Bethel Assisted Living

Type of visit: Required - 1 Year

On 04/21/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA Pascua met with Facility Designated Administrator (FDA), Melissa Orello and explained the purpose of the visit. Current Census was 115. A brief interview with FDA Orello was conducted. This facility has two buildings which are licensed to serve and retain residents who are 60 and over. 2325 Scenic Dr is licensed to serve and retain 26 ambulatory residents, 49 bedridden residents. This building also has delay egress on the 2nd floor, and the 3rd floor may only have ambulatory residents only. 2345 Scenic Dr is licensed to serve and retain 50 bedridden residents on the 1st floor. 2nd and 3rd floor are are used for independent living only. This facility also has a hospice waiver for 34. This facility also has a dementia plan on file. There are currently 23 residents receiving hospice services. LPAs reviewed 5 resident files and 6 staff files. All resident and staff files were complete and up to date. The Facility Administrator does have a current administrator certificate #7018768740 and expires on 03/28/2027. This facility has also conducted a fire sprinkler service and testing with the State Fire Marshal on 04/08/2026. At 1:00pm, a tour of the facility was initiated with FDA Orello. All rooms designated as activity areas and common areas for resident use were toured. Furniture and furnishings were observed to be present and sufficient to meet the needs of the residents at this time. Office rooms and other areas intended for resident use were toured. A review of the facility public restrooms was conducted. Hot water temperatures were taken to make sure that the hot water being dispensed was within the allowed range of 105-120 degrees at this time. Fire extinguishers, placed throughout this facility, were observed to have been annually inspected on 02/09/2026 by the local fire extinguisher company, Jorgensen Company, and in compliance at this time. Kitchen area was toured. Facility freezer and refrigerator units were toured. LPAs reviewed the food storage supply to make sure that there was always a 2-day perishable and 7-day nonperishable food quantities on site at all times. Medication was reviewed with facility staff. First aid kit was reviewed and had all the required components. Storage area for chemicals and cleaning supplies was observed to be locked and made inaccessible to the residents at this time. A tour of the facility resident bedrooms was conducted. Furniture and furnishings were observed to sufficient. A tour of the outside area was toured with no hazards present. This facility has a gated and locked pool made inaccessible to the residents in care. The following items were documents were requested to be submitted: -LIC 308 -LIC400 -LIC 500 -LIC 610E. There were no deficiencies observed or cited during today's annual visit. An exit interview was conducted and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Apr 21, 2026

Allegation investigated: Residents developed pressure injuries while in care Staff allow resident to be left in soiled clothing for extended periods of time Staff do not ensure medications are dispensed as prescribed Staff do not ensure residents medications are properly managed Licensee does not prevent staff from smoking inside the facility. Staff are not capable of performing assigned tasks due to intoxication while at the facility Staff do not follow residents prescribed dietary plans Staff do not ensure residents personal hygiene needs are being met

On 11/14/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to deliver complaint findings. LPA Pascua met with Facility Designated Representative (FDR), Maria Castillo Padilla and explained the purpose of the visit. Current census was 115. A brief interview with FDA Orello was conducted. Allegation: Residents developed pressure injuries while in care. It was alleged that the facility residents developed pressure injuries while in care. During the course of this investigation, this LPA conducted interviews and reviewed facility records. Based on interviews conducted it was denied by facility staff that the residents developed pressure injuries while in care. Facility staff state that care staff conduct daily skin checks on all residents. IIn addition, facility staff state that there were no current residents with pressure injuries. In addition, facility staff state that residents who do develop pressure injuries do get immediate assistance. Unsubstantiated LPA Pascua reviewed facility records which corroborate that there are currently no residents with pressure injuries while in care. Based on the information gathered, there is not sufficient evidence to prove that the residents developed pressure injuries while in care. Allegation: Staff allow resident to be left in soiled clothing for extended periods of time. During the course of this investigation, this LPA conducted interviews with facility staff and residents. Based on interview with facility staff it was denied that residents are left in soiled clothing for an extended period of time. In addition, facility staff state that each resident is seen at minimum every 2 hours. Facility staff state that residents are also changed as needed according to their care plans. An interview with 5 residents were conducted. 5 out 5 residents denied being left in soiled clothing for an extended period of time. Based on the information gathered, there is not sufficient evidence to prove that staff allow resident to be left in soiled clothing for extended periods of time. Allegation: Staff do not ensure medications are dispensed as prescribed Based on interviews, record reviews and observation it was determined that the residents have been receiving medications as ordered and on time for July 2025-current. Additionally, LPA Pascua observed medications stored at facility to match physician orders and medication dispensing logs. LPA Pascua interviewed 2 staff members, 2 out of 2 staff members stated that medication is given per doctors orders. 2 out of 2 staff members also state that medication logs are audited by the facility care director on a weekly basis to ensure that medication will match with the count of medication available. 2 out of 2 staff membered both reported that they watch residents to ensure that their medication was taken. Record review also revealed that medications are documented appropriately to indicate when medication is taken or refused. Based on facility files LPA Pascua did not observe any substantial evidence that presented that facility staff was not providing medication as prescribed. Allegation: Licensee does not prevent staff from smoking inside the facility. It was alleged that the Licensee does not prevent staff from smoking inside the facility. Based on interviews conducted, it was denied that any staff smoke inside the facility. An interview with 5 staff members was conducted. 5 out 5 deny seeing anyone smoke inside the facility have any knowledge of anyone smoking inside. 5 out 5 staff member state that they would not smoke inside the facility. An interview with 5 residents was conducted. 5 out 5 residents deny seeing staff members smoke inside the facility. Based on the information gathered, there is not sufficient evidence to prove that the licensee does not prevent staff from smoking inside the facility. Allegation: Staff are not capable of performing assigned tasks due to intoxication while at the facility It was alleged that the facility staff are not capable of performing assigned tasks due to intoxication while at the facility. Interviews with 5 staff members were conducted, it was denied that any staff have been intoxicated, have come to work intoxicated and have seen anyone intoxicated. An interview with 5 residents was conducted. 5 out 5 residents deny seeing staff members incapable of doing their job due to intoxication. Based on the information gathered, there is not sufficient evidence to prove that the facility staff are not capable of performing assigned tasks due to intoxication while at the facility. Allegation: Staff do not follow residents prescribed dietary plans During the course of this investigation, this LPA conducted interviews and reviewed facility records. Based on interviews conducted, it was denied that staff do not ensure that staff follow resident’s dietary plans. An interview with 2 residents with dietary restrictions were conducted. It was denied by both residents that they do not get their prescribed dietary plans. In addition, it was stated that these plans were implemented and planned with the facility and themselves. A review of the resident’s records shows that the facility and their staff have followed the residents dietary plans and parameters. Based on the information gathered, there is not sufficient evidence to prove that the facility staff do not follow residents prescribed dietary plans. Allegation: Staff do not ensure residents personal hygiene needs are being met During the course of this investigation, this LPA conducted interviews with facility staff and residents. Based on interview with facility staff it was denied that staff do not ensure resident’s personal hygiene needs are being met. In addition, facility staff state that each resident is seen at minimum every 2 hours. Facility staff state that residents are also changed as assisted according to their care plans. An interview with 5 residents were conducted. 5 out 5 residents denied that their hygiene needs are not being met. Based on the information gathered, there is not sufficient evidence to prove that facility staff did not ensure residents personal hygiene needs are being met. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was 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 to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Nov 14, 2025 · control 27-AS-20250929084454

Type of visit: Case Management - Other

On 10/06/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA met with Facility Designated Administrator (FDA), Melissa Orello and explained the purpose of the visit. The purpose of the visit to follow up on an a request regarding a new fire clearance. LPA Pascua spoke with FDA Orello regarding the requested documentation to be sent to the LPA by End of Day 10/07/2025, 5:00PM. The following documentation was requested: -LIC200 -Facility Sketch identifying new resident rooms An exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 6, 2025

Type of visit: Required - 1 Year

On 04/01/2025 at 10:20am, Licensing Program Analysts (LPAs) Arielle Pascua and Triel Lindstrom arrived unannounced to this facility to conduct an annual visit. LPAs met with Facility Staff, Maria Castillo-Padilla and explained the purpose of the visit. LPAs asked that Staff Member Padilla call the Facility Designated Administrator (FDA), Melissa Orello to inform them that CCL was present. LPAs were informed that FDA Orello would be arriving within 45 minutes. At 11:30am, LPAs met with FDA Orello. Current census was 114. A brief interview with FDA Orello was conducted. LPAs reviewed 7 resident files and 7 staff files. All resident and staff files were complete and up to date. The Facility Administrator does not have a current administrator certificate #6051630740 and expired on 03/28/2025 At 1:00pm, a tour of the facility was initiated with FDA Orello. All rooms designated as activity areas and common areas for resident use were toured. Furniture and furnishings were observed to be present and sufficient to meet the needs of the residents at this time. Office rooms and other areas intended for resident use were toured. A review of the facility public restrooms was conducted. Hot water temperatures were taken to make sure that the hot water being dispensed was within the allowed range of 105-120 degrees at this time. Fire extinguishers, placed throughout this facility, were observed to have been annually inspected on 03/11/2025 by the local fire extinguisher company, Jorgensen Company, and in compliance at this time. Kitchen area was toured. Facility freezer and refrigerator units were toured. LPAs reviewed the food storage supply to make sure that there was always a 2-day perishable and 7-day nonperishable food quantities on site at all times. Medication was reviewed with facility staff. First aid kit was reviewed and had all the required components. Storage area for chemicals and cleaning supplies was observed to be locked and made inaccessible to the residents at this time. A tour of the facility resident bedrooms was conducted. Furniture and furnishings were observed to sufficient. A tour of the outside area was toured with no hazards present. This facility has a gated and locked pool made inaccessible to the residents in care. The following items were documents were requested to be submitted: -LIC 308 -LIC400 -LIC 500 -LIC 610e. There were no deficiencies observed or cited during today's annual visit. An exit interview was conducted and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Apr 1, 2025

Allegation investigated: Staff filmed resident without consent

On 03/18/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Melissa Orello and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegation above. Current census was 113. A brief interview with FDA Orello was conducted. It was alleged that that staff filmed a resident without consent. During the course of this investigation, LPA conducted interviews and reviewed facility records. Based on interviews conducted it was learned that sometime in October, R1’s family member visited the facility to check on R1. During this time, R1’s family member witnessed S1 facetiming another staff member with the camera facing the resident and put their phone away. Substantiated S1 admitted that she was facetiming with a former staff member who used care for R1 because they were actively dying. On 12/16/2024, the facility conducted an internal investigation and found that S1 was in fact facetiming while caring for a resident and this staff member was terminated from the facility. A review of R1’s employee counseling form confirms that this staff member violated the resident’s rights by facetiming in the resident’s room. Based on the information gathered the staff member filmed resident without consent. 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.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. An exit interview was conducted and copy of this report and appeals rights were provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 27-AS-20241212131839

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80072(a)(1) · Plan of correction due date: Apr 18, 2025

(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This is not met as evidenced by: This is not met as evidenced by based on interviews and records review, the Licensee did not ensure that staff filmed resident with consent. It was learned that S1 was facetiming R1 with the camera facing the resident as R1’s family walked in. S1 confirmed that they were facetiming another staff member to show R1. This poses a potential health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2025

Plan of correction: The administrator shall provide a statement of acknowledgement and correction shall be provided to the LPA by POC date. In addition, training for no less than 1 Hour shall be provided. Training items, such as items discussed, and staff list shall be provided to the LPA

Allegation investigated: Staff not following resident’s dietary needs. Staff not serving meals in a timely manner. Staff refuses to provide resident snack.

On 11/07/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Representative (FDR), Maria Castillo-Padilla and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current Census was 108. A brief interview with FDR Padilla was conducted. Allegation: Staff not following resident’s dietary needs. It was alleged that the facility staff are not following resident’s dietary needs. During the course of this investigation LPA reviewed facility records and conducted interviews with staff and residents. Based on interviews conducted it was learned that this resident was currently on a special diabetic diet due to their diabetic diagnosis. It was learned that that facility had a care conference meeting to discuss some issues regarding the resident’s health. It was discussed that the facility would provide the resident with healthier snack options were brought to the resident’s room. Unsubstantiated In addition, it was learned that along with snacks, the facility provides a diabetic or low salt meals 3 times a day. Facility staff deny that the facility does not follow the resident’s dietary needs. An interview with the resident was conducted and it was learned that this resident does obtain snacks and meals however, they may be not what they would prefer to eat. In addition, a review of the residents care plan was conducted which confirmed that the facility is providing the resident their dietary needs. Based on the information gathered, it is unclear if the facility staff is not following resident’s dietary needs. Allegation: Staff not serving meals in a timely manner. It was alleged that the facility staff are not serving meals in a timely manner. During the course of this investigation, LPA conducted facility observations and conducted staff and resident interviews. An interview with 5 staff members was conducted. 5 out 5 staff members deny that they do not serve meals in a timely manner. 5 out 5 staff members state they some days they may be a couple minutes running late but meals can still be served hot to the residents in their rooms or in the dining room. An interview with 7 residents were conducted. 6 out 7 residents state that they get their meals within a reasonable time frame. 1 out 7 residents state that they do not get their meal in a timely manner. LPA observed lunch being served between the hours of 11:30am-1:30pm on 07/14/2024 and did not observe any indication that meals were not being served in a timely manner. Based on the information gathered, it is unclear if the facility staff are not serving meals in a timely manner. Allegation: Staff refuses to provide resident snacks. It was alleged that the staff refuses to provide resident snacks. During the course of this investigation, LPA conducted facility observations and conducted staff and resident interviews. Based on interviews conducted, 6 out 6 staff deny not providing residents with snacks. 6 out 6 staff state that they have enough food supply at this time to feed the residents. 6 out 6 staff members state that they are aware of where the snacks are if the kitchen would be locked and inaccessible. LPA conducted 9 resident interviews. out of 9 residents state that they do not get snacks or do not like the snacks provided. 6 out 9 residents state that they are able to have snacks throughout the day. Based on facility observations, LPA observed both perishable and non-perishable snacks in the kitchen that included but were not limited to, fresh fruits and vegetables, nature bars, fruit bar, and sandwiches. It was also observed that resident’s also obtained supply of snacks if requested to their bedrooms. Based on the observations, it is unclear if the facility staff refuse to provide resident snacks. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, Nov 7, 2024 · control 27-AS-20240710151805

Type of visit: Case Management - Incident

On 11/07/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA met with Facility Designated Representative (FDR), Maria Castillo-Padilla and explained the purpose of the visit. The purpose of this visit was to follow up on an incident report received by the department on 11/05/2024. Current census was 108. A brief interview with FDR Padilla was conducted. On 11/05/2024, the department received a Special Incident Report (SIR) from this facility stating that on 11/04/2024, a medication technician provided the wrong medication for R1. R1 was provided Lorazepam 1mg intended for another resident instead of their routine medication of Alprazaam 0.5mg. The Medication Technician notified facility management, who called poison control and provided directive to put the resident on a 72 hour observation period. The facility took the resident's vitals and additional check ins were conduct as requested by poison control. The facility will plan to conduct additional training on the 7 rights of medication as well as supplemental training for S1. Based on the information gathered during the course of this visit, per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. An exit interview was conducted, and a copy of the report will be given.the state’s words, verbatim · CDSS document, Nov 7, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87564(a)(4) · Plan of correction due date: Nov 8, 2024

(4) The licensee shall assist residents with self-administered medications as needed. This is not met as evidenced by: Based on interview and record review, the facility did not ensure that R1 was provided the correct medication at the time of med pass. It was learned that during medication pass R1 was provided another resident's routine medication instead of their own. This poses an immediate health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: Licensee/Administrator shall provide a statement of acknowledgement and correction to the LPA by the POC date of 11/08/2024. In addition, training shall be conducted no less than an hr of duration. A copy training shall be provided to the LPA upon completion.

Allegation investigated: Facility does not provide residents with adequate food service. Staff do not follow facility food menu. Staff do not ensure residents have access to water.

On 04/23/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Melissa Orello and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current census was 101. A brief interview with FDA Orello was conducted. Allegation: Facility does not provide residents with adequate food service. It was alleged that the facility does not provide residents with adequate food service. During the course of this investigation LPA conducted interviews, toured the facility, and reviewed facility records. A tour of the facility kitchen was conducted. LPA observed a walk in pantry with non-perishable food supply which included an array of oils, canned fruits, dried goods, and snacks. LPA observed a sufficient amount of non-perishable food supply in both kitchens. LPA observed a walk in refrigerator in which held perishable food supply. LPA observed a sufficient amount of perishable food supply in both kitchens. Unsubstantiated In addition, LPA conducted staff and resident interviews. Based on interviews conducted, 6 out 6 staff deny not providing residents with adequate food service. 6 out 6 staff state that they have enough food supply at this time to feed the residents. LPA conducted 9 resident interviews. 3 out 9 residents state that they do not obtain sufficient food service and wish that they would provide different options. 3 out of 9 residents state that they do not get snacks or do not like the snacks provided. 6 out 9 residents deny not obtaining adequate food service. 6 out 9 residents state that they are able to have snacks throughout the day. In addition, LPA reviewed facility records. LPA reviewed the last 6 months of food purchased through US foods. Based on record review it was found that the facility is purchasing food supply for between 111-120 residents monthly. It was found that the facility is spending an average of $294.24 per resident per month. In comparison to the USDA guidelines is between the low-cost to moderately cost food plan per month. Based on information gathered, it is unclear of the facility does not provide residents with adequate food service. Allegation: Staff do not follow facility food menu. It was alleged that staff do not follow facility food menu. During the course of this investigation LPA conducted interviews, toured the facility, and reviewed facility records. A review of the facility food menu was conducted prior to a tour of the facility kitchen. A review of the facility menu stated that on 12/12/2023, the facility was to serve the following options for Breakfast lunch and dinner. For breakfast, a choice of cold cereals, cream of wheat, homestyle biscuits and gravy, sausage links, and apricots. For lunch, a Caesar salad, manicotti with marinara sauce, Italian vegetables, garlic bread, tiramisu, seasonal fruit or an alternative lunch entrée of baked fish. For dinner, chef’s choice soup, grilled cheese with cheddar cheese on rye bread, Texas beans, and an apple turnover with powder sugar. LPA observed these items in the facility kitchen. In addition, LPA observed the facility providing the scheduled lunch and it’s alternative to the residents on this day. LPA conducted 9 resident interviews. 9 out 9 residents state that they like the food provided, however would like to have more input on what is served. LPA conducted 6 staff interviews. 6 out 6 staff state that they have food delivered twice a week to ensure that they have the correct food supply to serve the residents. 6 out 6 staff members deny not following the facility food menu. Based on the information gathered, it is unclear of the facility staff did not follow the facility menu. Allegation: Staff do not ensure residents have access to water. It was alleged that staff do not ensure residents have access to water. During the course of this investigation LPA conducted interviews and toured the facility. An interview with 9 residents were conducted. 9 out 9 residents state that they do have access to water. 9 out 9 residents state that they did have individual water bottles, however, the facility has changed to having water that is brought by the staff members to fill out their pitchers. An interview with 6 staff members were conducted. 6 out 6 staff members state that they have implemented a new system where the facility has hydration carts on each floor that includes excess water pitchers and cups. These hydration carts are monitored by staff and are used to fill the residents personal pitcher in their rooms. 6 out 6 staff members deny that they do not provide residents with water. LPA conducted a tour of the facility, where it was observed that the facility does have 3 separate hydration carts available for residents and staff to use throughout the day. Based on the information gathered, it is unclear if the staff do not ensure that residents have access to water. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, Apr 23, 2024 · control 27-AS-20231211155524

Type of visit: Required - 1 Year

On 04/16/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with Facility Designated Administrator (FDA), Melissa Orello and explained the purpose of the visit. The purpose of this visit was to conduct an annual visit. This facility has two buildings which are licensed to serve and retain residents who are 60 and over. 2325 Scenic Dr is licensed to serve and retain 26 ambulatory residents, 49 bedridden residents. This building also has delay egress on the 2nd floor, and the 3rd floor may only have ambulatory residents only. 2345 Scenic Dr is licensed to serve and retain 50 bedridden residents on the 1st floor. 2nd and 3rd floor are are used for independent living only. This facility also has a hospice waiver for 34. This facility also has a dementia plan on file. This facility has also a new management company, Northstar Management, which was effective on 01/01/2024. Current Census was 101. A brief interview with FDA Orello was conducted. A tour of the facility was conducted. LPA requested and reviewed 4 resident files, and 10 staff files. The administrator has a current administrator certificate #60516330740 expires on 03/28/2025. Due to insufficient time to conduct records review for resident files and conduct a tour of the facility, this LPA will return at a later date to continue the annual visit. A technical assistance was provided for the following: 87411(c)(6) No deficiencies or citations provided during the course of this visit. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Apr 16, 2024

Allegation investigated: Facility is in disrepair

On 04/12/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Melissa Orello and explained the purpose of the visit. The purpose of this visit was to inform the facility and it's representative that a complaint has been filed against it at this time. Current census was 101. A brief interview with FDA Orello was conducted. During the course of this visit LPA conducted a tour of the facility. LPA toured two facility kitchens. One facility kitchen housed food for Assisted Living Residents. This kitchen had two sinks and a dishwasher that was currently being used and in working condition. LPA conducted a interview with staff who stated they did not have any issues with the dishwasher. A tour of the kitchen in the main building, which houses food for assisted living and independing living residents. This kitchen also had two sinks and a dishwasher that was also currently being used and in working condition. LPA conducted interviews with kitchen staff who stated they did not have any issues with the dishwasher or any items in the kitchen at this time. Unsubstantiated Based on the information gathered during the course of this visit it is unclear if the facility is in disrepair at this time. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, Apr 12, 2024 · control 27-AS-20240403154725

Allegation investigated: Staff do not ensure reporting requirements are being followed Facility staff mismanages resident medication

On 04/02/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Melissa Orello and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current census was 112. A brief interview with FDA Orello was conducted. Staff do not ensure reporting requirements are being followed. It was alleged that the staff do not ensure reporting requirements are not being followed. During the course of this investigation LPA conducted interviews and reviewed facility documentation. Based on interviews conducted, 7 out 7 staff state that they receive annual training on reporting requirements and are aware what needs to be reported. 7 out 7 staff state that when an incident happens with a resident they fill out the incident form and will send it to management to review and sent to the department via fax. Unsubstantiated 2 out 7 staff members state that once reviewed by management they send the incident report within 10 days of occurrence via fax and notify the LPA via email if the fax is unsuccessful. LPA reviewed facility documentation to review incident reports for the past 3 months and was provided copies of all and any incident reports dating back to September 2023. It was observed by this LPA that the facility is properly reporting to all parties involved with supporting documents sent out as well. Based on the information gathered it is unclear of the staff do not ensure reporting requirements are being following. Facility staff mismanages resident medication. It was alleged that facility staff mismanages resident medication. During the course of this investigation, LPA conducted interviews, toured the facility and reviewed facility documentation. Based on interviews conducted, 7 out 7 staff members deny that they have mismanaged any resident medication. 7 out 7 staff members state that they are confident in ensuring that each resident is provided with the right and correct amount of medication. On 12/12/2023 and 03/12/2024 LPA Pascua observed 4 separate medication passes in which observed that the Medication Technicians were providing the residents with the correction medication. LPA observe medication stored at the facility to match physicians orders and medication dispensing logs. LPA Pascua reviewed medications on 12/12/2023 and 03/12/2024 which reflected that the facility was providing medication as ordered by the physician. Based on the information gathered, it is unclear if the facility staff mismanaged resident medication. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, Apr 2, 2024 · control 27-AS-20231204084247

Type of visit: Office

An informal conference was conducted on this day, 03/13/2024 via Microsoft Teams. The purpose of the informal conference was to discuss the facilities complaince with Title 22 Regulations. Present at today's meeting were Licensing Program Manager (LPM), Lisa Rios and Licensing Program Analyst (LPA), Arielle Pascua, Licensee, Mitchael Word, Northstar Management Company Representative, Jessica Quintana, and Facility Designated Administrator (FDA), Melissa Orellos. The following issues were discussed during the informal conference: · Sufficient Staffing including confirmation of current staffing agency contracts, Assisted Living staffing and Memory Care staffing · Food supply · Medications Licensees stated they will do the following to achieve continued and substantial compliance: Provide LPA Pascua a copy of food supply puchased within the last 6 months. Ensure that is sufficient staff on site to meet the residents needs Have hydration stations and extra snacks provided to the residents throughout the day Have a back up system to call staff in when staff on schedule call out on shift. Licensing will: Increase monitoring to verify: Internal Audits of Medications is being completed by the facility Staffing are sufficient to meet the needs of the residents Food supply is sufficient to meet resident needs. No deficiencies were cited from the California Code of Regulations, Title 22, Division 6 as a result of today's meeting. An exit interview was conducted and a facility report was provided via email read receipt.the state’s words, verbatim · CDSS document, Mar 13, 2024

Allegation investigated: Facility is not adequately staffed to meet the needs of residents in care

On 12/12/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA) Mitch Word, and Facility Designated Representative (FDR), Tim Sidoti and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current census was 111. A brief interview with FDA Word and FDR Sidoti was conducted. It was alleged that the facility is not adequately staffed to meet the needs of the residents in care. During the course of investigation, the LPA reviewed facility documents, conducted interviews, and conducted facility visits.LPA conducted 12 staff interviews. 3 out 12 staff members stated that they believed that there is sufficient amount of staff at this time to meet the residents needs. 9 out 12 staff members stated that there was not a sufficient amount of staff to meet the residents needs and feel that they cannot meet the needs of the residents at this time. Based on interviews conducted, it was learned that facility has undergone multiple call-outs throughout the last month that have not been covered or have learned about call outs the time of their shift and are asked to cover the shift while conducting other duties. Substantiated It was learned that often on NOC shift, there is only one caregiver and one medication technician to assist residents on the Memory Care building which hold approximately 60 residents at a time. Often, they are asked to ask another Medication Technician to come help their building out but will leave only one caregiver on the other side, which approximately holds 50 assisted living residents. It was reported that on some weeks during the AM and PM shift that they will only have 2 caregivers due to call outs. On 11/30/2023, LPA conducted an unannounced facility visit. During this visit, LPA observed 2 medication technicians’ clock in at 5:00am to the memory care building. Prior to the 2 medication technicians clocking there was only 1 medication technician and 1 caregiver. It was learned through that during this shift, 1 medication technician was called in at 2:30am because there was only 1 caregiver on site at the time. In a separate building, LPA observed 1 medication technician who also performed care giving duties for approximately 50 residents. A review of facility documentation was conducted. LPA reviewed 22 random resident files from the facility. Based on document review, it was observed that 17 out 22 residents were non-ambulatory, and 20 out 22 residents need hands on or one-on-one assistance one of the following items: grooming, bathing, showering, travel to and from meals and activities, and medication management. Upon further document review, it was found that approximately 10 residents need two person assists to help fully assist them to reposition, standing, turning or mobility needs. It was reported by staff that they could not help residents who are two person assists due to helping other residents who need immediate attention. It was stated that staff have resorted turning residents with their bedding and pulling them up from headboard to help alleviate residents needs. Additionally, it was reported that due to the lack of staffing, the residents are having later meals, showers are not being provided as scheduled, and medications are not provided on time and it takes approximately more than 15 minutes to respond to a resident. Based on the information gathered during the course of this investigation, the facility is not adequately staffed to meet the needs of the residents in care. 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. An exit interview was conducted, a copy of the LIC9099, LIC9099-C, 9099-D, and appeals rights was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 27-AS-20230915131650

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 13, 2023

(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 to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. 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. This is not met as evidenced by: Based on observation, record review, and interview, the licensee did not ensure that the facility has sufficient staffing to meet the residents needs. LPA conducted 12 staff interviews, 9 out 12 reported that they cannot meet the residents needs. This poses an immediate health, safety, and persons rights risks to persons in care.the state’s words, verbatim · CDSS document, Dec 12, 2023

Plan of correction: The Licensee agreed to provide LPA Pascua a staffing plan to meet the needs of the residents by the POC date. In addition, the Licensee shall provide a weekly schedule to reflect staffing hours and hours met during the week until 1/31/2024. The facility is activately hiring care staff at this time and will provide a call out plan with a call back up list will be provided

Allegation investigated: Licensee does not ensure facility has sufficient staffing to meet the care needs of residents

On 12/12/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA) Mitch Word, and Facility Designated Representative (FDR), Tim Sidoti and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current census was 111. A brief interview with FDA Word and FDR Sidoti was conducted. It was alleged the licensee does not ensure that the facility has sufficient staffing to meet the care needs of residents. During the course of investigation, the LPA reviewed facility documents, conducted interviews, and conducted facility visits. LPA conducted 12 staff interviews. 3 out 12 staff members stated that they believed that there is sufficient amount of staff at this time to meet the residents needs. 9 out 12 staff members stated that there was not a sufficient amount of staff to meet the residents needs and feel that they cannot meet the needs of the residents at this time. Substantiated Based on interviews conducted, it was learned that facility has undergone multiple call-outs throughout the last month that have not been covered or have learned about call outs the time of their shift and are asked to cover the shift while conducting other duties.It was learned that often on NOC shift, there is only one caregiver and one med tech to assist residents on the Memory Care building which hold approximately 60 residents at a time. Often, they are asked to ask another Medication Technician to come help their building out but will leave only one caregiver on the other side, which approximately holds 50 assisted living residents. It was reported that on some weeks during the AM and PM shift that they will only have 2 caregivers due to call outs. On 11/30/2023, LPA conducted an unannounced facility visit. During this visit, LPA observed 2 medication technicians’ clock in at 5:00am to the memory care building. Prior to the 2 medication technicians clocking there was only 1 medication technician and 1 caregiver. It was learned through that during this shift, 1 medication technician was called in at 2:30am because there was only 1 caregiver on site at the time. In a separate building, LPA observed 1 medication technician who also performed care giving duties for approximately 50 residents. A review of facility documentation was conducted. LPA reviewed 22 random resident files from the facility. Based on document review, it was observed that 17 out 22 residents were non-ambulatory, and 20 out 22 residents need hands on or one-on-one assistance one of the following items: grooming, bathing, showering, travel to and from meals and activities, and medication management. Upon further document review, it was found that approximately 10 residents need two person assists to help fully assist them to reposition, standing, turning or mobility needs. It was reported by staff that they could not help residents who are two person assists due to helping other residents who need immediate attention. It was stated that staff have resorted turning residents with their bedding and pulling them up from headboard to help alleviate residents needs. Additionally, it was reported that due to the lack of staffing, the residents are having later meals, showers are not being provided as scheduled, and medications are not provided on time and it takes approximately more than 15 minutes to respond to a resident. 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.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. This allegation is substantiated however no licensing citation will be given for this allegation. This allegation was cited on a complaint report on 12/12/2023. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 27-AS-20231204084247

Type of visit: Case Management - Deficiencies

On 12/05/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA met with Facility Designated Administrator, Mitch Word and Facility Designated Representative (FDR), Jim Sidoti and explained the purpose of the visit. The purpose of this visit was in response to the complaint visit to this facility that was conducted on 12/05/2023. It was learned during this visit that S1 was currently not associated to the facility roster. LPA reviewed the Licensing Information System (LIS) and Guardian portal to determine of S1 was associated at this time. It was observed that S1 was not associated to this facility as of this date. An immediate civil penalty of $500 was issued at the time of this visit due to violation of Section 87355(e)(2). Based on the information gathered during the course of this visit, per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. An exit interview was conducted, and a copy of the report will be given.the state’s words, verbatim · CDSS document, Dec 5, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Dec 6, 2023

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This is not met as evidenced by: Based on record review and observation, the Licensee did not ensure that S1 was currently associated to this facility as of 12/05/2023. LPA reviewed both LIS and Guardian and did not observed S1 currently associated to the facility at this time. This poses an immediate health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Dec 5, 2023

Plan of correction: Licensee shall provide a statement of acknowledge and correction of the mentioned Section. Licensee shall ensure that S1 is associated to the facility by POC date.