checks were given No deficiencies were cited during today's visit. An exit interview was conducted with the Executive Director. A copy of this report was provided to the Executive Director, Tyler Manzo, whose signature on this form confirms receipt of the report.the state’s words, verbatim · CDSS document, May 27, 2025

Type of visit: Required - 1 Year

On April 17, 2025, at 8:45 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. LPA met with the Executive Director (ED), Tyler Manzo, and disclosed the purpose of the inspection. LPA initiated a walk-through of the facility, accompanied by ED. LPA inspected randomly selected ten (10) resident rooms (#425, 402, 337, 318, 232, 227, 220, 208, 122, 108) in Assisted Living and Memory Care units. The rooms were found to be clean, well-lit, and equipped with the required furniture. Emergency pull cords were observed to be functioning in the resident rooms with an average response time of 2 minutes. LPA inspected the private bathrooms in random rooms. The bathrooms contained soap, grab bars, towels, a trash can, and non-slip flooring. The hot water temperature at the sink faucets measured between 114.4°F and 119.5°F. LPA inspected the fire extinguishers mounted on the hallway walls in Assisted Living and Memory Care and found them fully charged, with the last service tag dated 07/11/2024. All common areas were free from obstructions, and hallways were well-lit. The smoke detectors are tested semi-annually by a third-party vendor, JCI. A staff member tested the carbon monoxide detector in the resident room in LPA’s presence, and it was found to be functional. LPA observed bistro areas and recreational rooms such as activity rooms, PT/OT room, gaming area, library area, and town hall for events, movies, and other activities. The residents were seen actively engaged in recreational programs and activities. Continued on LIC809-C LPA inspected the main kitchen and found it clean. The refrigerator, freezer, and pantry were checked, and there was a sufficient supply of fresh perishable food for two (2) days and nonperishable staples for seven (7) days. No expired food items were found. All open food items were wrapped and dated. The dining room was inspected and found to be clean, with all furniture in good repair. LPA toured the garden and patio area and found ramps and passageways in good condition, free of obstructions, and without any blocking or tripping hazards. These areas had patio tables, chairs, and umbrellas for residents’ use. Delayed egress was observed on emergency exits and patio doors were locked. No accessible bodies of water or hazards were observed. LPA reviewed six (6) staff personnel records and five (5) resident records. The LPA observed that 5 of 5 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 6 of 6 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 6 of 6 staff members were associated with the facility. LPA observed locked centrally stored medication carts in the Assisted Living and Memory Care units. Medications were organized separately for each resident. Narcotics were locked. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete. LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster (Fire and Earthquake) Drills were conducted monthly, with the most recent fire drill completed on 02/27/2025. The following updated forms are requested to be submitted to CCLD by 04/24/2025: LIC 500: Personnel Report LIC 308: Designation of Facility Responsibility Certificate of Liability Insurance Administrator Certificate(s) Continued on LIC 809-C No deficiencies were cited during today's visit. An exit interview was conducted with the Executive Director. A copy of this report was provided to the Executive Director, Tyler Manzo, whose signature on this form confirms receipt of the report.the state’s words, verbatim · CDSS document, Apr 17, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Director of Resident Care Services, Dana Malengo. The purpose of the visit is to address incident reports and death reports that are submitted late to the Department from April 1, 2024 – July 25, 2024. The facility file for incident reports was reviewed. Based on review, between April 1, 2024 – July 25, 2024, the facility submitted 15 late incident reports and 4 late death reports to the Department. The incident reports and death reports were reported more than 7 days after the occurrence date. Based on interview, the Executive Director is the only person who is submitting the incident reports and/or death reports to Licensing. The ED states the incident reports and death reports are sometimes late when ED is not in the community. By the time the ED returns to the community is when the incident reports are submitted to Licensing. ED states a plan to ensure incidents and death reports are submitted within Title 22 reporting requirements. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Resident Care Services, Dana Malengo and a copy of the report and appeal right were provided.the state’s words, verbatim · CDSS document, Aug 1, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Aug 8, 2024

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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 requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure to report incidents and death reports to the Department within 7 days of the occurrence which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 1, 2024

Plan of correction: Licensee will work out a plan to ensure incidents are submitted within reporting requirements. Licensee will submit a statement of understanding of the section cited, to LPA Dolores via email by POC due date.

Allegation investigated: Staff neglect led to hospitalization of resident. Staff did not seek medical attention for a resident in a timely manner.

Licensing Program Analysts (LPAs) Steve Chang and Manuel Monter conducted an unannounced investigation visit to deliver the investigation findings and met with Executive Director (ED) Lola Bullock. On 07/28/2023, the Department received a complaint with the allegations that staff neglect led to hospitalization of resident, and staff did not seek medical attention for a resident in a timely manner. On 07/31/2023, the department conducted an initial investigation visit and obtained residents' incident reports, assessments, and shift communication logs. Continue on LIC9099-C. Page 1 of 3. Substantiated Staff neglect led to hospitalization of resident: Staff did not seek medical attention for a resident in a timely manner: The facility was alleged that staff neglect and led to R1's hospitalization, and staff did not seek medical attention for R1 in a timely manner. Resident R1 was admitted to the facility on 04/28/2023. R1 was able to ambulate with cane and was able to feed self. On 05/31/2023, R1 was tested COVID positive and was isolated in his/her room. As R1's COVID progressed, R1 was getting weaker. R1 was unable to feed self without staff assistance and was unable to ambulate. On 06/21/2023, two friends of R1' family member visited R1 and found R1 was weak and was unable to get out of bed. R1's visitor called 911 when R1's visitor visited R1. Based on the interviews conducted on 11/06/2023 and 11/14/2023 with Executive Director, Director of Resident Care Services, and the charge nurse, Executive Director and Director of Resident Care Services admitted that staff did not follow protocol regarding R1' change of condition and did not read the staff notes from the previous shifts regarding R1's condition. Staff S1 admitted that he/she did not read the staff notes from the previous shifts and that based on the previous staff notes, R1 should have been sent to hospital based on R1's declining condition. Staff documented R1's change of condition but did not report R1's change of condition to Executive Director or Director of Resident Care Services. Continue on LIC9099-C. Page 2 of 3. The Department has investigated the above allegations. Based on records reviews, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC9099-D. An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in serious injury to a resident in care. An additional Civil Penalty for violation resulting in serious bodily injury is pending review. Exit interview was conducted with ED. The report was provided to ED for signature. This report, LIC9099-D, and Appeal Rights were provided to ED. Page 3 Staff did not ensure resident was fed, resulting in significant weight loss: Resident R1 was admitted to the facility on 04/28/2023. R1 was able to eat and feed self. On 05/31/2023, R1 was diagnosed with COVID and was isolated in his/her room. As R1's COVID progressed, R1 was getting weak and was unable to feed self without staff's assistance. On 1/18/2024, the Department interviewed 5 staff. 4 out of 5 staff stated caregivers and Med Techs fed R1 during R1's isolation in his/her room. 1 out of 5 staff stated R1 did not lose weight during R1's stay in the facility. Resident R1 was eating less portion than usual. Facility staff encouraged R1 to eat more during R1's isolation period. Based on R1's weight records on May 2023, and June 2023, R1's did not lose weight during R1's isolation period. Staff do not maintain the facility in clean and sanitary condition: On 05/31/2023, resident R1 was tested COVID positive and was isolated in his/her room. It was reported that during R1's isolation period, R1's room was not maintained in clean and sanitary condition. On 1/18/2024, the Department interviewed the temporary Executive Director (TED). TED stated during the COVID isolation period, housekeepers do not enter the resident isolation room to conduct deep cleaning until they receive notice that the resident is out of isolation. The Department interviewed 5 staff. 5 out of 5 staff stated housekeepers did not enter R1's room to conduct deep cleaning during R1's isolation period. 3 out 5 staff stated caregivers cleaned R1's room during R1's isolation period. The caregivers took out plates, bowls, trays, and took garbage out from R1's room during R1's isolation period. Continue on LIC9099-C. Page 2 of 3. Staff did not notify resident's responsible party of a change in condition: On 1/18/2024, the Department interviewed the facility temporary Executive Director (TED). TED stated the facility received a notice from R1's main contact (FM1) stating that the facility to contact R1's second contact starting from 5/19/2023 due to FM1's out of country. The Department interviewed resident R1's second contact (FM2). FM2 stated he/she received a phone call from the facility regarding R1's health condition. FM2 stated he/she is not sure how many times the facility called him/her because he/she was also on vacations during the time FM1 was out of country. The Department interviewed staff S1. S1 stated he/she notified FM2 that R1 has a change of condition. Based on the record reviewed, a note was provided to the facility to contact R1's second contact due to R1's main contact is out of the country. 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 allegation did or did not occur. No citations noted for today’s visit. Exit interview was conducted with ED. A copy of this report was provided to ED. Page 3 Out of 3.the state’s words, verbatim · CDSS document, Jul 3, 2024 · control 26-AS-20230728155433

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 4, 2024

87464 Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision ... means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living ... taking medications, money management, or personal care. This requirement was not met as evidenced by:Based on the interviews and record reviewed, the facility did not provide care and supervision for R1. R1 had a change of condition and was not reported, and the facility did not take action on R1's change of condition, which led to R1's hospitalization.the state’s words, verbatim · CDSS document, Jul 3, 2024

Plan of correction: Administrator stated to submit a plan of correction by the POC due date to provide the staff training of responsibility for providing care and supervision to residents and reporting resident's change in condition, and submit the training log to CCL office.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jul 4, 2024

87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility... shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on the interviews and records reviewed, the facility did not assist or arrange medical care appropriately to the resident condition and needs when R1 had a change of condition, this poses/posed a immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 3, 2024

Plan of correction: Administrator stated to submit a plan of correction by the POC due date and provide the staff training of arranging or assisting to arrange medical care for residents if residents have change in condition, and submit the training log to CCL office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility annual required 1 - year inspection. LPA met with Executive Director (ED) Lola Bullock. LPA toured the facility inside and outside with ED to include the independent living, assisted living, and memory care unit. All fire exit routes were free and clear of obstruction. Stairwell observed to include an evacuation chair. Elevator in working condition. Activities calendar posted throughout the facility in the independent / assisted living unit and memory care unit. LPA observed residents participating in various activities throughout the day. Facility temperature maintained between 71 - 72 degrees Fahrenheit. Fire extinguisher was last services in July 2023. Facility has a carbon monoxide detector present. With the assistance of the ED, LPA entered into rooms #426, #402, #309, #326, #238, #243, #220, #206, #102, and #105. 10 out of 10 apartments observed with a bed, clean linens, adequate lighting, night-stand, chair, and dresser. Bathrooms observed with grab bars and non-slip mats. Hot water temperature in RM #426, #309, #243, and #102 maintained between 106 - 120 degrees Fahrenheit. Medication carts observed locked. LPA observed chemicals, disinfectants, sharp objects, and medications observed locked in memory care. Facility kitchen observed clean and well maintained. Refrigerator temperature maintained at 38 degrees Fahrenheit and freezer temperature maintained at 0 degrees Fahrenheit. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Food items in the refrigerator observed covered. Dining room equipped with utensils, plates, cups, and napkins. SEE LIC809-C. LPA reviewed 11 resident files. 11 out of 11 resident files observed maintained to include an updated medical assessment, TB result, updated needs and services plan, identification emergency information, admission agreement, consent forms, and personal rights. 3 out of 4 resident files contained a physician's order for a postural support. ED was advised regarding 1 out of 4 residents. 11 residents centrally stored medications and centrally stored medication records were reviewed. LPA observed multiple PRN medications for 5 out of 11 residents were not recorded in the centrally stored medication record binder. The medications that were not part of the centrally stored medication record binders were filled in 2023. Staff stated the CSMR is now archived in the facility's attic, however, the medication is documented in their Electronic - Medication Administration Record. ED was advised. LPA reviewed 6 staff files to include a 1st aid certification, health screening, TB result, personnel record, fingerprint clearance, and training records. LPA was unable to review 1 out of 6 staff health screening and TB result. 2 out of 6 staff files observed contained a 1st aid certification. 6 out of 6 staff are fingerprint cleared. LPA did not observed 2 out of 6 staff members received at least 20 hours of annual training to include topics to include but not limited to dementia, postural supports, restricted health conditions, and hospice care. Facility has an emergency disaster plan. Emergency drills are being conducted quarterly. LPA reviewed the infection control plan and infection control training. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Advisory notes provided. This report was reviewed with Executive Director, Lola Bullock and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 26, 2024

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

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - Legal/Non-compliance inspection and met with Executive Director (ED) Lola Bullock. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) office after a Non-Compliance Conference held on 07/25/2023. The case management of inspections will be conducted every 3 months for 2 years. LPA reviewed the plans and policies regarding the resolution for the prior deficiencies with ED. LPA reviewed the plans and policies addressing the resolutions for the prior deficiencies. LPA reviewed the staff training records. LPA discussed with ED regarding the facility protocol of completing residents' appraisals/reappraisals and training provided to staff regarding appraisal/reappraisals for residents, identifying fall risk residents and maintaining a list of fall risk residents and the safety plans for them. LPA discussed with ED regarding residents' needs and service plans, residents' hospital discharge orders, doctor orders and the changes of resident care plans are enforced and met. LPA discussed with ED regarding the residents' medications administration and maintenance of resident medication records. LPA discussed with ED regarding the duties and responsibilities of Administrator and staff to ensure residents' needs are met. LPA discussed with ED regrading providing regular staff training with medications, appraisal/reappraisal, care and supervision, and fall risk and prevention of fall. LPA toured the facility with ED from first floor to forth floor including the memory care unit, assisted living unit, wellness center, dining room, kitchen, activity room, kitchen and laundry room. Exit interview was conducted with ED. The report was provided to ED for signature. A copy of the report was provided to ED.the state’s words, verbatim · CDSS document, Apr 15, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - Incident visit and met with Executive Director (ED) Lola Bullock. LPA explained the purpose of the visit to ED. On 4/12/2024, the Department received an incident report regarding a resident R1 with left eye black and swollen. The incident occurred on 4/02/2024. LPA requested R1's physician report, appraisal/needs and service plan, wellness communication log, and discharge documents. LPA interviewed ED. ED stated R1 was found in bed on 4/2/2024, around 8:00AM with black eye and lacerations on head. R1 stated he/she fell at night and went back to the bed by self. ED stated R1 is ambulatory. R1 was sent to hospital after assessment by the facility nurse and discharged back to the facility on 4/4/2024 around 6:00PM. ED stated the facility updated R1's care plan immediately on 4/4/2024 after R1 returned back to the facility on 4/4/2024. ED stated the witnessed caregiver and nurse are off today. ED stated the facility added a bed alarm for R1. ED stated the facility to have staff escort R1 when R1 is walking. LPA interviewed resident R1. R1 stated he/she fell by self at night and went back to the bed by self. R1 stated the facility sent him/her to hospital. R1 stated no one abused him/her. R1 stated no one hit him/her. No citation noted today. Exit interview was conducted with ED. The report was provided to ED for signature.. A copy of the report was provided to ED.the state’s words, verbatim · CDSS document, Apr 15, 2024

Allegation investigated: Staff did not assist resident with obtaining medical care

On 3/26/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator Lola Bullock and explained the purpose of today's visit. Regarding the allegation of Staff did not assist resident with obtaining medical care, the Reporting Party (RP) stated that resident (R1) fell during an outing, was assessed, and did not refuse to be sent out to the emergency room, however staff took 3-4 hours before deciding to send R1. Based on record reviews, progress notes obtained from the facility stated that R1, despite complaints of back pain, was just provided first aid and water during the outing. No calls were made to 911 to send R1 to emergency room for further assessment. When R1 has returned to the facility and was assessed, the facility then called 911 and R1 was sent to emergency room. Substantiated LPA Donato also interviewed 2 staff members, S1 & S2, and both confirmed that 911 was not called when the incident happened. Therefore, based on interviews and records review and information collected, the above allegation is determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. A copy of this report and the Appeal Rights are provided. Based on records review, from 09/09/2022 – 09/10/2022, the room of R1 pulled the switch for assistance fifteen times. Acknowledgement time was between 0-17 minutes. There was only one instance where the time was 17 minutes and this was during dinner time in the facility. Based on interviews and records review, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Mar 26, 2024 · control 26-AS-20220928084540

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 27, 2024

Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. ... and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This was not met as evidenced by: Based in interviews & record reviews, no calls were made to 911 to send R1 to emergency room for further assessment when R1 fell during outing which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 26, 2024

Plan of correction: Licensee to submit a plan to ensure compliance to provide Incidental and Medical care to residents. Licensee to submit by POC due date

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

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - Legal/Non-compliance inspection and met with Executive Director (ED) Lola Bullock. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) office after a Non-Compliance Conference held on 07/25/2023. The case management of inspections will be conducted every 3 months for 2 years. LPA reviewed the plans and policies regarding the resolution for the prior deficiencies with ED. LPA obtained a copy of the plans and policies addressing the resolutions for the prior deficiencies. LPA obtained the staff training records. LPA discussed with ED regarding the facility protocol of completing residents' appraisals/reappraisals and training provided to staff regarding appraisal/reappraisals for residents, identifying fall risk residents and maintaining a list of fall risk residents and the safety plans for them. LPA discussed with ED regarding residents' needs and service plans, residents' hospital discharge orders, doctor orders and the changes of resident care plans are enforced and met. LPA discussed with ED regarding the residents' medications administration and maintenance of resident medication records. LPA discussed with ED regarding the duties and responsibilities of Administrator and staff to ensure residents' needs are met. LPA discussed with ED regrading providing regular staff training with medications, appraisal/reappraisal, care and supervision, and fall risk and prevention of fall. LPA toured the facility with ED including the memory care unit, assisted living unit, wellness center, dining room, kitchen, activity room and laundry room. Exit interview was conducted with ED. The report was provided to ED for signature. A copy of the report was provided to ED.the state’s words, verbatim · CDSS document, Jan 3, 2024