Brethren Hillcrest Homes

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual inspection utilizing the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by Maintenance Manager Raul Garcia, who was informed of the purpose of the visit and provided a tour of the community. Desiree Eudave, Sr. Director of Residential Care, arrived shortly thereafter. This facility is licensed to serve fourteen (14) ambulatory residents and five hundred and sixty (560) non-ambulatory residents, age 60 and over. The facility may retain no more than fifteen (15) hospice residents. At the time of the inspection, there was (1) resident receiving hospice services. The facility provides care to assisted living residents in four (4) different areas of the community with the following census: · Pinecrest – eighteen (20) residents · Cedar Court – eleven (10) residents · Maple Court/Birch Court – thirty-one (59) residents · Southwood Lodge Memory Care – twenty-four (21) residents--Southwood Lodge Memory Care is approved for delayed egress. The total community census for memory care and assisted living at the time of the inspection was one hundred and twenty (120) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool during today's inspection and observed the following: (continued on 809C) Physical Plant and Environmental Safety: The community is centrally located within the City of La Verne and is considered a Continuing Care Retirement Community (CCRC). LPA toured the Memory Care unit (Southwood Lodge) and the Assisted Living areas, including Maple Court, Birch Court, and Cedar Court. A total of ten (10) resident bedrooms were inspected. All resident rooms contained the required furniture, linens, and adequate lighting. Water temperatures in resident grooming and bathing areas measured between 105°F and 120°F. Restrooms displayed postings encouraging proper handwashing, and resident bathrooms were equipped with grab bars adjacent to toilets and inside showers. Disinfectants, cleaning supplies, poisons, and other hazardous materials were observed to be secured and inaccessible to residents. Carbon monoxide detectors and smoke alarms were observed in resident bedrooms and hallways. LPA also observed evacuation chairs positioned in stairwells for emergency use. Food Service: LPA toured both dining areas and the kitchens that serve the Assisted Living and Memory Care residents. LPA observed proper food storage, food preparation, and food handling practices throughout both kitchen areas. No chemicals, cleaning supplies, or other hazardous substances were observed in food preparation or food storage areas. LPA discussed with kitchen staff the process for monitoring and providing meals to residents with physician-ordered special diets. Kitchen staff explained that resident dietary needs and special meal plans are tracked through the community's Dine OS system, which assists staff in ensuring meals meet nutritional needs. Staff further stated that the community employs a certified nutritionist who oversees menu planning to ensure meals meet residents' nutritional needs. LPA observed the community’s daily and weekly menus, which were posted and available for resident review. Food menus were readily available throughout the community, and printed copies are available for residents upon request. The facility maintained at least a one-week supply of nonperishable food and a minimum two-day supply of perishable food. Soaps, detergents, and cleaning compounds were stored separately from food supplies. Freezers and refrigerators were clean and maintained at appropriate temperatures. Freezers measured approximately 0°F (-17.7°C), and refrigerators were maintained at or below 40°F (4.4°C). Planned Activities: LPA observed several residents participating in a staff-led seated exercise program. A July 2026 activity calendar was posted and included a variety of recreational activities and scheduled community outings. LPA observed adequate outdoor recreational space for residents in both the Assisted Living and Memory Care areas. However, a section of the Southwood Lodge Memory Care outdoor patio lacked adequate shade, and portions of the patio were observed to be in disrepair. A citation will be issued. Amenities: LPA observed that the community offers a variety of amenities for resident use, including a movie theater, an enclosed swimming pool area, a fully equipped fitness gym, and an on-site beauty salon. These amenities provide residents with opportunities for recreation, exercise, personal care, and social engagement. LPA observed the amenities to be clean, well-maintained, and available for resident use. Residents Council Meeting: LPA reviewed documentation of the facility's monthly Resident Council meetings. The meetings provide residents with an opportunity to voice concerns, offer suggestions, discuss community matters, and participate in decisions affecting their living environment. Documentation reflected the facility's ongoing efforts to encourage resident participation and promote resident rights within the community. Resident Rights/Information: LPA observed the required postings displayed throughout the facility's common areas, including the Complaint Poster (PUB 475), Personal Rights, and the Nondiscrimination Notice. Internet access was also available for resident use. Health-Related Services & Records Ten (10) resident files were reviewed. Files contained current required documentation, including Admission Agreements, signed consents, Needs and Services Plans, Physician's Reports documenting TB results and ambulatory status, and signed Resident Rights acknowledgments. Residents' medications were reviewed. Medications were observed to be centrally stored in the facility's medication room in locked medication cabinets, locked medication carts, and a locked medication refrigerator. All medications observed were maintained in a secure manner and inaccessible to residents. (continued on 809C) Disaster Preparedness LPA received copies of the facility's Wet Pipe Sprinkler Inspection/Test Reports, including the required comprehensive inspection reports for both the Assisted Living and Southwood Lodge Memory Care wings. Facility records reflected that the last fire and earthquake drill was conducted on June 12, 2026. Documentation of emergency drills were available for LPA's review. LPA observed that the facility's LIC 610D, Emergency Disaster Plan, was in the process of being updated. Emergency disaster supplies, including potable water, nonperishable food, flashlights, batteries, and first aid supplies, were observed and appeared sufficient to meet emergency preparedness requirements. Personnel Records & Training Five (5) staff files were reviewed and included criminal record clearances, CPR/First Aid, required training and TB screenings. Administrator Certificate for Keith Kasin was valid through August 10, 2026. An exit interview was conducted with Desiree Eudave, Sr. Director of Residential Care. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights will be provided.the state’s words, verbatim · CDSS document, Jul 2, 2026

Allegation investigated: Staff left resident in the sun for an extended period of time causing sun burns Staff handle resident roughly when assisting with oral care Staff take residents blankets away Resident fell and staff did not address the residents injury

Licensing Program Analysts (LPA) Luis De Leon conducted an initial unannounced complaint investigation visit for the allegation listed above. LPA met with the Director Keith Kasin and explained the reason for the visit. The investigation consisted of the following: On today’s visit, LPA De Leon toured the physical plant and obtained the current resident and staff roster. Reviewed R1’s file and obtained copies of relevant documents from R1's file. LPA interview residents and staff. Report continues on page LIC-9099C... Unsubstantiated Regarding allegation: Staff left resident in the sun for an extended period of time causing sunburns. It is alleged that R1 was left outdoors for a long period from morning to late evening. Staff did not ensure R1’s safety which caused R1 to get sunburn on her body. The investigation reveals the following: Residents interviews reveal that ten (10) out of ten (10) residents denied the allegation above. Staff interviews reveal that seven (7) out of seven (7) staff denied the allegations above. Residents responded that residents prefer to remain indoors, and residents are not aware of other residents being left outside for long period of time. Residents’ interviews reveal that residents who are observed to be outside are monitored by staff. S2 stated that staff provide hats, sunscreens, or move residents to shaded areas to prevent sunburn. S4 stated that R1’s has not been observed with any skin bruises, rashes, or tears during morning or evening shifts that would indicate any sun damage. Record review revealed that recent hospital visit on 10/02/2025 did not change any current medications or indicate any new prescription for any skin damage. Based upon investigation, client and staff interviews, and LPA observations, there was no evidence that R1 has been left out exposed in the sun for long period of time that may have caused sunburn. Regarding allegation: Staff handle resident roughly when assisting with oral care. It is alleged that staff has hurt R1 by forcefully removing dentures. The investigation reveals the following: Residents interviews reveal that nine (9) out of ten (10) residents denied the allegation above. Residents stated that staff were considerate of their needs when helping with activities of daily livings (ADLs) such as transferring, toileting, or showering. Residents stated that staff were not rough when assisting residents with removing devices such as dentures. Staff interviews revealed that seven (7) out of seven (7) staff denied above allegation. S1 or S2 denied knowing any staff being rough when assisting residents with prosthetic devices. R1 interview reveals that R1 feels pain in the gums because R1 has been losing teeth. R1 did not express that staff were causing pain. S4 stated that dental appointment had been made but dental appointments were cancelled twice to assist R1 with other medical needs. Based upon the investigation, client and staff interviews, and LPA observations, staff did not handle resident rough when assisting with oral care and staff is assisting with dental appointments to meet R1’s dental needs. Report continues on page LIC-9099C... Regarding allegation: Staff take residents blankets away. It is alleged that staff forcefully removed R1’s blanket while R1 was sleeping. The investigation reveals the following: Residents interviews reveal that nine (9) out of ten (10) residents denied the allegation above. Residents stated that staff were considerate of their needs when helping with activities of daily living (ADLs) such as transferring, toileting, or showering. Residents stated that staff treat them respectfully and are not rude to residents. Three residents stated that there is no other place the residents would like to be. Residents stated that none had experienced staff pulling their blanket or pillows away from them. Staff interviews revealed that seven (7) out of seven (7) staff denied above allegation. S1 and S2 stated that community policy allows staff anonymous reporting. S1 stated that community administration does not tolerate staff mistreating residents and an investigation would be initiated. S1 stated that staff would be transferred to other duties during investigation. S1 stated that there has been no recent staff report of staff mistreating any residents. Based upon the investigation, client and staff interviews, and LPA observations, there is no evidence to show that staff are handling residents in an unprofessional manner by pulling residents blanket away. Regarding allegation: Resident fell and staff did not address the residents injury. It is alleged that R1 fell causing a left bruise on her ankle and staff did not ensure R1 received proper care for injury. The investigation reveals the following: On discharge hospital documents dated 10/02/2025, R1 was taken to hospital to get X-ray and there was no ankle injury found. S2 and S4 identified hospital visit on 10/02/2025 as a result of R1’s fall. Interview with S2 indicates that R1 participates in a care plan where a nurse practitioner visits R1 twice a week and a doctor visit once a month for residents who are not easily able to attend appointments. S2 and S4 stated that R1 complains of pain whenever someone touches her. S2 and S4 denied refusing to provide medical assistance to R1 for her pain. The Community has licensed nurses on site and S1 stated that it is community policy to have nurse attend residents who have fallen. An assessment is made, and licensed nurse may decide to transport resident to hospital. The community will call the party responsible and doctors who may decide to transport residents to hospital even if license nurse assessment did not recommend transport to hospital. Residents’ interviews reveal that ten (10) out of ten (10) residents denied the allegation above. Report continues on page LIC-9099C... A resident (R10) described two incidents where resident fell and nurse immediately responded and stayed with resident until paramedics arrived. Ten (10) out of ten (10) residents stated that staff is responsive to residents medical needs. Staff interviews reveal that seven (7) out of seven (7) staff denied the allegations above. Staff is responsive to residents call for help and provide medical assistance as needed. Staff interview revealed that staff is not aware of any other staff refusing to provide medical assistance to residents. Based upon the investigation, client and staff interviews, document review, and LPA observations, the staff provided medical assistance to residents and has an operating plan to handle residents falls. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was held with Director Keith Kasin. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 16, 2025 · control 28-AS-20251009150951

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Gabby Castro conducted subsequent annual inspection on 8/05/2025. LPAs identified themselves and met with Administrator Keith Kasin and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: This facility is licensed to serve fourteen (14) ambulatory residents and five hundred sixty (560) non-ambulatory residents over the age of 60. This facility may retain no more than fifteen (15) hospice residents. There are eight (8) residents under hospice care at this time. This facility provides care to assisted living residents in 4 different wings of the facility. Pinecrest census – seventeen (17), Cedar Court census – ten (10), Maple Court/Birch Court census – forty-nine (49), and twenty-four (24) in Southwood Lodge Memory Care. The Southwoods Lodge Memory Care is approved for delay egress. The total census for this facility is two hundred seventy-seven (277) as of 08/5/2025. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: See 809-C for continuation. Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for eight (8) out of the eight (8) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for eight (8) out of the eight (8) personnel records reviewed. Staffing: Administrator Certificate for Keith Kasin (70005649740) expires 08/10/2026. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. The facility provides incidental medical services. Resident Records/Incident Reports: LPA Ramirez reviewed Resident files for eight (8) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No deficiencies were observed during this inspection. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 5, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a unannounced required annual inspection on 08/01/2025. LPA Ramirez identified herself and met with CEO-Matthew Neeley and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: This facility is licensed to serve fourteen (14) ambulatory residents and five hundred sixty (560) non-ambulatory residents over the age of 60. This facility may retain no more than fifteen (15) hospice residents. There are eight (8) residents under hospice care at this time. This facility provides care to assisted living residents in 4 different wings of the facility. Pinecrest census – seventeen (17), Cedar Court census – ten (10), Maple Court/Birch Court census – forty-nine (49), and twenty-four (24) in Southwood Lodge Memory Care. The Southwood Lodge Memory Care is approved for delay egress. The total census for this facility is two hundred seventy seventy (277) as of 08/1/2025. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: See 809-C for continuation. Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained the required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observed postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed evacuation chairs in stairways. Food Service: LPA Ramirez observed sufficient supply of non-perishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with a maximum temperature of 40-degree F. (4 degree C). LPA Ramirez observed facility weekly and daily menu. LPA Ramirez observed kitchen staff performing a deep cleaning of the kitchen area. LPA Ramirez observed several dining room servers disinfecting tables and counters while wearing gloves and hair nets. Planned Activities: LPA Ramirez observed several residents participating in a staff-led seated exercise. LPA Ramirez observed a calendar for August of 2025 with various activities and outings for residents. LPA Ramirez observed sufficient outdoor space in both assisted living section and in memory care. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed internet access and a facility land line. SEE 809-C for continued report. Residents with Special Needs: Facility pool was observed to be inaccessible to residents with physical and mental disabilities. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps, or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. Due to time constraints, LPA Ramirez will return later to complete annual inspection. No deficiencies were cited at this time. Exit interview was conducted with Matthew Neeley. A copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 1, 2025

Type of visit: Collateral

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced collateral visit at the facility to conduct interviews regarding a recent incident at a different licensed facility. LPA met with Desiree Eudave Director of Resident Care and explained the reason for the visit. The purpose of this visit was to conduct interviews with 1 resident regarding the incident that occurred at the residents' previous facility. Exit interview was conducted with Desiree Eudave and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 4, 2025

Allegation investigated: Staff do not have adequate staffing to meet resident's needs.

LPA made subsequent visit to deliver revised report.The subsequent visit is to provide additional information and clarification not included on the previous reports dated and 08/16/24 and 10/25/2024 02/18/2025. Also new report corrected name at the end of report. LPA met with Administrator Keith Kasin and discussed the purpose of the visit. This report supersedes report 10/25/2024 It was created to add additional information and nothing else has change. The findings remain the same. This report supersedes report dated 08/16/2024. It has been revised to correct grammatical errors. Nothing else has changed. Licensing Program Analyst (LPA) Alberto Lopez conducted subsequent complaint visit to address the above allegation. LPAs met with Desiree Eudave, Supervisor and Keith Kasin, Administrator. LPA explained the reason for the visit. 08/16/2024 On this date, LPA interviewed six (6) staff, and six (6) (Continued On 9099C) Substantiated (continued from 9099C) six (6) residents from Assisted Living and LPA also obtained staff and resident roster and reviewed and obtained two (2) residents' relevant medical documentation, and current training documentation. LPA asked for R6 Woods discharge paperwork and updated LIC602 to be emailed and proof of emergency disaster training for night shift staff. 10/15/2024 LPA interviewed a total of ten (10) staff including staff previously interviewed on earlier visit. LPA interviewed one (1) additional resident. LPA interviewed six (6) residents total and LPA obtained R6 file and 08/2024 and 10/2024 staff schedule. Allegation: Staff do not have adequate staffing to meet resident's needs. It is alleged that facility does not have enough staff to meet resident's needs during the overnight shift. LPA interviewed ten (10) staff, and seven (7) of ten (10) staff corroborated the allegation. Four (4) of six (6) residents interviewed confirmed concerns with staffing: one disclosed there is one staff on shift at night and when the resident called for help it took forty-five minutes for staff to respond, one stated there was a staffing problem, one stated staff are not capable of meeting residents needs and one stated staff are overworked which poses a potential risk to resident in care. Some residents stated staff are very good, but sometimes it takes a long time to assist them during the overnight shift. Some staff interviewed stated that they were stretched thin, and have to leave their assigned building to go to another building to administer medications, or assist residents without any staff during that time. Some staff stated the overnight security guard assists them with residents at times. S2 and S9 also corroborated the allegation and stated, at times, the security guard will assist staff with lifting residents who have fallen overnight. Review of staff schedule for the month of August 2024 shows, one (1) staff assigned to Birch Court, and one (1) staff assigned to Cedar Court each day. The schedule for August 2024 shows two (2) staff scheduled for Southwoods Memory Care each day, one (1) Med-Tech (MT), and one Resident Assistant (RA). The October 2024 schedule shows one (1) staff at Cedar Court building for the overnight shift, one (1) staff at Birch Court, and two (2) staff at Memory Care each night. (Continued on 9099C) (Continued on 9099C) Based on interviews which were conducted with staff, residents and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the Administrator Kevin Kasin along with the Appeals Rights.the state’s words, verbatim · CDSS document, Feb 18, 2025 · control 28-AS-20240808160230

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 25, 2025

87411(a) Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement is not being met as evidenced by: Staff interviews disclosed six out of ten staff felt there was an insufficient number of staff during the night shift. Four of six residents interviewed confirmed concerns with staffing: one disclosed there is one staff on shift at night and when the resident called for help it took forty-five minutes for staff to respond, one stated there was a staffing problem, one stated staff are not capable of meeting residents needs and one stated staff are overworked which poses a potential risk to resident in care.the state’s words, verbatim · CDSS document, Feb 18, 2025

Plan of correction: Facility is to adhere to Section 87411 at all times. Administrator is to submit facility’s current personnel policies including staff coverage and work schedules to the licensing agency for review. The facility’s ratio of staff to residents in both assisted living and memory care and a current LIC500 must be included by POC due date.

Allegation investigated: Staff do not have adequate staffing to meet resident's needs.

LPA made subsequent visit to deliver revised report. the subsequent visit is to provide additional information and clarification not included on the previous reports dated and 08/16/24 and 10/25/2024. LPA met with Administrator Keith Kasin and discussed the purpose of the visit. This report supersedes report dated 10/25/2024 It was created to add additional information and nothing else has change. The findings remain the same. This report supersedes report dated 08/16/2024. It has been revised to correct grammatical errors. Nothing else has changed. Licensing Program Analyst (LPA) Alberto Lopez conducted subsequent complaint visit to address the above allegation. LPAs met with Desiree Eudave, Supervisor and Keith Kasin, Administrator. LPA explained the reason for the visit. 08/16/2024 On this date, LPA interviewed six (6) staff, and six (6) (Continued On 9099C) Substantiated (continued from 9099C) six (6) residents from Assisted Living and LPA also obtained staff and resident roster and reviewed and obtained two (2) residents' relevant medical documentation, and current training documentation. LPA asked for R6 Woods discharge paperwork and updated LIC602 to be emailed and proof of emergency disaster training for night shift staff. 10/15/2024 LPA interviewed a total of ten (10) staff including staff previously interviewed on earlier visit. LPA interviewed one (1) additional resident. LPA interviewed six (6) residents total and LPA obtained R6 file and 08/2024 and 10/2024 staff schedule. Allegation: Staff do not have adequate staffing to meet resident's needs. It is alleged that facility does not have enough staff to meet resident's needs during the overnight shift. LPA interviewed ten (10) staff, and seven (7) of ten (10) staff corroborated the allegation. Four (4) of six (6) residents interviewed confirmed concerns with staffing: one disclosed there is one staff on shift at night and when the resident called for help it took forty-five minutes for staff to respond, one stated there was a staffing problem, one stated staff are not capable of meeting residents needs and one stated staff are overworked which poses a potential risk to resident in care. Some residents stated staff are very good, but sometimes it takes a long time to assist them during the overnight shift. Some staff interviewed stated that they were stretched thin, and have to leave their assigned building to go to another building to administer medications, or assist residents without any staff during that time. Some staff stated the overnight security guard assists them with residents at times. S2 and S9 also corroborated the allegation and stated, at times, the security guard will assist staff with lifting residents who have fallen overnight. Review of staff schedule for the month of August 2024 shows, one (1) staff assigned to Birch Court, and one (1) staff assigned to Cedar Court each day. The schedule for August 2024 shows two (2) staff scheduled for Southwoods Memory Care each day, one (1) Med-Tech (MT), and one Resident Assistant (RA). The October 2024 schedule shows one (1) staff at Cedar Court building for the overnight shift, one (1) staff at Birch Court, and two (2) staff at Memory Care each night. (Continued on 9099C) (Continued on 9099C) Based on interviews which were conducted with staff, residents and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the Supervisor Desiree Eudave along with the Appeals Rights.the state’s words, verbatim · CDSS document, Feb 18, 2025 · control 28-AS-20240808160230

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 25, 2025

87411(a) Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement is not being met as evidenced by: Staff interviews disclosed six (6) out of ten (10) staff felt there was an insufficient number of staff during the night shift. Four (4) of six (6) residents interviewed confirmed concerns with staffing: one disclosed there is one staff on shift at night and when the resident called for help it took forty-five minutes for staff to respond, one stated there was a staffing problem, one stated staff are not capable of meeting residents needs and one stated staff are overworked which poses a potential risk to resident in care.the state’s words, verbatim · CDSS document, Feb 18, 2025

Plan of correction: Facility is to adhere to Section 87411 at all times. Administrator is to submit facility’s current personnel policies including staff coverage and work schedules to the licensing agency for review. The facility’s ratio of staff to residents in both assisted living and memory care and a current LIC500 must be included by POC due date.

Allegation investigated: Staff do not have adequate staffing to meet resident's needs.

This report supersedes report dated 08/16/2024. It has been revised to correct grammatical errors. Nothing else has changed. Licensing Program Analyst (LPA) Alberto Lopez conducted subsequent complaint visit to address the above allegation. LPAs met with Desiree Eudave, Supervisor and Keith Kasin, Administrator. LPA explained the reason for the visit. 08/16/2024 On this date, LPA interviewed six (6) staff six (6) residents from Assisted Living and LPA also obtained staff and resident roster and reviewed and obtained two (2) residents' relevant medical documentation, and current training documentation. LPA asked for R6 Woods discharge paperwork and updated LIC602 to be emailed and proof of emergency disaster training for night shift staff. (continued on 9099C) Substantiated (continued from 9099) 10/15/2024 LPA interviewed a total of ten (10) staff including staff previously interviewed on earlier visit. LPA interviewed one (1) additional resident. LPA interviewed six (6) residents total and LPA obtained R6 file and 08/2024 and 10/2024 staff schedule Allegation: Staff do not have adequate staffing to meet resident's needs. It is alleged that facility does not have enough staff to meet resident's needs during the overnight shift. LPA interviewed ten (10) staff, and seven (7) of ten (10) staff corroborated the allegation. LPA interviewed six (6) residents, and five (5) of six (6) residents were able to corroborate the allegation. Some residents stated staff are very good, but sometimes it takes a long time to assist them during the overnight shift. Some staff interviewed stated that they were stretched thin, and have to leave their assigned building to go to another building to administer medications, or assist residents without any staff during that time. Some staff stated the overnight security guard assists them with residents at times. S2 and S9 also corroborated the allegation and stated, at times, the security guard will assist staff with lifting residents who have fallen overnight. Review of staff schedule for the month of August 2024 states, one (1) staff assigned to Birch Court, and one (1) staff assigned to Cedar Court each day. The schedule for August 2024 states two (2) staff scheduled for Southwood Memory Care each day, one (1) Med-Tech (MT), and one Resident Assistant (RA). The October 2024 schedule shows one (1) staff at Cedar Court building for the overnight shift, one (1) staff at Birch Court, and two (2) staff at Memory Care each night. The fact that staff have to seek the security guard’s assistance at times is evidence that facility does not have enough staff to meet the resident's needs during the overnight shift. Based on interviews which were conducted with staff and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the Supervisor Desiree Eudave along with the Appeals Rights.the state’s words, verbatim · CDSS document, Oct 25, 2024 · control 28-AS-20240808160230

Allegation investigated: Staff do not have adequate staffing to meet resident's needs.

Licensing Program Analyst (LPA) Alberto Lopez conducted subsequent complaint visit to address the above allegation. LPAs met with Desiree Eudave, Supervisor and Keith Kasin, Administrator. LPA explained the reason for the visit. 08/16/2024 On this date, LPA interviewed six (6) staff six (6) residents from Assisted Living and LPA also obtained staff and resident roster and reviewed and obtained two (2) residents' relevant medical documentation, and current training documentation. LPA asked for R6 Woods discharge paperwork and updated LIC602 to be emailed and proof of emergency disaster training for night shift staff. 10/15/2024 LPA interviewed a total of ten (10) staff including staff previously interviewed on earlier visit. LPA interviewed one (1) additional resident. LPA interviewed six (6) residents total and LPA obtained R6 file and 08/2024 and 10/2024 staff schedule. (Continued on 9099C) Substantiated (Continued on 9099) Skill Nursing documentation paperwork dated 12/01/2023 shows R6 with wound which contradicts R6 statement. R1 arrived at facility with wound and currently both are getting Home Health services for their wounds. There is not enough evidence to substantiate this allegation. Allegation: Staff does not provide adequate supervision resulting in residents wandering away from facility. It is alleged that residents have wandered off and put in harms way due to coyotes roaming around. LPA interviewed ten (10) staff and eight (8) of (10 staff) denied the allegation. Six (6) of six (6) residents could not corroborate the allegation. There have been no reports of residents wandering off by local police or other authorities. There is not enough evidence to substantiate this allegation. Allegation: Staff does not have proper training to administer medications. It is alleged that resident assistants that are not trained are administering medications during the overnight shift. LPA interviewed ten (10) staff and nine (9) of 10 (ten) staff denied the allegation. LPA interviewed six (6) residents and six (6) of six (6) residents could not corroborate the allegations. S9 stated that only qualified staff has access to the medications so that cannot occur. S2 stated that only qualified staff are administering medications at facility. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted with and a copy of this report was provided. (continued from 9099) Allegation: Staff do not have adequate staffing to meet resident's needs. It is alleged that facility does not have enough staff to meet resident's needs during the overnight shift. LPA interviewed ten (10) staff and seven (7) of ten (10) staff corroborated the allegation. LPA interviewed six (6) residents and five (5) of six (6) residents were able to corroborate the allegation. Some residents stated staff are very good but sometimes time a long time to assist them during the overnight shift. Some staff interviewed stated that the are stretched thin and have to leave some their assigned building and go to another building to administer medications or assist residents, leaving their assigned building without any staff during that time. Some staff stated that they will seek the assistance of the security guard to help out with resident's needs. Some staff agreed that overnight security guard assists then with residents at times. S2 and S9 also corroborated the allegation and stated security guard will assist staff with lifting residents who have falls overnight at times. Review of staff schedule for the month of August 2024 shows One (1) staff assigned to Birch court and one (1) staff assigned to Cedar court each day. The schedule for August 2024 also shows two (2) staff scheduled for Southwoods Memory care each day, one Med-tech (MT) and one resident Assistant (RA). The October 2024 schedule shows one (1) staff at Cedar court building for the overnight shift, one (1) staff at Birch Court and two (2) staff at memory care each night. The fact that staff have to seek the security guards assistance at times is evidence that facility does not have enough staff to meet the resident's needs during the overnight shift. Based on interviews which were conducted with staff and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the Supervisor Desiree Eudave along with the Appeals Rights.the state’s words, verbatim · CDSS document, Oct 15, 2024 · control 28-AS-20240808160230

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 22, 2024

Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement is not being met as evidenced by: Overnight staff has had to seek the assistance of the security guard to assist residents due to lack of qualified staff.the state’s words, verbatim · CDSS document, Oct 15, 2024

Plan of correction: Administrator will review Title 22 Regulations Section 87411 on Personnel Requirements – General and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date which is 10/22/2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kimberly Ramirez conducted subsequent annual inspection on 7/13/2024. LPA met with Lynn Palin (Director of Social Work) and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Operational Requirements: This facility is licensed to serve fourteen (14) ambulatory residents and five hundred sixty (560) non-ambulatory residents over the age of 60. This facility may retain no more than fifteen (15) hospice residents. There are six (6) residents under hospice care. This facility provides care to assisted living residents in 4 different wings of the facility. Pinecrest census – four (4), Cedar Court census – eleven (11), Maple Court/Birch Court census – thirty-four (34), and twenty-two (22) in Southwoods Lodge Memory Care. Southwoods Lodge Memory Care is approved for delay egress. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for six (6) out of the nine (9) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for nine (9) out of the nine (9) personnel records reviewed. Staffing: Administrator Certificate for Keith Kasin (70005649740) expires 08/10/2024 and is in the process of being renewed. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. The facility provides incidental medical services. See 809-C for continuation. Resident Records/Incident Reports: LPA Ramirez reviewed Resident files for nine (9) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No deficiencies were observed during this inspection. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 13, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Lynn Palin (Director of Social Work) and discussed the purpose of today’s visit. Dan Townsend (Director of Facility Operations) arrived shortly after to assist with tour. This facility is licensed to serve fourteen (14) ambulatory residents and five hundred sixty (560) non-ambulatory residents over the age of 60. This facility may retain no more than fifteen (15) hospice residents. There are six (6) residents under hospice care. This facility provides care to assisted living residents in 4 different wings of the facility. Pinecrest census – four (4), Cedar Court census – eleven (11), Maple Court/Birch Court census – thirty-four (34), and twenty-two (22) in Southwoods Lodge Memory Care. Southwoods Lodge Memory Care is approved for delay egress. Total census for this facility is seventy-one (71). LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected ten (10) rooms; of which three (3) in Southwoods Lodge Memory Care and seven (7) random rooms in assisted living wing of the facility. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observe postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez tested emergency pull cord in room#209. Staff responded 3 minutes later to assist. LPA Ramirez observed evacuation chairs in stairways. See 809-C for continuation. Food Service: LPA Ramirez observed sufficient supply of non-perishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). LPA Ramirez observed facility weekly and daily menu. LPA Ramirez observed kitchen staff preparing for lunch while wearing hair nets and gloves. LPA Ramirez observed several dining room servers disinfecting tables and counters while wearing gloves and hair nets. Planned Activities: LPA Ramirez observed several residents participating in a staff led seated exercise. LPA Ramirez observed a calendar for June of 2024 with various activities and outings for residents. LPA Ramirez observed sufficient outdoor space in both assisted living section and in memory care. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed internet access and a facility land line. Residents with Special Needs: Facility pool was observed to be inaccessible to residents with physical and mental disabilities. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps, or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. Due to time constraints, LPA Ramirez will return later to complete annual inspection. No deficiencies were cited at this time. Exit interview was conducted with Lynn Palin (Director of Social Work). A copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 22, 2024

Allegation investigated: Resident's refrigerator is in disrepair. Facility does not have sufficient maintenance support staff over the weekend.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Desiree Eudave and explained the reason for the visit. The investigation consisted of the following: LPA requested copies of staff/resident roster, conducted a tour of 9 assisted living resident rooms; room #170, 174,176,178,233,236,237,243, and 278. LPA interviewed 7 residents and 7 staff. LPA requested copies of assisted living staff schedule. The investigation revealed the following: Regarding allegations: Resident’s refrigerator is in disrepair and Facility does not have sufficient maintenance support staff over the weekend. It is alleged resident’s refrigerator was not working, it is unknown how long the refrigerator was not working, and maintenance staff is not available on the weekends to assist. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews conducted with residents revealed, 7 out of 7 residents interviewed stated their appliances, including refrigerator have been in working condition. 1 out of the 7 residents mentioned that the refrigerator currently in the apartment had been placed within the last 4 days and was not able to provide further information due to cognitive skills. Per residents, staff respond quickly to residents’ work order reports. The turnaround to fixing something is no later than the same day, including weekends. Interviews with staff revealed, 7 out of 7 staff interviewed stated facility has a security staff on duty 24 hours every day to which the reports can be made, and who will route or provide the services accordingly on the weekends. Other than that, there is a work order line to which residents report any work order services. Per Director of Facility Operation on 10/14/23, he received a call around 5:00pm reporting a refrigerator was not working. At 5:45pm the staff arrived at the facility and replaced the refrigerator with a temporary refrigerator, as a permanent refrigerator attempted to be place in the room did not fit through the door. An order for a fitting refrigerator has been placed and will be put in the resident’s room once it arrives. Per staff, appliances are kept in the facility’s storage room which allows the facility to provide appliances upon a resident reporting an appliance is out of order. Staff also stated that staff are on call when not available at the facility after working hours. Interview with housekeeper serving Resident #1’s room did not observe any issues with the refrigerator within the last three weeks. Interview with Operations Coordinator who receives all the work orders, stated there have not been any work orders received prior to 10/14/23 for a refrigerator being out of order. LPA observed 9 refrigerators/freezers in the residents’ rooms, each seem in working order. Although the allegations may have occurred, the facility responded within two hours to the report of the refrigerator not working and provided a working refrigerator within a window of 2 hours. Although maintenance manager was not scheduled on Saturday, a technician was on schedule until 4:00pm. After hours the manager and director were on call and responded to the call and provided assistance within 45 minutes. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Desiree Eudave and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 24, 2023 · control 28-AS-20231016162911