Brittany House

Allegation investigated: Facility staff do not properly address changes in condition of resident(s).

On 10/20/25 at 8:51 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with as the purpose of today’s visit was explained. The investigation consisted of the following: On 10/20/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #11-13 (R11-R13) emergency ID form, preappraisals, physicians reports, service plans, and home health or hospice documentation if applicable. On 10/20/25 from 9:00 am- 11am LPA conducted Interviews with R1-R10, and from 1pm-2:30pm LPA conduct interviews with staff #1-7 (S1-S7). On 10/20/25 conducted a file review for R11-13. The investigation revealed the following: Allegation: Facility staff do not properly address changes in condition of resident(s). Substantiated It is being alleged that change in conditions are going unnoticed which lead to hospitalization's. On 10/20/25 from 9:00 am- 11am LPA conducted Interviews with R1-R10 regarding the allegation above. 8 of 10 residents denied the allegation above and reported seeing a Dr. when needed. 2 of 10 residents confirmed the allegation and reported they have not been seen by a Dr. when they do not fell good. On 10/20/25 from 1pm-2:30pm LPA conduct interviews with S1-S7. 7 of 7 staff interviewed denied the allegation above and reported med techs or LVN will assess a resident for change in condition, and resident will be sent out as needed. On 10/20/25 conducted a file review for R11-13, LPA observed that there was no re-assessment available for review for R11. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided. It is being alleged that facility is frequently admitting residents without proper triage or assessment. On 10/20/25 from 9:00 am- 11am LPA conducted Interviews with R1-R10 regarding the allegation above, 3 of 10 residents interviewed denied the allegation above, and reported having a pre-placement appraisal conducted prior to admitting to Brittany House. 7 of 10 residents interviewed reported they could not remember if a pre placement appraisal was conducted prior to admitting to Brittany House. On 10/20/25 from 1pm-2:30pm LPA conduct interviews with S1-S7, 7 of 7 staff interviewed denied the allegation above. On 10/20/25 conducted a file review for R11-13, LPA observed completed pre-placement appraisal conducted prior to admitting to Brittany House. Allegation: Facility staff are retaining resident(s) beyond their level of care. It is being alleged that residents at Brittany House require a higher level of care by qualified personnel. On 10/20/25 from 9:00 am- 11am LPA conducted Interviews with R1-R10 regarding the allegation above. 9 of 10 residents interviewed denied the allegation above and reported Brittany House is meeting their care needs 1 of 10 residents interviewed confirmed the allegation above, and reported their needs are not being met. On 10/20/25 from 1pm-2:30 pm LPA conduct interviews with S1-S7 regarding the allegation above. 4 of 7 staff interviewed denied the allegation above. 3 of 7 staff interviewed confirmed the allegation as reported there are residents who require a higher level of care. 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 conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 20, 2025 · control 11-AS-20251015105817

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Nov 3, 2025

87463 Reappraisals :The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition.... based on records review and interviews LPA did not observe a re-assessmnet on file for when R11 returned to the facility which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 20, 2025

Plan of correction: Licensee/Executive Director to review regulation cited and submit a plan to CCLD detailing how facility will get into compliance. In service to be conducted on reappraisal proceudres, LPA to obtain copy of inservice sign in sheet and maerials reviewed.

Allegation investigated: Staff did not seek timely medical attention. Licensee did not ensure resident records were maintained and readily available for emergency medical staff.

On 10/20/2025 at 8:25am, Licensing Program Analysts (LPAs) Zina Brown conducted a subsequent complaint visit at this facility to deliver findings. During today’s visit, LPAs met with Joel Niblett (Executive Director) & explained the purpose of the visit. The investigation consisted of the following: On 09/10/2025, an unannounced initial complaint visit was conducted at the facility by Licensing Program Analysts (LPA) Zina Brown. On 09/10/25 LPA Brown interviewed the Residents (R1-R12), between the hours of 10:17am - 11:52, Administrator (A1) between the hours of 3:20pm - 3:38pm and Staff (S1) between the hours of 2:07pm - 2:15pm. LPA requested the resident and staff roster, resident roster, LIC 601; Emergency Info (for R1-R2,R13), LIC 602: Physician's Report for Resident Care Facilities for the Elderly (for R1-R2,R13), Admission Agreement (for R1-R2,R13), LIC 603: Pre-Placement Appraisal (for R1-R2, R13) and Medication Administrator Record (for R1-R2,R13), and Staff Schedule (dated 09/05/2025). Report continues on LIC 9099-C Substantiated The investigation revealed the following: Allegation: Staff did not seek timely medical attention It is being alleged that facility staff failed to contact emergency services for a resident in care. On 09/19/2025, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated that documentation reflected staff recognized the change in the resident’s condition and called 911 for medical attention. A1's expectation of the staff is to respond appropriately and take immediate action when a resident exhibits serious symptoms. A1 indicated that staff are expected to notify a Certified MedTech and/or a Licensed Nurse immediately, and 911 should be called as needed. On 09/10/2025 and 10/13/2025, LPA conducted interviews with Staff (S1- S4) regarding the allegation above. 1 out of 4 staff interviewed confirmed the allegation above and reported witnessing the incident in question with Resident 13 (R13), per 1 of 4 staff protocol was followed and 911 was called. 1 out of 4 staff interviewed reported being aware of the incident but did not witness it. 2 out of 4 staff interviewed denied the allegation and stated not having knowledge nor witness any emergency regarding the Resident 13 (R13). On 09/10/2025, between the hours of 10:17am - 11:42am LPA Brown conducted interviews with Residents 1-12 (R1-R12), regarding the allegation above. 1 of 12 residents confirmed the allegation and stated that on the day of 09/10/2025 and a week from 09/10/2025 their neighboring resident had to wait a long time before getting help from the facility staff. 11 of the 12 residents reported having no knowledge of the allegation above. On 10/17/2025 between the hours of 4:11pm - 4:20pm LPA conducted a records review and observed the following: the department did not receive a LIC 625: Serious/Unusual Incident Report in regard to Resident 13 (R13) shaking from fever and having chills. On 10/17/25 LPA reviewed the staff schedule (dated on 09/05/2025), and observed the following: during the AM shift two (2) caregivers in Units 1 and Unit 4, three (3) caregivers in Unit 2, one (1) caregiver in Units 3 and Unit 5. During the PM shift in Unit 1, Unit 3 , and Unit 5 - two (2) caregiver each were scheduled to work. In Unit 4 - one (1) caregiver is scheduled to work. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). Allegation: Licensee did not ensure resident records were maintained and readily available for emergency medical staff It is being alleged that facility staff are not properly trained to communicate with emergency medical staff. On 08/11/2025, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated when emergency responders requested information for the resident, it is unknown what records were readily available for the first responders. A1 stated the Licensed Nurses and MedTech staff are trained and aware of where the medical chart is located, which includes the physician’s report, emergency contacts, insurance, and medication lists. A1 added that staff are instructed to provide this information upon request from emergency medical personnel. On 09/10/2025 and on 10/13/2025, LPA Brown conducted interviews with Staff (S1- S4) regarding the allegation. 3 out 4 staff interviewed confirmed of the allegation and stated caregivers are not trained on how to obtain resident records, and it's only Medtechs and/or LVNs who manage records in the event of an medical emergency. 1 out 4 staff denied the allegation and stated staff are trained to locate and provide LIC 602, medication list and facesheet of the resident. On 09/10/2025, between the hours of 10:17am - 11:42am LPA Brown conducted interviews with Residents 1-12 (R1-R12) regarding the allegation above. 9 of 12 residents interviewed reported being unaware of the allegation and stated not knowing if the facility has in their file their doctors name, list of medication and family contact information. 3 of 12 residents interviewed denied the allegation and stated they know the facility has their personal record on file. On 10/17/2025 between the hours of 4:20pm, LPA conducted a records review and observed that there is no training on file for staff to ensure resident record are maintained and readily available for emergency first responders. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D).the state’s words, verbatim · CDSS document, Oct 20, 2025 · control 11-AS-20250909103914

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 24, 2025

Reporting Requirements(a)(1)Each licensee shall submit serious incident reports to. . . the Department may require, including the following: (1) A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurrence of any of the events. This requirement was not met as evidenced by: based observation, LPA observed that the facility did submit a LIC 624 to the department within 7 day of incident occurringthe state’s words, verbatim · CDSS document, Oct 20, 2025

Plan of correction: The facility shall will submit a serious incident reports for the incident that occur on 09/09/2025 with the resident who had symptoms of chill and fevers. The report must be fax to 424-544-1016 to department by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(5) · Plan of correction due date: Oct 27, 2025

Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training &/or related experience shall provide knowledge of & skill in the following: (5) Knowledge necessary in early signs of illness & the need for professional help. This requirement was not met as evidenced by: based on observation and interview staff did not provide emergency first responders with the proper documentation such as medical insurance card, primary care physician information, etc. needed for the resident to be admitted to the hospitalthe state’s words, verbatim · CDSS document, Oct 20, 2025

Plan of correction: The facility will conduct an in service training for all staff to be trained on how to provide all necessary documentation needed upon request by emergency first responders. Also the facility shall create form to be signed by the emergency first responders for proof of receiving resident records before . . . transporting the resident to the hospital. The facility will submit proof of staff in-service training with signatures and the proof of resident record form provided to emergency first responders to department by POC due date via email Zina.Brown@dss.ca.gov

Type of visit: Case Management - Deficiencies

On 10/20/25, Licensing Program Analyst (LPA) Villegas conducted an unannounced case management deficiencies. The purpose of the visit is to issue a citation observed during the complaint investigation - Control 11-AS-20251015105817. During the complaint investigation, LPA learned that there was no documented care plan for the use of a catheter. Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D. Exit interview conducted with Executive Director Joe Niblett and copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Oct 20, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87623(b)(2)(B)(C) · Plan of correction due date: Dec 4, 2025

87623 Indwelling Urinary Catheter In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for thefollowing:Ensuring that the bag and tubing are changed by an appropriately skilled professional should the resident require assistance. There should be written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed...This requirement was not met as there was no plan in place for catheter care which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 20, 2025

Plan of correction: Licensee/Executive director to review section cited and submit a plan on how to get into compliance. Facility will ensure there are care plans available for review, plan should detail what staff will oversee the care.

Allegation investigated: Staff are not following proper eviction procedures

On 10/14/2025 at approximately 1:00 PM, LPA Alfonso Iniguez conducted an unannounced initial complaint visit. LPA Iniguez met Joel Niblett/Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrators Interview (A#1) and Facility Staff Interview (S#1). LPA obtained and reviewed the following documents: Resident Roster dated: 10/14/25, Staff Roster dated: 10/9/25. Evaluation Report continues LIC 9099-C Substantiated Investigation Revealed the Following: Allegation: Staff are not following proper eviction procedures The details of the complaint alleged that facility does not want to take (R#1) back from hospital. On October 14, 2025, at approximately 2:00 PM, during an interview with (S#1), it was mentioned that (R#1) is currently hospitalized and has a Foley catheter in place. (S#1) expressed concern about who would assist (R#1) with catheter care outside the hours when the Licensed Vocational Nurse (LVN), identified as (S#2), is on duty from 8:00 AM to 4:00 PM. Additionally, (S#1) noted that (R#1)’s insurance does not cover home health services for assistance with the Foley catheter. (S#1) also stated that they spoke with the hospital social worker to inform them that (R#1) requires more support than the facility can provide. Furthermore, (S#1) acknowledged that they did not assess (R#1) before discharge while the resident was still at the hospital, which prevented (R#1) from returning to the facility. During this investigation, the Department found sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). An exit interview was conducted, and a copy of the Complaint Report was given to Joel Niblett/Administrator.the state’s words, verbatim · CDSS document, Oct 14, 2025 · control 11-AS-20251013130805

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Oct 17, 2025

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)... This requirement was not met as evidence by: Based on interviews with (S#1), the facility failed to ensure that resident (R#1) was properly assessed prior to hospital discharge. (S#1) informed the hospital social worker that (R#1) required more assistance than the facility could provide, which resulted in (R#1) not being able to return to the facility upon discharge. This poses a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: License will adhere to Title 22 at all times. As Plan of Correction, the licensee will conduct a proper discharge assessment of (R#1) and accommodate their medical needs at the facility. A proof of correction will be provided to the department before POC due date.

Allegation investigated: Staff did not provide resident with proper notification prior to rate increase. Staff did not follow proper eviction procedures.

On 10/09/2025 Licensing Program Analyst (LPA) Troy Watson conducted an initial complaint visit to the facility listed above. LPA met with Administrator Joel Niblett and the purpose of the visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: On 10/09/2025 LPA Watson requested, reviewed and obtained the following: Personnel Report, Resident Roster, Admission Agreement, Medical Assessment, emailed correspondence, and an Account Balance Sheet 10/10/25. On 10/09/2025 LPA Watson conducted interviews with Resident # 1- Residents #12 (R1-C12) and Staff#1 – Staff #7 (S1-S7). LPA Watson toured the facility with the Care Giver Dafne Diaz and found the facility clean and in good repair. CONTINUED ON LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not provide residents with proper notification prior to rate increase. On 10/09/2025 LPA Watson interviewed Staff #1-Staff #7 (S1-S7). Of those interviewed, 7 out of 7 staff denied the above allegation. On 10/09/2025 LPA Watson interviewed Residents #1 – Residents #12 (R1-R12). Of those interviewed 11 out of 12 denied the above allegation. LPA Watson reviewed the Notice or Rate increase document and it showed that they were properly notified of the rate increase of their room. Based on record reviews, staff and client interviews and observations there is insufficient evidence to support the allegation: “Staff does not treat residents with dignity and respect” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff did not follow proper eviction procedures. On 10/09/2025 LPA Watson interviewed Staff #1-Staff #7 (S1-S7). Of those interviewed, 7 out of 7 staff denied the above allegation. On 10/09/2025 LPA Watson interviewed Residents #1 – Residents #12 (R1-R12). Of those interviewed 11 out of 12 denied the above allegation. LPA Watson requested an eviction notice in regard to the complainant from the Administrator Joel Niblett, and he stated that he never formerly gave an eviction notice to anyone. LPA Watson requested and did not receive any records that showed an eviction notice was given. Based on record reviews, staff and client interviews and observations there is insufficient evidence to support the allegation: “Staff does not treat residents with dignity and respect” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with the Administrator Joel Niblett and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 11-AS-20251001083704

Allegation investigated: Staff did not provide adequate supervision resulting in resident falling and sustaining a fracture. Staff did not seek medical attention to resident

On 10/02/2025 the Community Care Licensing Division (CCLD) conducted a subsequent visit to deliver an updated version of the investigation report regarding the allegations listed above. The purpose of this report is to provide additional information and to provide the correct definition of serious bodily injury. CCLD staff met with Manager Dafne Villavelazques and the purpose of the visit was explained. The investigation consisted of the following: 09/10/2025 CCLD staff conducted a subsequent complaint investigation to deliver the investigation findings for the allegations listed above. On 01/27/2025 CCLD staff toured the facility and requested copies of Staff and Resident roster, LIC500, Needs and Service Plan, Physician Report, Hospital Records, incident reports for 1 of 6 residents and interviewed 5 staff and 6 residents. On 02/12/2025 CCLD staff interviewed the witness (W1). CCLD staff obtained and reviewed the following: Facility Service Plan 01/02/2025, 01/14/2025, 01/15/2025), St. Mary Hospital records (dated 02/01/2024 to 01/28/2025) and Specialty Hospice Care records (dated 06/14/2024 to 02/03/2025). Substantiated On 08/07/2025 CCLD staff requested copies of Staff and Resident roster, LIC500, Physician Report, Incontinence care records, caregiver notes, Medication Administration Record for R1 and interviewed 4 staff and 6 residents. The investigation revealed the following: Regarding the allegation: “Staff did not provide adequate supervision, resulting in the resident falling and sustaining a fracture.” Records reviewed indicate the following: The Physician Report (dated 10/31/2024) indicates that R1 was non-ambulatory and had secondary diagnoses of Dementia. The Facility Service Plan (dated 09/06/2024) notes that R1 wanders throughout the building and into other residents’ rooms. R1 requires assistance with orientation, redirection, and wayfinding due to forgetfulness and difficulty concentrating. On 11/05/2024, the Specialty Hospice Care nurse instructed facility staff to assist R1 and not leave R1 unattended due to declining health and generalized body weakness. The Incident Report states that on 01/02/2025, R1 experienced a witnessed fall and was taken to the hospital. On 01/14/2025, R1 had an unwitnessed fall and was found on the floor near R1’s room, complaining of hip pain. On 01/15/2025, R1 again complained of right hip pain and was transported to the hospital. St. Mary’s Hospital medical records (dated 01/15/2025) confirm that R1 was diagnosed with a right femoral fracture. Interviews indicate the following: Witness W1 stated that R1 was a fall risk and required supervision while ambulating with a walker. Staff members S1 through S13 consistently indicated that R1 was a fall risk and required supervision. S1 reported that on 01/14/2025, S1 and S2 were supervising R1 and other residents in the dining room. However, both staff members left the dining room to respond to an unexpected death in another resident’s room, leaving R1 unsupervised for approximately 20 minutes. During this time, R1 wandered away and had an unwitnessed fall in another resident’s room. Based on the records review and interviews, the preponderance of evidence standard has been met. Therefore, the allegation that “staff did not provide adequate supervision, resulting in the resident falling and sustaining a fracture” is found to be SUBSTANTIATED. Regarding the Allegation: “Staff Did Not Seek Medical Attention for Resident.” This complaint alleged that staff failed to seek timely medical attention for a resident who was in pain after an unwitnessed fall. Records reviewed indicate the following: Physician Report (dated 10/31/2024) indicates that R1 was non-ambulatory and had secondary diagnoses of Dementia. R1 requires assistance with orientation, redirection, and wayfinding due to forgetfulness and difficulty concentrating. The Incident Report states that on 01/02/2025, R1 experienced a witnessed fall and was taken to the hospital. The incident reports dated 01/14/2025 and 01/15/2025 show that on 01/14/2025, R1 was found on the floor following an unwitnessed fall. On 01/15/2025, R1 complained of pain in the right hip. The medical report from St. Mary Medical Center indicates that R1 had fallen on 01/14/2025 and complained of right hip pain. On 01/15/2025, R1 was transported to the hospital and diagnosed with a right femoral fracture. Interviews revealed the following: Staff members S1 through S13 confirmed that R1 experienced an unwitnessed fall on 01/14/2025 and complained of right hip pain. Medtech Jordan Morales and caregiver Marie Reyes recognized that R1 was experiencing pain in the right hip/leg but did not notify the hospice agency or R1’s daughter/POA at the time. Based on observations and interviews conducted by CCLD staff, as well as the records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation that “Staff did not seek medical attention for the resident” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are cited on the attached LIC 9099D. An immediate civil penalty of $500.00 is being assessed, please see LIC421IM. At this time, an additional civil penalty determination is pending in reference to The Welfare and Institutions Code Section 15610.67 which defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” An exit interview was conducted, and plans of corrections were developed and a copy of this report and appeals rights were provided to Administrator JOEL NIBLETT.the state’s words, verbatim · CDSS document, Oct 2, 2025 · control 11-AS-20250124110111

Allegation investigated: Staff did not provide adequate supervision resulting in resident falling and sustaining a fracture. Staff did not seek medical attention to resident

On 09/18/2025 the Community Care Licensing Division (CCLD) staff conducted a subsequent complaint investigation at Brittany House Facility to deliver the investigation findings for the allegations listed above. CCLD staff met with Manager Joel Niblett (S1) and the purpose of the visit was explained. The investigation consisted of the following: On 01/27/2025 CCLD staff toured the facility and requested copies of Staff and Resident roster, LIC500, Needs and Service Plan, Physician Report, Hospital Records, incident reports for 1 of 6 residents and interviewed 5 staff and 6 residents. On 02/12/2025 CCLD staff interviewed the witness (W1). CCLD staff obtained and reviewed the following: Facility Service Plan 01/02/2025, 01/14/2025, 01/15/2025), St. Mary Hospital records (dated 02/01/2024 to 01/28/2025) and Specialty Hospice Care records (dated 06/14/2024 to 02/03/2025). On 08/07/2025 CCLD staff requested copies of Staff and Resident roster, LIC500, Physician Report, Incontinence care records, caregiver notes, Medication Administration Record for R1 and interviewed 4 staff and 6 residents. Substantiated The investigation revealed the following: Regarding the allegation: “Staff did not provide adequate supervision, resulting in the resident falling and sustaining a fracture.” Records reviewed indicate the following: The Physician Report (dated 10/31/2024) indicates that R1 was non-ambulatory and had secondary diagnoses of Dementia. The Facility Service Plan (dated 09/06/2024) notes that R1 wanders throughout the building and into other residents’ rooms. R1 requires assistance with orientation, redirection, and wayfinding due to forgetfulness and difficulty concentrating. On 11/05/2024, the Specialty Hospice Care nurse instructed facility staff to assist R1 and not leave R1 unattended due to declining health and generalized body weakness. The Incident Report states that on 01/02/2025, R1 experienced a witnessed fall and was taken to the hospital. On 01/14/2025, R1 had an unwitnessed fall and was found on the floor near R1’s room, complaining of hip pain. On 01/15/2025, R1 again complained of right hip pain and was transported to the hospital. St. Mary’s Hospital medical records (dated 01/15/2025) confirm that R1 was diagnosed with a right femoral fracture. Interviews indicate the following: Witness W1 stated that R1 was a fall risk and required supervision while ambulating with a walker. Staff members S1 through S13 consistently indicated that R1 was a fall risk and required supervision. S1 reported that on 01/14/2025, S1 and S2 were supervising R1 and other residents in the dining room. However, both staff members left the dining room to respond to an unexpected death in another resident’s room, leaving R1 unsupervised for approximately 20 minutes. During this time, R1 wandered away and had an unwitnessed fall in another resident’s room. Based on the records review and interviews, the preponderance of evidence standard has been met. Therefore, the allegation that “staff did not provide adequate supervision, Regarding the Allegation: “Staff Did Not Seek Medical Attention for Resident.” This complaint alleged that staff failed to seek timely medical attention for a resident who was in pain after an unwitnessed fall. Records reviewed indicate the following: Physician Report (dated 10/31/2024) indicates that R1 was non-ambulatory and had secondary diagnoses of Dementia. R1 requires assistance with orientation, redirection, and wayfinding due to forgetfulness and difficulty concentrating. The Incident Report states that on 01/02/2025, R1 experienced a witnessed fall and was taken to the hospital. The incident reports dated 01/14/2025 and 01/15/2025 show that on 01/14/2025, R1 was found on the floor following an unwitnessed fall. On 01/15/2025, R1 complained of pain in the right hip. The medical report from St. Mary Medical Center indicates that R1 had fallen on 01/14/2025 and complained of right hip pain. On 01/15/2025, R1 was transported to the hospital and diagnosed with a right femoral fracture. Interviews revealed the following: Staff members S1 through S13 confirmed that R1 experienced an unwitnessed fall on 01/14/2025 and complained of right hip pain. Medtech Jordan Morales and caregiver Marie Reyes recognized that R1 was experiencing pain in the right hip/leg but did not notify the hospice agency or R1’s daughter/POA at the time. Based on observations and interviews conducted by CCLD staff, as well as the records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation that “Staff did not seek medical attention for the resident” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are cited on the attached LIC 9099D. An immediate civil penalty of $500.00 is being assessed, please see LIC421IM. At this time, an additional civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An exit interview was conducted, and plans of corrections were developed and a copy of this report and appeals rights were provided to Administrator Manager Joel Niblett (S1). The investigation consisted of the following: Regarding the Allegation: “Staff did not prevent residents from developing a UTI while in care.” This complaint alleged that staff failed to provide residents with adequate assistance for their incontinent needs, resulting in Resident 1 (R1) developing two urinary tract infections (UTIs) while in care. Records reviewed indicate the following: At Specialty Hospice Care, R1 has a history of falls and a recent right hip fracture. The Physician Report (dated 10/31/2024) lists the primary diagnosis as non-ambulatory and the secondary diagnosis as urinary tract infection (UTI). It also notes bladder and bowel impairments and states that R1 requires assistance with bathing and toileting. St. Mary’s Hospital records (dated 01/15/2025) indicate that, multiple UTIs in the past, which were resolved with antibiotics. Interviews indicate the following: 9 out of 9 staff members denied the allegation. R1 could not be interviewed, as R1 no longer resides at the facility. 9 out of 12 residents denied the allegation. Based on the records reviewed and interviews conducted, the preponderance of evidence standard has not been met. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that "Staff did not prevent resident from developing a UTI while in care" is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided to Administrator Manager Joel Niblett (S1).the state’s words, verbatim · CDSS document, Sep 18, 2025 · control 11-AS-20250124110111

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 22, 2025

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: Based on record reviews and interviews conducted the licensee failed to ensure that supervision was provided to meet the residents’ needs. On 01/14/2025 staff S1 and S2 left R1 unsupervised which resulted to R1 falling and sustaining a fracture which posed an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: POC: The licensee agreed to create a plan to ensure that staff are sufficient in numbers and competent to provide the services necessary to meet resident needs. Proof of correction will be submitted to jose.calderon@dss.ca.gov.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Sep 22, 2025

Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidence by: Based on records and interviews conducted the licensee failed to ensure that 911 was called after R1’s unwitnessed fall on 11/14/2024, which posed an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: The licensee agreed to provide additional training to staff on PIN 25-06-ASC Calling 9-1-1 in Residential Care Facilities for the Elderly (RCFE), proof of correction will be submitted to jose.calderon@dss.ca.gov.

Allegation investigated: Staff not treating resident with dignity and respect. Staff leave residents soiled for an extended period of time. Staff are not answering call buttons in a timely manner.

On 09/10/2025 at 9:15am, Licensing Program Analyst (LPA) Zina Brown conducted a unannounced subsequent complaint visit at this facility to deliver the complaint findings. During today’s visit, LPA met with Joel Niblett and explained the purpose of the visit. On 07/09/2025, at 8:55 am Licensing Program Analyst (LPA) Zina Brown conducted an initial complaint visit LPA met with Joel Niblett (Administrator) explained the purpose of the visit. The investigation consisted of the following: On 07/09/2025, LPA Brown interviewed the staff (S1-S7), and Residents (R1-R8). LPA requested the resident and staff roster, resident roster, Face Sheet & Emergency Info (for R1), Medicine History & Physical MCH (for R1), Discharge Medication Reconciliation Order Report (for R1),Admission Agreement (for R1), LIC 603: Pre-Placement Appraisal (for R1),Service Plan (for R1) andLIC 602: Medical Assessment for Resident Care Facilities for the Elderly. Report continues on LIC 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff not treating residents with dignity and respect It is alleged that a staff member has been verbally abusive, calling Resident 7 derogatory names such as "stupid bitch" and using profanity. On 07/09/2025 at 10:02 AM, LPA interviewed A1. A1 who denied the allegation stated not hearing nor witness staff using profanity nor being disrespectful to the residents. A1 states staff must be respectful at all time which is standard practice at the facility. On 07/09/2025 between the hours of 10:00am - 1:58pm. LPA interviewed (7) staff regarding the allegation. Of the 7 staff: 6 out of 7 staff denied the allegation. 1 out of 7 staff did not confirm nor deny the allegation. On 07/09/2025, between the hours of 2:35pm - 3:35 pm and on 09/10/2025, between the hours of 10:45am - 1:42, LPA interviewed (11) residents regarding the allegation. Of the (11) residents: 1 out of 11 confirmed the allegation. 10 out of 11 denied the allegation. 10 of the residents stated the facility it's alright, everyone is treated fair, and with respect. 1 of the resident stated an employee has used inappropriate language and has threatened her. Based on interviews conducted, records review and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED Report continues on LIC 9099-C Allegation: Staff leave residents soiled for an extended period of time It is alleged that residents are not being changed in a timely manner, resulting in them remaining soiled for prolonged periods. On 07/09/2025 at 10:02 AM, LPA interviewed A1. A1 who denied the allegation stated not aware of residents being left soiled nor not being changed in a timely manner as the facility documents when residents are changed and provided incontinence care. Between the hours of 10:00am - 1:58pm, LPA interviewed (7) staff regarding the allegation. Of the 7 staff: 6 out of 7 staff denied the allegation (1) out of (7) staff confirmed the allegation. Staff states R7 will be assisted with their changing needs by staff and just minutes later R7 will request to have a depends and or diapers changed although the resident is not soiled. Also, its been stated by the staff R7 only wants certain staff to meet her needs and if R7's does not get their way and or needs met immediately, the resident throws food, water and or items at the staff. On 07/09/2025, between the hours of 2:35pm - 3:35 pm and on 09/10/2025, between the hours of 10:45am - 1:42pm, LPA interviewed (11) residents regarding the allegation. 2 out of 11 confirmed the allegation. 9 out of 11 denied the allegation. Out of the 11 residents: (4) residents are incontinent and stated staff come quickly to help residents to the bathroom and or help with getting dressed. (5) of the residents stated they do not wear depends nor diapers and are fully independent and is capable of taking care of themselves. (2) of residents who confirmed the allegation, one stated she is not incontinent but just can't walk but as a result of having to wait a long time to be changed or cleaned as of result of that they have had an accident. On 09/05/2025 at 11:35am, LPA conducted a records review and observed the following: On the LIC 602A Medical Assessment for Residential Care Facilities for the Elderly, on page 4 of 9 under the section 1. Overall Physical Health the following physical health status are checked yes: bowel incontinence, bladder incontinence, motor impairment/paralysis (with a history of Cerebrovascular Accident (CVA) and requires assistance with repositioning and transferring due to left side weakness. In the comments it states that R7 had a stroke in 2023 that resulted in left hemiparesis. Since the stroke R7 has been mostly bed-bound occasionally sits up in a wheelchair. On page 5 of 9 on the LIC 602A under the section 2. Capacity for Self-Care d. Able to Care for Own Toileting Needs is checked no which explains due to left sided weakness. On the Face Sheets and Emergency Info form on page 2 of 7 under the toileting section it states full assistance by a caregiver is needed daily with grooming in the morning and at bedtime with two-person assistance. Based on interviews conducted, records review and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED Allegation: Staff are not answering call buttons in a timely manner It is alleged that there is a delay in staff responding to residents’ call button requests. On 07/09/2025 at 10:02 AM, LPA interviewed A1. A1, who denied the allegation, stated that when the facility is alerted by the call light, the protocol requires staff to respond promptly. A1 does not recall any incidents on or around 07/07/2025–07/08/2025 where Resident 7’s (R7) request for assistance was not received in a timely manner. Between the hours of 10:00am - 1:58pm, LPA interviewed seven (7) staff regarding the allegation. Of the (7) staff, 7 out of 7 staff denied the allegation. Of the 7 staff, 2 of the caregiver stated most of the resident's do not use their call light button as most of the resident will yell out for the staff to come assist and or staff caregivers typically conduct 30 minute rounds around the facility to check on the residents. On 07/09/2025, between the hours of 2:35pm - 3:35 pm and on 09/10/2025, between the hours of 10:45am - 1:42pm, LPA interviewed (11) residents regarding the allegation. 1 out of 11 resident confirmed the allegation. 10 out of 11 residents denied the allegation. 11 of the residents, 9 stated not using, don't need a call button and or will call out for the staff to assist with their needs. 1 resident stated the staff response when pressing the call button. 1 resident stated the call string from the call button came off so resident yells but the staff still does not respond when she does so. On 09/10/2025 between the hours of 1:53pm - 3:20pm, LPA conducted a tour of the Memory Care Unit (located in Unit 1, Unit 2 and Unit 5) and Assisted Living Unit (located in Unit 3 - Unit 4). LPA observed the following respond time for staff to answer the residents call lights: Room 114 (3:05pm - 3:06pm), Room 201 (3:05pm - 3:06pm), Room 230 (3:11pm - 3:20pm), Room 304 (1:53pm - 2:00pm) and Room 407(3:03pm - 3:04pm). Estimated response time was 7-10 minutes for staff to clear the resident call lights. Based on interviews conducted, records review and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Joel Niblett (Administrator) and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 10, 2025 · control 11-AS-20250708131324

Allegation investigated: Staff left resident in soiled clothing for a period of time. Staff not keeping resident’s room free from odor.

On 08/27/25, at 09:30am, Licensing Program Analyst (LPA) Perry Scott conducted an initial complaint visit to the facility and was greeted by Joel Niblett, Executive Director. LPA explained the purpose of this visit is to gather information about the complaint, gather facility files, interview staff and residents, and deliver findings for the allegations mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S5) and residents (R1-R10). The department received the following: Resident Roster (No Date) Staff Roster (Dated: 08/25/2025), Admission Record (Dated: 06/26/2025), Physician Report LIC 602A (Dated: 07/02/2025), Medical Assessment (Dated: 08/06/2025), Service Plan (Dated: 07/09/2025), CalAIM Tier Level Assessment Form (Dated: 07/11/2025), and Caregiver Daily Flow Sheet and Shower Schedule (Dated: 08/01/2025-08/31/2025), and Discharge Notes from Memorial Care (Dated: 08/20/25) were obtained from the facility. Report Continued on LIC9099-C Substantiated The investigation revealed the following: Allegation #1- Staff left resident in soiled clothing for a period of time. The details of the complaint alleged that emergency services came to the facility on 08/20/25 because the resident (R1) was having difficulties that needed to be addressed. While at the facility it was reported that (R1) was observed to not have been cared for properly and smelled as though (R1) had not showered in weeks and was in soiled clothing. On 08/27/25, from 9:30am-2:00pm, the department interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. 4 of 5 staff stated that the resident has a history of refusing to shower and urinating on themselves as well as in their room. They state that they make every effort to change the resident when they discover that the resident has urinated or defecated on themselves but adds that the resident is very aggressive and combative when they try to change the resident. They further state that it takes several caregivers to achieve this, and it happens multiple times per day, but they do their best to keep the resident dry. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that they were never left in soiled clothing for an extended period of time. They state that the staff is attentive to their needs, when assistance is needed. The department reviewed the Caregiver Daily Flow Sheet and Shower Schedule (Dated: 08/01/2025-08/31/2025) and Service Plan (Dated: 07/09/2025) and observed the resident has refused to take a shower on the following dates: 08/01/25, 08/03/25, 08/05/25, 08/06/25, 08/10/25, and 08/18/25 which were the resident’s scheduled shower days. The department did not find any evidence that the issue was being properly addressed by the facility knowing that the resident has these particular ongoing issues. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff left resident in soiled clothing for a period of time, is found to be Substantiated. California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D. Allegation #2- Staff not keeping resident’s room free from odor. The details of the complaint alleged that the staff does not ensure that the resident’s room is free from odor. It was reported that staff is not ensuring that the resident is not urinating in the resident’s room and therefore the resident’s room smells of urine. On 08/27/25, from 9:30am-2:00pm, the department interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. 4 of 5 staff corroborated the allegation that Staff not keeping resident’s room free from odor. The majority of staff stated that the resident does urinate in their room and in their bed. They state that the resident’s room must be cleaned daily because the resident urinates in their urinal container and then pours it out onto the bed as well as on the floor. They further state that they make every effort to keep the room sanitized and clean and to change the resident often. However, this is an ongoing occurrence with the resident, stated staff. Report Continued on LIC9099-C The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that their room does not have any odors, and staff cleans their room daily. The department toured the resident’s room and observed that there is a strong urine smell as you enter the room, as well as stains on the carpet, which smells of urine. Based on observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation Staff not keeping resident’s room free from odor, is found to be Substantiated. California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D. Note: *Citations that are not cleared by the due date of 09/12/25 will have a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. Deficiency was cleared at the time of the visit. Deficiencies were issued and plans of corrections were discussed. An exit interview was conducted with Joel Niblett, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 11-AS-20250820143555

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Sep 12, 2025

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and the appropriate assistance is provided when such observations\ reveals unmet needs…This requirement was not met as evidence by: Based on observation and interviews, staff did change resident, however due to the frequency of the urination, the resident continued to be in soiled clothing for a period of time due to the resident urinating on themselves and in their bed. This violation poses a potential health and safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Licensee/Administrator shall read Title 22 Section 87466 Observation of the Resident. Licensee to do in-service training with staff on observation of residents and send proof of the in-service with signatures of staff working in assisted living and acknowledgement of the regulation. The facility will submit the plan of correction by the due date of 09/12/25 and email it to LPA Perry Scott’s email at perry.scott@dss.ca.gov to avoid monetary penalties.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 12, 2025

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observation, the resident’s bedroom #207 has a strong odor of urine and the carpet was observed to have liquid stains, possibly urine stains based on the odor emanating from the carpeting. This violation poses a potential health and safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: The Administrator will develop a plan of correction that will address the resident urinating in the room; and ensure that the carpeting in the room is cleaned and sanitized regularly to ensure the health and safety of the resident, employees, and visitors. The facility will submit the plan of correction by the due date of 09/12/25 and email it to LPA Perry Scott’s email at perry.scott@dss.ca.gov to avoid monetary penalties.

Type of visit: Case Management - Deficiencies

On 08/20/2025, Licensing Program Analyst (LPA), Antonine Richard, conducted a case management visit to document deficiencies observed during an investigation related to Complaint Control Number:11-AS-20250812125512. LPA explained the purpose of the visit to staff member Girma Yodit. On 08/20/2025 at 10:00 am, LPA conducted a file review. LPA found that one of the facility staff members did not have background clearance and was not associated with the facility. Interviews conducted, observation, and records reviewed revealed that the facility was not in compliance with the California Code of Regulations Title 22. Deficiency cited based on interviews conducted, records reviewed, and observation in accordance with the California Code of Regulations, Title 22. A copy of the appeal rights and this report was left with the Staff Girma Yodit. On 08/21/2025, the license was cited with Title 22 Criminal Clearance Record Regulations 87355(e)(2). Based on interviews, observation, and record reviews, the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiency was issued. An exit interview was conducted with staff member, Girma Yodit. A copy of this report, appeal rights, and civil penalty was provided.the state’s words, verbatim · CDSS document, Aug 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Aug 22, 2025

87355 Criminal Record Clearance - (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 requirement is not met as evidenced by: Based on review of records, the licensee did not comply with the section. LPA identified that one staff member did not have a Criminal Clearance Background, Clearance Transfer associated with this facility. This violation poses an immediate health, safety, or personal rights risk to the person in care.the state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: Licensee to ensure that all staff, before working in the facility, obtain a Criminal Background Clearance and Criminal Background Transfer Request and provide proof of correction to CCLD by the POC due date. Proof of Correction due date: 08/22/25. Antonine.Richard@dss.ca.gov

Allegation investigated: Facility unlawfully evicted resident

On 8/20/2025, at 10:50 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct an investigation and deliver findings for the alleged allegation. LPA identified herself and met Joel Niblett-Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 8/20/2025 at 10:50 AM, LPA Allen obtained and reviewed files for Resident 1 (R1), which included face sheet, medical assement date 7/9/2025, physicians orders for life sustaining treatment, pre-placement appraisal unsigned but dated 6/17/2025, concent for treatment dated 7/9/2025 ,Admission agreement from Mission Community Hospital dated 4/16/2025 and discharge report dated 6/14/2025,Resident sign-out sheet dated 7/19/2025, A written statement of resident transfer to new facility Simla Villas dated 8/20/2025. LPA also conducted interviews with staff members 1-2 (S1-S2),Witness1-2 (W1-W2) and Resident 1(R1). Continued Unsubstantiated Investigation revealed the following: Allegation: Facility unlawfully evicted resident On August 20, 2025, at 11:00 AM, LPA Allen conducted interviews with Staff 1-2 (S1–S2). 2 out of 2 staff members stated that Resident 1 (R1) was not evicted from the facility. LPA did not observe any documentation indicating that R1 was evicted. According to S1 and S2, R1 had been requesting relocation to another facility since June 17, 2025, due to concerns that the current staff could not meet their level of care needs. Upon R1’s arrival on June 17, 2025, staff began the process of identifying a new facility that could accommodate R1’s required services. R1 was scheduled to transfer to the new facility, Simla Villas, on July 19, 2025. However, R1 declined the transfer and informed S1 and S2 that they would be leaving the facility with a friend. S2 advised R1 that leaving the facility without transferring to the new location would be considered leaving Against Medical Advice (AMA), and that re-admittance would not be possible under those circumstances. LPA also conducted an interview with Witness 1 (W1), who stated that Resident 1 (R1) was scheduled to be relocated to a new facility on July 19, 2025, but refused the transfer. Witness 2 (W2) confirmed that R1 was expected to be admitted to their facility on the same date; however, R1 never arrived. W2 was unable to confirm or deny the reason for R1 not being admitted. Additionally, LPA interviewed R1, who confirmed that they left the facility on July 19, 2025, of their own free will with a friend who would be providing care. R1 stated they were never issued a written eviction notice. R1 denied ever wanting to leave the facility. Based on the evidence gathered during the interviews, records reviewed, and observations during the investigation, the above allegations are found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Joel Niblett-Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 11-AS-20250814140557

Allegation investigated: Staff mishandle the residents medications.

On 08/20/2025, at 09:30 am, Licensing Program Analyst (LPA) Antonine Richard conducted an initial complaint visit and delivered findings. LPA met with Joel Niblett Administrator, and explained the purpose of the visit. The investigation consisted of the following: On 08/20/2025, LPA Richard requested the residents and staff roster, Medication Mar (Dated July 20, 2025), License vocational Nurse (LVN), and Med Teck (MT) scheduled (Dated July 20, 2025),Timecard by labor Level (Dated 07/20/2025). On 08/20/2025, LPA interviewed seven residents #1-7 (R1-R7), four staff #1-4 (S1-S4), and the Administrator #1 (A1). Continued Report LIC9099C Unsubstantiated Allegation: Staff mishandled the residents' medications. The complaint alleges that medication errors occurred and delays happened on 07/20/2025. On 08/20/2025, from 10:30 am to 1:45 pm, LPA Richard interviewed Administrator #1 (A1), who denied the allegation and stated that no medication errors or delays took place that day. The facility had a staff member call off, but the facility found a staff member to cover the shift. During the same time frame, LPA Richard also interviewed seven residents #1-7 (R1-R7), all of whom denied any medication delays or missed doses since they have been living here. Additionally, LPA interviewed four staff members #1-4 (S1-S4), all of whom denied the allegation. On 08/20/2025, LPA Richard reviewed medication records showing that all residents received their medications, and there were no discrepancies. LPA also reviewed the facility's Chat Note confirmed there were no medication errors or missing medications administered to any residents. Based on the information collected from the facility inspection, interviews, and records reviewed, LPA found no evidence to support the above allegations. Although the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegation is unsubstantiated. No deficiencies cited. An exit interview conducted. A copy of this report was provided to the Administrator Joe Niblettthe state’s words, verbatim · CDSS document, Aug 20, 2025 · control 11-AS-20250812125512

Type of visit: Case Management - Other

On 08/13/2025 around 08:00am Licensing Program Analyst (LPA) Jose Calderon initiated an announced Case Management - Other to Brittany House provide Technical Assistance to the above said facility. The LPA Calderon requested copies of the facility's records which include but are not limited to staff and resident rosters, 5 resident records. LPA Calderon conducted an interview with Administrator Joel Niblett. The Administrator Joel Niblett will provide updated status of resident’s records are secured. An exit interview was conducted with Administrator Joel Niblett and a hard copy was provided via email for signature.the state’s words, verbatim · CDSS document, Aug 13, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Aug 22, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidence by: Based on observation and interviews conducted S1 could not locate or find R1 file. This is a safety risk to clients in care.the state’s words, verbatim · CDSS document, Aug 13, 2025

Plan of correction: Administrator to move all closed and open resident files to a centeral location which is locked. Administrator to have a sign in sheet for residents files which are pulled by staff.

Allegation investigated: staff do not meet resident's dietary needs. staff do not meet resident's dental hygiene needs. staff do not provide outdoor activities to residents. staff do not provide comfortable accommodations to residents. staff do not provide refunds to responsible parties. staff do not keep the facility in a sanitary condition.

** The report dated 8/1/2025 serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected in the report published on 12/20/24. ** On 04/30/2025 LPA Watson conducted a subsequent complaint visit to the facility listed above. LPA met with the Resident Care Coordinator Marcus Fulanai and the purpose of today’s visit was explained. LPA was given access to the facility. CONTINUED ON LIC9099-C Unsubstantiated The investigation consisted of the following: On 12/20/2024 Licensing Program Analyst (LPA) Watson requested, reviewed, and obtained copies of the Staff Roster, Client Roster, Face Sheet & Emergency Info. Appraisal Needs and Services, Admission Agreement (05/25/21), Physicians Reports (09/28/24), ID & Emergency Information (12/06/24) Copy of Citi Bank Check, December Dietary Calendar, December Activities Calendar (12/25). On 12/20/24 LPA Watson interviewed Staff#1-Staff#4 (S1-S4) and Residents #1-Residients #5 (R1-R5). CONTINUED ON LIC-9099C The investigation revealed the following: Allegation: Staff do not meet residents’ dietary needs. It is being alleged that the staff do not make the necessary dietary adjustments for meals served to the residents. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the visit. LPA Watson asked the residents if staff neglected to meet their dietary needs. Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if they met the residents’ dietary needs. Of those interviewed, 4 out of 4 staff stated that residents’ dietary needs were met. ON 7/25/2025 LPA reviewed the Physicians Report for (R1), and it showed a special diet recommendation of mechanical soft food. On 7/25/2025 a letter was provided by facility cook, which states that facility kitchen prepared a mechanical soft diet for R1. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not meet residents’ dental hygiene needs. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff helped them with their dental hygiene needs. Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if they assisted residents with their hygiene needs. Of those interviewed, 4 out of 4 staff denied the above allegation. On 7/25/2025 LPA Watson reviewed the Physicians Report for R1 and it showed that R1 needs help with her dental hygiene. Based on the information gathered, interviews conducted, and review of records LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not provide outdoor activities for residents. It is being alleged that staff do not schedule outdoor activities for the residents. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff provided outdoor activities for them. Of those interviewed, 5 out of 5 residents interviewed stated that activities were provided to them by the facility. On 04/30/25 LPA Watson asked the residents if they were allowed to go outside and participate in outdoor activities. 5 out of 5 residents interviewed stated that they were allowed to go outside and participate in outdoor activities. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if the facility provided outdoor activities for the residents. 4 out of 4 staff interviewed stated that the facility provided outdoor activities for the residents. On 04/30/25 LPA Watson asked the staff if residents were allowed to go outside and participate in outdoor activities. 4 out of 4 staff interviewed stated that residents were allowed to go outside and participate in outdoor activities. On 12/20/24 LPA Watson reviewed the facilities Activities Calendar for December 2024 and observed that every day of the month, the facility scheduled activities for the residents. Further review of records shows that admissions agreement, addendum O, states facility activities programing includes neighborhood walks, field trips and occasional outings. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not provide comfortable accommodation to residents. It is being alleged that staff do not ensure that residents living accommodations are comfortable at the facility. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff provided comfortable accommodation. Of those interviewed, 5 out of 5 residents stated that the staff provided comfortable accommodations for the residents. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if they provided comfortable accommodation such as private rooms free of noise. Of those interviewed, 4 out of 4 staff stated that residents are provided with comfortable accommodation. LPA Watson toured the facility with the Resident Care Coordinator Marcus Falanai and observed residents being accommodated comfortably in a minimal noise free environment. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not provide refunds to responsible parties. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff provided refunds to responsible parties. Of those interviewed, 5 out of 5 stated that the staff have never had to issue a refund to them because they and or their responsible parties handled their money. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if they provided refunds to responsible parties. Of those interviewed, 4 out of 4 staff stated that they do not handle or have access to the residents’ monies. LPA Watson reviewed the Admission Agreements for (R1) and it shows on Page 8, under Section VI A. Termination:” This Agreement may be terminated by Resident within thirty (30) days’ written notice, with the rate provided in this Agreement and thereafter modified from time to time, payable to the end of that termination date or Resident’s unit is vacated.” LPA Watson reviewed the Admission Agreement for Resident # 1 (R1) and it states on Page 8, under Section VI “Refunds: Refunds are generally available only if Resident gives Community thirty (30) – days’ advanced notice of his/her intention to leave Community, Refunds , needs will not be adequately met by care provided in the Community, and Resident’s condition prevents him/her giving thirty (30)-days’ written notice to Community/ In such case, a refund will be made on a daily pro-rated basis. Daily charges will not be incurred if the Resident’s person effects are removed from the Community by 12:00 p.m.” LPA Watson followed up with Administrator Joel Niblett regarding refunds and was informed that facility did not receive Thirty day notice of termination from family of R1. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not keep the facility in a sanitary condition. It is being alleged that the facility is not maintained in a clean and sanitary condition. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff do not keep the facility in a sanitary condition? Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if they do not keep the facility in a sanitary condition. Of those interviewed, 4 out of 4 staff denied the above allegation. LPA Watson toured the facility with the Resident Care Coordinator Marcus Fulanai and observed the facility clean, sanitary and in good repair. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with the Administrator Joel Niblett and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 1, 2025 · control 11-AS-20241216112039

Type of visit: Case Management - Other

On 07/24/2025 Licensing Program Analyst (LPA) Troy Watson made an unannounced subsequent visit to deliver findings regarding the above allegation(s). Because of more documentation needed this investigation will have to continue at a later date. Please : REFERENCE COMPLAINT # 11-AS-20241216112039.Due to insufficient time the above allegations need further investigation. An exit interview was conducted with the Administrator Joel Niblet and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 24, 2025

Allegation investigated: Staff do not prevent a residents from suffering multiple falls while in care. Untrained staff administer medication. Staff handle residents in a rough manner.

***This report supersedes the original report delivered on 5/28/2025. On 7/17/2025, the LPA arrived at the facility to deliver the corrected 9099, providing clarification on the original report issued on 5/28/2025. *** On 5/28/2025, at 9:00 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met Joel Niblett-Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 5/28/2025 at 01:25 PM, LPA Allen obtained and reviewed files for Resident 1- 10 (R1-R10) , Special Incident Reports/Death-LIC624A (UIR) for R1 and R3, LPA conducted a search in Community Care Licensing (CCL) data base for death reports resulting from falls. LPA also conducted interviews with staff members1-10 (S1-S10) and Residents 1 – 10 (R1–R10) Unsubstantiated LPA reviewed current in-service training conducted on 1/10/2025 residents’ rights, 2/25/2025 In-service-reporting trainings, and 4/7/2025 Medication Administration (MARS)Training's signed by staff members. Investigation revealed the following: 1 Allegation: Staff do not prevent a resident from suffering multiple falls while in care. Interviews with staff members (S1-S10) stated residents are closely monitored throughout the day & night and are not left unattended for extended periods. For residents identified as fall risks, staff maintain close supervision, either by remaining nearby while assisting other residents or by coordinating with additional staff to ensure continuous observation and support is provided to residents. LPA also interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members help them with their needs and have not fallen. The remaining 8 residents were unable to engage in a clear conversation. A random audit of resident files (R1-R6) and Special Incident Reports (SIRs) in the Community Care Licensing (CCL) database revealed no incident reports indicating that a resident death resulted from a fall. Furthermore, LPA reviewed UIRs for residents who had passed away and confirmed that their causes of death were unrelated to falls. During a facility tour, LPA observed staff actively assisting residents, with no individuals appearing to be left unattended. Based on these observations, it appears that residents receive consistent supervision, and staff have a structured plan in place to promote safety and prevent falls. LPA reviewed current in-service training conducted on 2/25/2025 and 4/7/2025, Medication Administration Training's signed by staff members. 2. Allegation: Untrained staff administer medication On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10). All 10 staff members stated that, to their knowledge, all medication technicians (MedTechs) are certified to pass out medications. During the investigation, LPA observed that the MedTech certifications for S7 and S9 were up to date and dispense medications. Interviews with S1, S2, S3, and S8 confirmed that they hold certifications, and LPA requested and obtained staff training records for MedTechs. LPA observed re-certifications through Elite Medical Academy for S1, S2, S3, and S8. Interviews with staff also indicated that they have not seen staff members S4, S5, and S6 dispensing medications, and there are no records of current MedTech training for these staff members, only in-service training's. 3 Allegation: Staff handle residents in a rough manner. On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - 10 (S1–S10), Of all the staff interviewed 10 out of the 10 staff stated residents have not been handled in a rough manner that could have resulted in injuries to any resident in care. LPA interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members have not handled them in a rough manner. The remaining 8 residents were unable to engage in a clear conversation. Based on the evidence gathered during the investigation, the above allegations are found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the report was provided to the Joel Niblett- Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 11-AS-20241217143234

Allegation investigated: Unstageable pressure injury due to lack of care from staff Staff did not provide resident's medication as prescribed Staff did not provide daily activities for residents Staff did not ensure that resident was adequately fed

**This report supersedes the original report delivered on 5/28/2025. On 7/17/2025 , LPA Allen arrived at the facility to deliver the corrected 9099, which included corrections based on resident interviews conducted for the original report issued on 5/28/2025.** On 5/28/2025, at 8:15 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met with Joel Niblett-Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 5/12/2025 at 9:00 AM, LPA Allen obtained and reviewed files for Resident 1 (R1), which included a face sheet, medication list, appraisal, needs and services plan, physician's report, admissions agreement with personal property valuables list dated 4/21/2023, staff and client roster for 6/2024 & 4/2025. Continued Unsubstantiated healthcare progress notes/summary from Brittany House & Shoreline Healthcare Center dated 4/28/2023, and Specialty Hospice Care records dated 8/5/2024 - 10/11/2024. LPA also conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - 8 (R1–R8), Witness 1(W1) and attempted to interview Resident 9 (R9) who no longer resides at the facility. Investigation revealed the following: #1- Allegation: Resident sustained an unstageable pressure injury due to lack of care from staff. On 5/12/2025, at 11:00 AM, LPA Allen conducted interviews with Staff 1 - Staff 10 (S1–S10). All 10 staff members denied knowing if R1 suffered from a pressure wound or whether an outside agency was providing wound care. LPA interviewed Residents 1 - 8 (R1–R8). Of the 8 residents, 2 stated that they do not have any pressure injuries, The remaining 6 residents were unable to engage in a clear conversation, and LPA did not observe any visible pressure injuries on residents. W1 stated there was a pressure injury caused due to lack of care but could not provide evidence to corroborate the allegation. LPA reviewed R9’s facility file and found hospice records from Specialty Hospice confirming services were provided 2x/week from 06/14/2024 - 10/11/2024, and The Wound Pros provided care 1x/week from 8/5/2024- 10/11/2024. The needs and service plan dated 4/28/2023 - 10/16/2023 does not indicate the presence of a pressure injury. LPA could not obtain sufficient evidence to substantiate that R9 sustained a pressure injury due to a lack of care by facility staff. #2- Allegation: Staff did not provide resident's medication as prescribed On 5/12/2025, LPA conducted interviews with Staff 1- Staff 10 (S1-S10), of those interviewed, 10 out of 10 stated that all residents are given their medications as prescribed by their physicians. On 5/12/2025 LPA reviewed R9’s file and found no records to verify whether R9 received their medication as prescribed. On 5/12/2025 and 5/22/2025 the Medication Administration Records (MARS) could not be provided for R9 therefore, LPA was unable to verify if their medications were given or not. LPA interviewed Residents 1 – Resident 8 (R1–R8) of the 8 residents, 2 stated they get their medications daily the remaining 6 residents were unable to engage in a clear conversation. #3- Allegation: Staff did not provide daily activities for residents. On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10). All 10 staff members stated that residents are provided with daily activities and showed a schedule of activities posted on the wall and provided a printed copy. LPA interviewed Residents 1 - 8 (R1–R8). Of the 8 residents, 2 stated they have engaged in daily activities, while the remaining 6 residents were unable to engage in a clear conversation. On 5/12/2025, during a facility tour, LPA observed the activity director conducting rounds throughout the premises, actively facilitating various activities with the residents. These included morning exercise, coloring, nail painting, and arts & crafts. Additionally, a monthly activity schedule dated September 2024, outlining events from 9:15 AM to 6:00 PM, was available for review. #4- Allegation: Staff did not ensure that residents were adequately fed On May 12, 2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10). All 10 staff members stated that all residents in care receive three meals daily, including snacks, and that meals are determined based on their dietary needs. S10 mentioned that R9 was on a fortified mechanical soft meal and thin liquids, but specific dates could not be provided. LPA reviewed R9’s physician's report dated 4/27/2023 and Specialty Hospice Care records dated 6/14/2024, which confirmed that R9 was on a fortified mechanical soft meal and thin liquids diet. Additionally, LPA interviewed Residents 1 - 8 (R1–R8). Of the 8 residents, 2 stated they receive three meals daily, while the remaining 6 residents were unable to engage in a clear conversation. On 5/12/2025, LPA observed residents having meals, including a balanced breakfast of bacon, eggs, and oatmeal, followed by lunch consisting of baked pork chops, mashed potatoes, mixed vegetables, cornbread, water, and juice. Continued On May 22, 2025, LPA again observed residents consuming a balanced lunch, which included tuna casserole, green beans, salad, cornbread, juice, and water. LPA also observed menus that coincided with the meals being provided each day. During a tour of the facility kitchen, LPA noted a five-day supply of perishable food and a seven-day supply of non-perishable food items. The kitchen appeared clean, and no health or safety concerns were observed during the visit. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Joel Niblett- Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 11-AS-20240909085113

Allegation investigated: Staff handled residents in a rough manner which resulted in injuries Staff inappropriately restrained resident Staff did not provide a safe and comfortable environment for residents Staff did not provide residents with privacy Staff mismanaged residents’ medication Residents are being left unattended for extended periods Staff did not provide adequate food service Medications are not being stored properly Residents are not being changed in a timely manner

**This report supersedes the original report delivered on 5/22/2025. On 7/17/2025, LPA Allen arrived at the facility to deliver the corrected 9099, which included corrections based on resident interviews conducted for the original report issued on 5/22/2025.** On 5/22/2025, at 8:00AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met Joel Niblett- Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 5/12/2025 at 9:00 AM, LPA Allen obtained and reviewed records for Resident 1 (R1), including the face sheet dated July 5, 2024, Controlled Drug Record dated for July 5,2024 through September 8, 2024,Medication Administration log dated for August 2024 , Supportive Hospice Care-Discharge Unsubstantiated Summary and Post Discharge Plan of care dated 7/5/2024, Identification and Emergency Information, Needs and services plan dated 7/5/2024, Physician's Report dated 7/2/2024. Admissions Agreement dated 7/3/2024, Personal property valuables list dated 7/3/2024 , Staff and Resident rosters for 6/2024 and 4/2025, LPA also conducted interviews with Staff 1- Staff 10 (S1–S10) and Residents 1 - Resident 10 (R1–R10), in addition to observations made during the tour of the facility. Investigation revealed the following: 1 Allegation: Staff handled residents in a rough manner which resulted in injuries On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - Resident 10 (R1–R10). The 10 staff members interviewed stated that residents have not been handled in a rough manner that could have resulted in injuries. LPA interviewed Residents 1 - 10 (R1–R10) Of the interviews conducted, 3 residents stated that staff members have not handled them in a rough manner causing injury. The remaining 7 residents were unable to engage in a clear conversation. 2 Allegation: Staff inappropriately restrained resident LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members interviewed stated that residents have not been inappropriately restrained in any way. LPA requested any special incident reports during the visit, but none could be provided as there were no incidents to report regarding restraining residents. LPA interviewed Residents 1 - 10 (R1–R10) Of the interviews conducted, 3 residents stated that staff members have not restrained them in any way. The remaining 7 residents were unable to engage in a clear conversation. 3 Allegation: Staff did not provide a safe and comfortable environment for residents LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members interviewed stated that staff provides a safe and comfortable environment for residents. LPA interviewed Residents 1 - 10 (R1–R10) Of the interviews conducted, 3 residents stated that staff members have provided a safe and comfortable environment . The remaining 7 residents were unable to engage in a clear conversation. During the tour of the facility, LPA observed that the residents were in a safe and comfortable environment, with no health and safety concerns noted. 4 Allegation: Staff did not provide residents with privacy On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members interviewed stated that staff provide residents with privacy while assisting with showers and any ADLs requiring privacy. LPA interviewed Residents 1 - 10 (R1–R10) Of the 10 residents, 3 stated that staff provide them with privacy, while the remaining 7 residents were unable to engage in a clear conversation. During the tour of the facility, LPA did not observe any residents’ rights being violated. 5 Allegation: Staff mismanaged residents’ medication On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members interviewed stated that staff have not mismanaged residents’ medication. LPA interviewed Residents 1 - 10 (R1–R10). Of the 10 residents, 3 stated that staff provide them with their medications daily, while the remaining 7 residents were unable to engage in a clear conversation. On 5/12/2025, LPA observed R1's Medication Administration Records (MARS) and based on LPA's observations and documentation it appeared that R1's medications had been administered as prescribed by their physicians. 6 Allegation: Residents are being left unattended for extended periods On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members interviewed stated that residents are not left unattended for extended periods of time. Staff mentioned that there are no records of residents being changed, but residents are checked on every 2-3 hours to address incontinence issues and as needed. LPA interviewed Residents 1 - 10 (R1–R10). Of the 10 residents, 3 stated that staff help them with their Activities of Daily Living (ADLs) as needed or when asked and has not been left unattended to for extended periods. The remaining 7 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were receiving incontinence and (ADLs) assistance from staff members. Continued 7 Allegation: Staff did not provide adequate food service On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members stated that residents are provided adequate food service based on their dietary needs or modified diets. LPA interviewed Residents 1 - 10 (R1–R10). Of the 10 residents, 3 stated they receive three meals and snacks daily, while the remaining 7 residents were unable to engage in a clear conversation. On 5/12/2025, LPA observed residents being fed and eating a balanced meal for breakfast (hot cereal, eggs, bacon, and toast) and lunch (baked pork chops, cornbread, mashed potatoes, and mixed veggies). On 5/22/2025, LPA toured the kitchen and observed a 5-day supply of perishables and a 7-day supply of non-perishable food items. Lunch served included tuna casserole, green salad, green beans, cornbread, water, juice, and coffee. A menu available for review reflected the meals served. 8 Allegation: Medications are not being stored properly On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10). All 10 staff members stated that the medication room is locked when not in use. LPA observed residents’ medications stored properly in the medication room, locked in drawers inaccessible to residents. LPA also observed Medication Technicians (MEDTECHS) using their keys to open the medication drawers during a random audit of records/medications. LPA interviewed Residents 1 - 10 (R1–R10). Of the 10 residents, 3 stated they were unsure about medications being stored properly, while the remaining 7 residents were unable to engage in a clear conversation. 9 Allegation: Residents are not being changed in a timely manner. On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members stated that staff have not left residents unattended for extended periods of time. Staff mentioned that there are no records of residents being changed, but residents are checked on every 2-3 hours or as needed to address incontinence issues. Continued... LPA interviewed Residents 1 - 10 (R1–R10). Of the 10 residents, 3 stated that staff help them with their Activities of Daily Living (ADLs) /incontinence issues and or as needed in a timely manner. The remaining 7 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were receiving incontinence assistance from staff members. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Joel Niblett- Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 11-AS-20240719115501

Allegation investigated: Staff did not assist resident with care needs in a timely manner.

On 07/02/25, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced complaint visit. LPA Richard met with Joel Niblett, the Executive Director (ED), and explained the purpose of this visit. The investigation consisted of the following: the Licensing Program Analyst (LPA) interviewed, reviewed, and obtained records, along with a tour of the facility. Interviews were conducted with six staff members (S1-S6), five residents (R1-R5), and the Admission/Social Service Director (ASSD). LPA Richard reviewed multiple documents, including the Personnel Report LIC 500, the Resident Roster, the Face Sheet and Identification/Emergency Information for Resident #1 (R1), the Service Plan, the Resident Assessment, Preplacement Appraisal Information, the Admissions Agreement, the Medication Administration Record (MAR), and other relevant records related to this complaint. Report Continued LIC9099-C Unsubstantiated Allegation: Staff did not assist resident with care needs in a timely manner. The complaint alleges that a resident has been neglected, specifically claiming that they have been unable to use the bathroom and have had to sit in their urine. On July 2, 2025, between 10:00 AM and 1:00 PM, the Licensing Program Analyst (LPA) interviewed six staff members (S1-S6), all of whom denied the allegations and stated that they provide care for all residents. Staff members S5 and S6, who primarily assist resident #1 (R1), also denied the claims, asserting that R1 has not been neglected and has not been left sitting in urine or unable to use the bathroom. LPA additionally interviewed the Assistant Director of Staff Development (ASSD), who denied the allegations and explained that all three shifts routinely perform incontinent services every two hours or as needed. R1 is scheduled for diaper changes every two hours or as needed. Later, on July 2, 2025, between 1:30 PM and 2:30 PM, LPA interviewed five residents (R1-R5). Four out of five residents denied the allegations, stating that staff regularly change their diapers and assist with their activities of daily living (ADLs). They also reported that when they pull the alarm cord, staff usually respond within two to four minutes. Report continued LIC9099-C A review of the Caregiver Daily Flow Sheet and staff notes for residents' ADLs, dated July 01 to July 02, 2025, confirmed that R1 receives daily assistance unless R1 refuses. LPA reviewed the Nursing-issued 24-hour report dated June 22 to June 29, 2025, which showed that R1 refused staff assistance very often. Furthermore, on July 2, 2025, the LPA pulled the alarm cord in R1's room, and staff arrived to assist within two minutes. The LPA also observed that the residents looked well-groomed and clean, and they did not appear to be neglected. Based on the information collected from the facility inspection, observations, interviews, and records analysis, LPA found no evidence to support the above allegations. Although the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of the report was provided to Executive Director Joel Niblett.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 11-AS-20250624095034

Allegation investigated: Lack of supervision resulting in resident being assaulted by another resident while in care.

This report supersedes report dated 05/08/2025 to include additional information. The complaint investigation findings remain the same. On 06/18/2025 at 8:47am Licensing Program Analyst (LPA) Zina Brown conducted a subsequent complaint visit at this facility to deliver the complaint findings. During today’s visit, LPA met with Joel Niblett, Administrator Designee and the explained the purpose of the visit. The investigation consisted of the following: On 04/03/2025, LPA interviewed Administrator (A1), Staff #1 - Staff #6 (S1 - S6) and Resident #1- #6 (R1 – R6). LPA requested copies of the staff roster (dated 01/31/2025) and resident roster, centrally stored medication record (for R7), Service Plans (for R6 - R7), Physician's Order (List of Medication for R6-R7), LIC 602: Physician Report for RCFE, LIC 601 Identification and Emergency Information. Unsubstantiated On 06/18/2024, LPA interviewed Staff# 8 - Staff# 10, requested a copy of the LIC 624: Unusual Incident Injury for R1-R2 (dated 12/21/2024) and staff schedule (December 2024). The investigation revealed the following: Allegation: Lack of supervision resulting in resident being assaulted by another resident while in care. On 04/03/2025 between the hours of 12:18pm - 12:28pm, LPA interviewed the Administrator (A1), regarding the above allegation. A1 stated she was unaware of the allegation. On 04/03/2025 between the time of 9:31am - 12:28pm, LPA interviewed Staff # 1 (S1)– Staff 6 (S6) and on 04/23/2025 between the hours of 9:21am – 9:38am, LPA interviewed Staff (7) regarding the allegation. On 06/18/2025, between the hours of 10:53am - 12:05pm, LPA interviewed Staff #8 (S8) - Staff #10 (S10) regarding the allegation. 3 out 10 staff interviewed confirmed an incident occurred between Resident #1 (R1) and Resident #2 (R2), but Staff had different various of the incident that occurred between R1 and R2. 7 out 10 staff interviewed had no knowledge of the incident that occurred between R1 and R2. On 04/03/2025 between the hours 1:17pm - 2:26pm, LPA interviewed Resident #1(R1) – Resident #5 (R5). On 04/03/2025 LPA attempted to interview Resident# 1 (R1) but due to the communication barriers, the resident was unable to answer interview questions. On 04/03/2025 LPA attempted to interview Resident #2 (R2) who declined to be interviewed. Report continues on LIC 9099-C 5 out of the 5 residents interviewed were unaware of the incident. On 05/06/2025 between the hours of 2:30pm – 3:30pm, LPA conducted a records review for Resident #7 (R1) records and observed the following: No history of aggravation per the resident’s physicians report (dated 09/29/2023) and need and service plan (dated 10/30/2024) No history and or record of LIC 624: Unusual Incident/Injury Report (from December 2024 – April 2025) On 06/18/2025, LPA returned to the facility and conducted a records review of the staff scheduled (December 2024) during the time of the incident. On the date of the incident 12/21/2024 at approximately 4:45pm, seven (7) staff worked between the hours of 8:45am - 6:12pm. On shift, there were a total of 6 Caregivers, 1 Medtech and Administrative Staff. During the time of the incident, the facility had a census of 61. This incident is the first occurrence between R1 and R2. No similar incidents were reported for R1 and R2. The incident occurred suddenly which did not allow the staff to prevent the incident from occurring at the time Based on the information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is unsubstantiated. Exit interview conducted with Joel Niblett, Administrator Designee & copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 11-AS-20250401131451

Allegation investigated: Staff handled residents in a rough manner which resulted in injuries Staff inappropriately restrained resident Staff did not provide a safe and comfortable environment for residents Staff did not provide residents with privacy Staff mismanaged residents’ medication Residents are being left unattended for extended periods Staff did not provide adequate food service Medications are not being stored properly Residents are not being changed in a timely manner

**This report supersedes the original report delivered on 5/22/2025. On June 4,2025 at 8:30 LPA arrived at the facility to deliver the revised 9099, providing clarification on the original report issued on 5/22/2025.** On 5/22/2025, at 8:00AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met Joel Niblett- Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 5/12/2025 at 9:00 AM, LPA Allen obtained and reviewed records for Resident 1 (R1), including the face sheet dated July 5, 2024, Controlled Drug Record dated for July 5,2024 through September 8, 2024,Medication Administration log dated for August 2024 , Supportive Hospice Care-Discharge Summary and Post Discharge Plan of care dated 7/5/2024, Identification and Emergency Information, Needs and services plan dated 7/5/2024, Physician's Report dated 7/2/2024 Continued.... Unsubstantiated Admissions Agreement dated 7/3/2024, Personal property valuables list dated 7/3/2024 , Staff and Resident rosters for 6/2024 and 4/2025, LPA also conducted interviews with Staff 1- Staff 10 (S1–S10) and Residents 1 - Resident 10 (R1–R10), in addition to observations made during the tour of the facility. Investigation revealed the following: 1 Allegation: Staff handled residents in a rough manner which resulted in injuries On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). Of all the staff interviewed 10 out of 10 staff interviewed stated residents have not been handled in a rough manner that could have resulted in injuries. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the interviews conducted 2 residents stated staff members have not handled them in a rough manner causing injury. The remaining 8 residents were unable to engage in a clear conversation. 2 Allegation: Staff inappropriately restrained resident On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). Of all the staff interviewed 10 out of 10 staff members stated residents have not been inappropriately restrained in any way. LPA requested any special incident reports during the visit, and none could be provided because there were no incidents to report regarding restraining residents. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the interviews conducted 2 residents stated staff members have not restrained them in any way. The remaining 8 residents were unable to engage in a clear conversation. Continued... 3 Allegation: Staff did not provide a safe and comfortable environment for residents On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated staff does provide a safe and comfortable environment for residents. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated that staff members have provide a safe and comfortable environment. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility LPA observed the residents to be in a safe and comfortable environment and no health and safety concerns were observed. 4 Allegation: Staff did not provide residents with privacy On 5/12/2025, LPA conducted interviews with Staff 1 -Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated staff does provide residents with privacy while assisting with showers and any ADL's requiring privacy. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated that staff members have provide them with privacy. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility LPA didn’t observe any residents’ rights being violated. 5 Allegation: Staff mismanaged residents’ medication On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated staff has not mismanaged residents’ medication. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated staff members have provided them with their medications daily. The remaining 8 residents were unable to engage in a clear conversation. On 5/12/2025 LPA observed R1 Medication Administration Records (MARS) and based on LPA observations it appeared that R1s medications had been administered as prescribed by their physicians. Continued... 6 Allegation: Residents are being left unattended for extended periods On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated residents are not left unattended for extended periods of time. Staff stated there is no records of residents being changed however residents are checked on every 2-3 hours to ensure their incontinence issues are addressed or as needed. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated that staff members help them with their Assistance with Daily Living (ADLS) as needed or when asked. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were getting incontinence assistance from staff members. 7 Allegation: Staff did not provide adequate food service On 5/12/2025 LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated the residents are provided adequate food service based on their dietary needs or modified diets. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated they get three (3) meals and snacks daily the remaining 8 residents were unable to engage in a clear conversation. On 5/12/2025, LPA observed the residents in care being fed and eating a balanced meal for breakfast -hot cereal, eggs, bacon and toast, Lunch- Baked pork chops, cornbread, mashed potatoes, and mixed veggies. On 5/22/2025 LPA toured the kitchen and observed there to be a 5-day supply of perishables and a 7-day supply of non-perishable food items. Lunch served tuna casserole, green salad, green beans and cornbread, water, juice and coffee. There was a menu available for review that reflected meals served. 8 Allegation: Medications are not being stored properly On 5/12/2025 LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), 10 out of 10 staff members stated the medication room is locked when not in use. LPA observed the residents’ medications to be stored properly in the medication room locked in drawers inaccessible to the residents. LPA also observed the Medication Technicians (MEDTECHS) using their keys to open the medication drawers during the random audit of records/medications. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated they are not sure about medications being stored properly. Continued .. 9 Allegation: Residents are not being changed in a timely manner. On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated staff has not left residents unattended for extended periods of time. Staff stated there is no records of residents being changed however residents are checked on every 2-3 hours to ensure their incontinence issues are addressed. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated that staff members help them with their Assistance with Daily Living (ADLS) as needed or when asked. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were getting incontinence assistance from staff members. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Joel Niblett- Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 11-AS-20240719115501

Allegation investigated: Staff do not prevent a residents from suffering multiple falls while in care. Untrained staff administer medication. Staff handle residents in a rough manner.

On 5/28/2025, at 9:00 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegation. LPA identified herself and met Joel Niblett-Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 5/28/2025 at 01:25 PM, LPA Allen obtained and reviewed files for Resident 1-Resident 6 (R1-R6) files, Special Incident Reports/Death-LIC624A (SIR) for R1-R3, LPA conducted a search in Community Care Licensing (CCL) data base for death reports resulting from falls. Continued... Unsubstantiated Investigation revealed the following: 1 Allegation: Staff do not prevent a resident from suffering multiple falls while in care. Interviews with staff members (S1-S10) stated residents are closely monitored throughout the day & night and are not left unattended for extended periods. For residents identified as fall risks, staff maintain close supervision, either by remaining nearby while assisting other residents or by coordinating with additional staff to ensure continuous observation and support. LPA also interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members help them with their needs and have not fell. The remaining 8 residents were unable to engage in a clear conversation. A random audit of resident files (R1-R6) and Special Incident Reports (SIRs) in the Community Care Licensing (CCL) database revealed no incident reports indicating that resident deaths resulted from falls. Furthermore, LPA reviewed SIRs for residents who had passed away and confirmed that their causes of death were unrelated to falls. During a facility tour, LPA observed staff actively assisting residents, with no individuals appearing to be left unattended. Based on these observations, it appears that residents receive consistent supervision, and staff have a structured plan in place to promote safety and prevent falls. 2. Allegation: Untrained staff administer medication On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Of those interviewed, 10 out of 10 staff stated to their knowledge all medication technicians (Medtech) are certified to pass out medications. During the investigation LPA observed MedTech certifications for S7 and S9 which were up to date. Interviews with S1, S2, S3, and S8 confirmed that they hold certifications but were unable to provide current copies. Staff have also stated they have registered for re-certification through Elite Medical Academy and they have not seen staff members S4, S5, and S6 dispensing medications. Continued... 3 Allegation: Staff handle residents in a rough manner. On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). Of all the staff interviewed 10 out of the 10 staff all stated residents have not been handled in a rough manner that could have resulted in injuries to any resident in care. LPA interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members have not handled them in a rough manner. The remaining 8 residents were unable to engage in a clear conversation. Based on the evidence gathered during the investigation, the above allegations are found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the report was provided to the Joel Niblett- Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 29, 2025 · control 11-AS-20241217143234

Type of visit: Case Management - Deficiencies

On 5/29/2025, at 8:15 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations for complaint Control Number 11-AS-20241217143234. LPA identified herself and met Joel Niblett- Administrator who was informed of the purpose of the visit. On May 12, 2025, the LPA conducted a random audit of the Medication Administration Record (MAR) for Residents 1 through 4 (R1–R4). During the audit, LPA observed that R1’s medications appeared to have been dispensed; however, staff were unable to provide the corresponding MAR for review. Additionally, LPA noted that R2’s medications were recorded as dispensed on May 2 and May 12, 2025, but were still in their original packaging. Marcus Falanai resident care coordinator, was unable to confirm whether R2’s medications had actually been dispensed. Meanwhile, LPA verified that R3 and R4’s medications had been dispensed and signed off by a medtech. This violation poses a potential health, safety, or personal rights risk to residents in care and a citation was issued. On May 29, 2025, LPA conducted interviews, observations and reviewed the LIC500, noting that some staff members are listed as caregivers and medtechs. Interviews with S1, S2, S3, and S8 confirmed that they hold certifications but were unable to provide current copies. They also stated that they have registered for re-certification through Elite Medical Academy. Additionally, staff members S4, S5, and S6 have not been observed dispensing medications. Joel was informed that the absence of current certification documentation for staff members presents a potential health, safety, and personal rights risk to residents in care. As a result, a citation will be issued for failure to maintain complete and up-to-date staff files for review at the time of the visit. Continued.... Interviews with S4, S5, and S6 confirmed that they do not have certification to dispense medications and have not administered medications to residents in care. The interview with Joel Niblette, the Administrator, verified that all staff members (S1–S9) have been provided links to register for medtech training through Elite Medical Academy as of May 29, 2025. Joel was informed that medtechs who are not certified should not be listed as medtechs. LPA requested that the LIC500 be updated with accurate titles until certifications are obtained. LPA also suggested to Joel Niblett the following regulations be read 87413,87412,87411,87465 and health and safety code 1569.625 An exit interview was conducted where this report LIC809, LIC809 -C and LIC809-D was discussed and provided to Joel Niblett at the conclusion of the visitthe state’s words, verbatim · CDSS document, May 29, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a)-(h) · Plan of correction due date: Jun 6, 2025

Personnel Records (a) - (h) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:... This requirement was not met as evidenced by: LPA reviewed staff 1-9 files and observed that there were no annual tranings, mectech certifications for S1-S7 This violation poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: Joel Niblett-Administrator has agreed to conduct an audit of all staff files monitouring progress daily to esure files are completed with all documents by the POC date. Joel has agreed to provide proof of annual training to all staff members, including medtech trainings . Details of the course prvided and signed by all staff will be emailed to LPA by the POC date of 6/6/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(c)(3) · Plan of correction due date: Jun 6, 2025

Incidental Medical and Dental Care (c) (3)If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:... This requirement was not met as evidenced by: LPA observed R1 and R2 medications were not signed as being dispensed and there was medication signed off as being disspensed but in package. This violation poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: Joel Niblett-Administrator has agreed to conduct training to all medtecs LVNs on documentation requirements policy and procedures standards by the POC date of 6/6/2025. Proof of traing signed by all staff and certifications will be emailed to LPA by the POC date 6/6/2025.

Allegation investigated: Resident sustained an unstageable pressure injury due to lack of care from staff Staff did not provide resident's medication as prescribed Staff did not provide daily activities for residents Staff did not ensure that resident was adequately fed

On 5/28/2025, at 8:15 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met with Joel Niblett-Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 5/12/2025 at 9:00 AM, LPA Allen obtained and reviewed files for Resident 1 (R1), which included face sheet, medication list, appraisal, needs and services plan, physicians report, admissions agreement with personal property valuables list dated 4/21/2023, staff and client roster for 6/2024 & 4/2025, healthcare progress notes/summery from Brittany house & Shoreline Healthcare Center dated 4/28/2023,Specialty Hospice Care dated 8/5/2024-10/11/2024. LPA also conducted interviews with Staff 1- Staff 10 (S1 – S10), Residents 2-Resident 8 (R2-R8) and observations during the tour of the facility. Continued .... Unsubstantiated #2- Allegation: Staff did not provide resident's medication as prescribed On 5/12/2025, LPA conducted interviews with Staff 1- Staff 10 (S1-S10), of those interviewed, 10 out of 10 stated that all residents are given their medications as prescribed by their physicians. On 5/12/2025 LPA reviewed R1’s file and found no records to verify whether R1 received their medication as prescribed. On 5/12/2025 and 5/22/2025 the Medication Administration Records (MARS) could not be provided for R1 therefore, LPA was unable to verify if their medications were given or not. LPA interviewed Residents 2 – Resident 8 (R2–R8) of the 8 residents, 2 stated they get their medications daily the remaining 6 residents were unable to engage in a clear conversation. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. #3- Allegation: Staff did not provide daily activities for residents. On 5/12/2025, LPA conducted interviews with Staff 1- Staff 10 (S1 – S10), of those interviewed, 10 out of 10 stated residents are provided with daily activities and showed a schedule of activities on the wall posted and provided a printed copy. LPA interviewed Residents 2 – Resident 8 (R2–R8) of the 8 residents, 2 stated they have engaged in daily activities the remaining 6 residents were unable to engage in a clear conversation. On May 12, 2025, during a facility tour, LPA observed the activity director conducting rounds throughout the premises, actively facilitating various activities with the residents. These included morning exercise, coloring, nail painting, and arts & crafts. Additionally, a monthly activity schedule dated September 2024, outlining events from 9:15 AM to 6:00 PM, was available for review. Continued Investigation revealed the following: #1- Allegation: Resident sustained an unstageable pressure injury due to lack of care from staff. On 5/12/2025, at 11:00 AM, LPA Allen conducted interviews with Staff 1–Staff 10 (S1–S10). Of those interviewed, 10 out of 10 staff denied knowing if R1 suffered from a pressure wound or whether an outside agency was providing wound care. LPA interviewed Residents 2 – Resident 8 (R2–R8) of the 8 residents, 2 stated that they do not have any pressure injuries and based on LPA observations there was no visible pressure injuries. The remaining 6 residents were unable to engage in a clear conversation and LPA did not observe any visible pressure injuries. LPA reviewed R1’s facility file and found no medical records indicating wound care services were provided. The needs and service plan dated 4/28/2023–10/16/2023 does not indicate the presence of a pressure injury. However, hospice records from Specialty Hospice confirm services were provided 2x/week from 06/14/2024–10/11/2024, and The Wound Pros provided care 1x/week from 8/5/2024–10/11/2024. LPA could not obtain sufficient evidence to substantiate that R1 sustained a pressure injury due to a lack of care by facility staff. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. #4- Allegation: Staff did not ensure that resident was adequately fed On May 12, 2025, the LPA conducted interviews with Staff 1 - Staff 10 (S1– S10), of those interviewed, 10 out of 10 state all residents in care receive three meals daily, including snacks and meals are determined based on their dietary needs. S10 stated that R1 was on a fortified mechanical soft meal and thin liquids but specific dates could not be provided. LPA reviewed R1’s physicians report date 4/27/2023 and Specialty Hospice Care dated 6/14/2024 which states R1 was on a fortified mechanical soft meal and thin liquids. Additionally, LPA interviewed Residents 2 - Resident 8 (R2–R8); 2 stated they receive three meals daily, the remaining 6 residents were unable to engage in a clear conversation. On 5/12/2025, LPA observed residents having meals, including a balanced breakfast of bacon, eggs, and oatmeal, followed by lunch consisting of baked pork chops, mashed potatoes, mixed vegetables, cornbread, water, and juice. On May 22, 2025, LPA again observed residents consuming a balanced lunch, which included tuna casserole, green beans, salad, cornbread, juice, and water. LPA also observed menus which coincides with the meals being provided for each day. A tour of the facility kitchen was also conducted, during which LPA observed a five-day supply of perishable food and a seven- day supply of nonperishable food items were noted. The kitchen appeared clean, and no health or safety concerns were observed during the visit. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Joel Niblett- Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 28, 2025 · control 11-AS-20240909085113

Allegation investigated: Staff handled residents in a rough manner which resulted in injuries Staff inappropriately restrained resident Staff did not provide a safe and comfortable environment for residents Staff did not provide residents with privacy Staff mismanaged residents’ medication Residents are being left unattended for extended periods Staff did not provide adequate food service Medications are not being stored properly Residents are not being changed in a timely manner

On 5/22/2025, at 8:00 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met Joel Niblette- Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 5/12/2025 at 9:00 AM, LPA Allen obtained and reviewed files for Resident 1 (R1), including the face sheet, medication list/MAR date 8/27/2024, appraisal, needs and services plan, physician's report, admissions agreement with personal property valuables list, staff and client rosters for 4/2025 and 6/2024, medication review report dated 7/5/2024, and outside service agency visit sheets date range of 7/11/2024 - 9/12/2024. LPA also conducted interviews with Staff 1- Staff 10 (S1–S10) and Residents 1 - Resident 10 (R1–R10), in addition to making observations during the tour of the facility. Unsubstantiated Investigation revealed the following: 1 Allegation: Staff handled residents in a rough manner which resulted in injuries On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). Of all the staff interviewed 10 out of the 10 staff interviewed all stated that residents have not been handled in a rough manner that could have resulted in injuries. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members have not handled them in a rough manner. The remaining 8 residents were unable to engage in a clear conversation. 2 Allegation: Staff inappropriately restrained resident On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). Of all the staff interviewed 10 out of 10 staff members stated that residents have not been inappropriately restrained in any way including R1. LPA requested any special incident reports during the visit, and none could be provided because there has not been any incidents to report pertaining to restraining any residents. LPA also searched the Departments of Social Services (DSS) database to confirm if there were any unusual incident reports (UIR) submitted which could not be found. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members have not inappropriately restrained them in any way. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility LPA did not observe any residents being inappropriately restrained by the staff. Continued... 3 Allegation: Staff did not provide a safe and comfortable environment for residents On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated staff does provide a safe and comfortable environment for residents. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members have provide a safe and comfortable environment for residents. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility LPA observed the residents to be in a safe and comfortable environment and no health and safety concerns were observed. 4 Allegation: Staff did not provide residents with privacy On 5/12/2025, LPA conducted interviews with Staff 1 -Staff 10 (S1–S10), Residents 1 through Resident 10 (R1–R10). 10 of 10 staff members stated staff does provide a safe and comfortable environment for residents providing them privacy while conducting showers and any ADL's requiring privacy. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members provide them with privacy the remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility LPA didn’t observe any residents’ rights being violated by not providing privacy. 5 Allegation: Staff mismanaged residents’ medication On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 of 10 staff members stated staff has not mismanaged residents’ medication. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated they don't believe their medication is mismanaged. The remaining 8 residents were unable to engage in a clear conversation. On 5/12/2025 and LPA observed R1 Medication Administration Records (MARS) and based on LPA observation it appeared that R1s medications had been administered as prescribed by their physicians. 6 Allegation: Residents are being left unattended for extended periods On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 of 10 staff members stated staff has not left residents unattended for extended periods of time. Staff stated there is no records of residents being changed however residents are checked on every 2-3 hours to ensure their incontinence issues are addressed. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that they get help when they need it, and the remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were getting incontinence assistance from staff members. 7 Allegation: Staff did not provide adequate food service On 5/12/2025 LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated the residents are provided adequate food service. LPA observed the residents in care being fed and eating a balanced meal for breakfast -hot cereal, eggs, bacon and toast, Lunch- Baked pork chops, cornbread, mashed potatoes, and mixed veggies. On 5/22/2025 LPA toured the kitchen and observed there to be a 5-day supply of perishables and a 7-day supply of non-perishable food items. Lunch served tuna casserole, green salad, green beans and cornbread,water,juice and coffee. There was a menu available for review that reflected meals served. LPA conducted interviews with Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that they get three (3) meals and snacks daily the remaining 8 residents were unable to engage in a clear conversation. 8 Allegation: Medications are not being stored properly On 5/12/2025 LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), 10 out of 10 staff members stated the medication room is locked when not in use and LPA observed the residents medications to be stored properly in the medication room locked in drawers inaccessible to the residents. LPA also observed the Medication Technicians (MEDTECHS) using their keys to open the medication drawers during the random audit of records. 9 Allegation: Residents are not being changed in a timely manner. On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 of 10 staff members stated they have not left residents unattended for extended periods of time. Staff stated there is no records of residents being changed however residents are checked on every 2-3 hours to ensure their incontinence needs are met. Continued.... LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that they get help when they need it, and the remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were getting assistance from staff members addressing their incontinence needs. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Joel Niblett-Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 22, 2025 · control 11-AS-20240719115501

Allegation investigated: Lack of supervision resulting in resident being assaulted by another resident while in care.

On 05/08/2025 at 1:10pm Licensing Program Analyst (LPA) Zina Brown conducted a subsequent complaint visit at this facility to deliver the complaint findings. During today’s visit, LPA met with Marcus Falanai Resident Care Coordinator and the explained the purpose of the visit. The investigation consisted of the following:On 04/03/2025, LPA interviewed Administrator (A1), Staff #1 - Staff #6 (S1 - S6) and Resident #1- #6 (R1 – R6). LPA requested copies of the staff roster (dated 01/31/2025) and resident roster, centrally stored medication record (for R7), Service Plans (for R6 - R7), Physician's Order (List of Medication for R6-R7), LIC 602: Physician Report for RCFE, and LIC 601 Identification and Emergency Information. The investigation revealed the following: Allegation: Lack of supervision resulting in resident being assaulted by another resident while in care. Report continues LIC 9099-C Unsubstantiated On 04/03/2025 between the hours of 12:18pm - 12:28pm, LPA interviewed the Administrator (A1), regarding the above allegation. A1 stated she was unaware of the allegation. On 04/03/2025 between the time of 9:31am - 12:28pm, LPA interviewed Staff # 1 (S1)– Staff 6 (S6) and on 04/23/2025 between the hours of 9:21am – 9:38am, LPA interviewed Staff (7) regarding the allegation. 2 out 7 staff interviewed confirmed an incident occurred between Resident #6 (R6) and Resident #7 (R7), but Staff had different various of the incident that occurred between R6 and R7. 5 out 7 staff interviewed had no knowledge of the incident that occurred between R6 and R7. On 04/03/2025 between the hours 1:17pm - 2:26pm, LPA interviewed Resident #1(R1) – Resident #5 (R5). On 04/03/2025 LPA attempted to interview Resident# 6 (R6) but due to the communication barriers, the resident was unable to answer interview questions. On 04/03/2025 LPA attempted to interview Resident #7 (R7) who declined to be interviewed. 5 out of the 5 residents interviewed were unaware of the incident. On 05/06/2025 between the hours of 2:30pm – 3:30pm, LPA conducted a records review for Resident #7 (R7) records and observed the following: No history of aggravation per the resident’s physicians report (dated 09/29/2023) and need and service plan (dated 10/30/2024) No history and or record of LIC 624: Unusual incident/Injury Report (from December 2024 – April 2025) Based on the information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is unsubstantiated Exit interview conducted with Marcus Falanai Resident Care Coordinator & copy of the report was provided.the state’s words, verbatim · CDSS document, May 8, 2025 · control 11-AS-20250401131451

Allegation investigated: staff do not meet resident's dietary needs. staff do not meet resident's dental hygiene needs. staff do not provide outdoor activities to residents. staff do not provide comfortable accommodations to residents. staff do not provide refunds to responsible parties. staff do not keep the facility in a sanitary condition.

On 04/30/2025 the department conducted a subsequent complaint visit to the facility listed above. LPA met with the administrator Marcus Fulanai and the purpose of today’s visit was explained. LPA was given access to the facility. The investigation consisted of the following: On 12/20/2024 Licensing Program Analyst (LPA) Watson requested, reviewed, and obtained copies of the Staff Roster, Client Roster, and Face Sheets. The department interviewed Staff#1-Staff#4 (S1-S4) and Residents #1-Residients #5 (R1-R5). CONTINUED ON LIC-9099C Unsubstantiated The investigation revealed the following: Allegation: Staff do not meet resident's dietary needs. It is being alleged that staff do not meet residents’ dietary needs. On 12/20/2024 the department conducted interviews with Residents #1- Residents #5 (R1-R5). The department asked the residents if staff did not meet their dietary needs. Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 the department interviewed Staff #1- Staff #4 (S1-S4). The department asked the staff if they did not meet residents’ dietary needs? Of those interviewed, 4 out of 4 staff denied the above allegation. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. Allegation: staff do not meet resident's dental hygiene needs. It is being alleged that staff do not meet residents’ dental hygiene needs. On 12/20/2024 the department conducted interviews with Residents #1- Residents #5 (R1-R5). The department asked the residents if staff did not meet their dental hygiene needs. Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 the department interviewed Staff #1- Staff #4 (S1-S4). The department asked the staff if they did not meet residents’ hygiene needs? Of those interviewed, 4 out of 4 staff denied the above allegation. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not provide outdoor activities to residents. It is being alleged that staff do not provide outdoor activities to residents. On 12/20/2024 the department conducted interviews with Residents #1- Residents #5 (R1-R5). The department asked the residents if staff did not provide outdoor activities to residents. Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 the department interviewed Staff #1- Staff #4 (S1-S4). The department asked the staff if they did not provide outdoor activities to residents? Of those interviewed, 4 out of 4 staff denied the above allegation. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. Allegation: staff do not provide comfortable accommodations to residents. It is being alleged that staff do not provide comfortable accommodations to residents. On 12/20/2024 the department conducted interviews with Residents #1- Residents #5 (R1-R5). The department asked the residents if staff do not provide comfortable accommodations to residents? Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 the department interviewed Staff #1- Staff #4 (S1-S4). The department asked the staff if they do not provide comfortable accommodations to residents? Of those interviewed, 4 out of m4 staff denied the above allegation. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not provide refunds to responsible parties. It is being alleged that staff do not provide refunds to responsible parties. On 12/20/2024 the department conducted interviews with Residents #1- Residents #5 (R1-R5). The department asked the residents if staff do not provide refunds to responsible parties? Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 the department interviewed Staff #1- Staff #4 (S1-S4). The department asked the staff if they do not provide refunds to responsible parties? Of those interviewed, 4 out of m4 staff denied the above allegation. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. Allegation: staff do not keep the facility in a sanitary condition. It is being alleged that staff do not keep the facility in a sanitary condition. On 12/20/2024 the department conducted interviews with Residents #1- Residents #5 (R1-R5). The department asked the residents if staff do not keep the facility in a sanitary condition? Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 the department interviewed Staff #1- Staff #4 (S1-S4). The department asked the staff if they do not keep the facility in a sanitary condition? Of those interviewed, 4 out of 4 staff denied the above allegation. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with the Resident Care Coordinator Marcus Fulanai and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2025 · control 11-AS-20241216112039

Allegation investigated: Resident sustained unexplained injuries while in care Staff do not meet a resident's grooming need while in care Staff did not timely address a resident's change in medical condition

On 4/28/25, Licensing Program Analyst, (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Resident Care Coordinator, Marcus Falanai and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 4/28/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA Shirley requested and received copies of the following: Staff Roster, Resident Roster, incident reports for April 2025, reviewed client’s facility files and toured the facility. LPA interviewed Staff 1 – Staff 9 (S1 – S9) and Resident 1 – Resident 7 (R1 - R7). The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Resident sustained unexplained injuries while in care The details of the complaint allege that R1 was observed with bandages on both hands and did not remember what happened or was choosing not to say. LPA Felisa Shirley requested and received copies of all incident reports for April 2025. LPA Shirley observed an Unusual incident/Injury report, stating date occurred 4/18/25. Per interview with S9, R1 was agitated, had a suitcase packed and was trying to leave. LPA interviewed S2 and she stated that R1 was agitated that morning and S2 observed R1 sitting and scratching her wrist and observed that R1 was bleeding. R1’s wristed were treated and wrapped up by S9 and 911 was called and the family was notified. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, has there been any reports of a resident with unexplained injuries. Of those interviewed, 9 out of 9 staff answered no. LPA interviewed Resident-1 thru Resident-7 (R-1 thru R-7). LPA asked, have you reported any unexplained bruises to staff. Of those interviewed, 7 out of 7 answered no. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff do not meet a resident’s grooming need while in care On 4/28/25, LPA Shirley observed R1’s Physician Report dated, 9/1/23. The report stated that R1 has the capacity to groom herself. LPA Shirley reviewed R1’s Service Plan dated, 11/5/24, stating that R1is independent with grooming and would monitor for changes in condition and conduct a reappraisal as appropriate. During file review, LPA observed R1’s Comprehensive Geriatric Assessment dated, 9/14/23, which stated, always well-groomed without assistance, can cut and clean fingernails. LPA Shirley interviewed R1 and she stated that she likes her nails. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff meet residents grooming needs while in care. Of those interviewed, 9 out of 9 staff answered yes. LPA interviewed Resident-1 thru Resident-7 (R-1 thru R-7). LPA asked, does staff meet all of your grooming needs. Of those interviewed, 5 out of 7 answered yes, 1 did not answer and 1 groom themselves. Con'd on 9099-C Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff did not timely address a resident’s change in medical condition LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff address change in medical condition in a timely manner. Of those interviewed, 9 out of 9 staff answered yes. LPA interviewed Resident-1 thru Resident-7 (R-1 thru R-7). LPA asked, have you ever been ill and staff did not report your change in condition. Of those interviewed, 6 out of 7 answered no, and 1 did not answer. On 4/18/25, R1 had bandages on her wrist. S9 was notified by S2 and S8 that R1 was bleeding. S2 observed R1 sitting and scratching herself with her nails. R1 was treated by S9, 911 was called and the family was notified. Per S9, the paramedics rebandaged the wound with the original bandages and did not take R1. The family arrived later and took R1 to the hospital. LPA observed the unusual incident/injury report which stated in the comments area, will have a meeting with family about updated service plan. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Regarding the allegations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiencies were cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Resident Care Coordinator, Marcus Falanai.the state’s words, verbatim · CDSS document, Apr 28, 2025 · control 11-AS-20250418155530

Type of visit: Case Management - Deficiencies

On 04/03/2025 at 9:22am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced case management deficiencies. The purpose of the visit is to issue a citation observed during the complaint investigation - Control 11-AS-20250401131451. During the complaint investigation, LPA learned of an incident that occurred around December 2024 - January 2025. The facility failed to report the incident as required. Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D. Exit interview conducted with Marcus Falanai Resident Care Coordinator and copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Apr 3, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Apr 7, 2025

Each licensee shall submit serious incident reports to the licensing agency such as the Department may require, including the following: (1) A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurrence of any of the eventsthe state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: The facility need submit a serious incident report of the incident that occurred with Resident #6 & Resident #7. Also facility need to review Title 22 Regulations for Reporting Requirements and self certify that all staff read Title 22 Regulations.

Allegation investigated: Staff mismanaged resident's medication.

On February 19, 2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) conducted a subsequent, unannounced complaint visit. The Resident Service Coordinator Marcus Falanai greeted the Department. The Department explained that the purpose of this visit was to investigate the allegation mentioned above. The investigation included interviews, collection of records and tour of the facility. Interviews were conducted with staff members #1 to #5 (S1-S5), resident members #1-#6 (R1-R6), and witness #1-#6 (W1-W6). The Department reviewed several documents, including the Personnel Report LIC 500, the Resident Roster, Resident #1 (R1)'s Face Sheet; Identification and Emergency Information; Service Plan; Resident Assessment; Preplacement Appraisal Information; Admissions Agreement; Physicians Report; Los Alamitos Medical Center Medical Records, Home Health Plus Service Medical Records, and other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #4: Staff mismanaged resident's medication. The complaint detailed allegation of mismanagement regarding Resident #1's (R1's) medications by the staff. It has been reported that the facility issued pain medications and antifungal cream that were not authorized by R1's primary physician. Additionally, the facility authorized refills for medications from R1's former primary physician instead of the current physician. On November 2, 2024, R1 was admitted to the hospital, where it became evident that the facility had failed to administer necessary diabetic medications. This oversight raised significant concerns, especially since R1's blood glucose levels were not being consistently monitored, which is critical for effective diabetes management. On November 2, 2024, R1 was admitted to Los Alamitos Medical Center for altered mental status caused by low blood sugar. An Unusual Incident Report from November 6, 2024, noted that R1 was feeling lightheaded in the dining area at 8:30 PM, just moments before the observation. On January 10, 2025, between 9:15 AM and 10:20 AM, the Department interviewed five staff members (Staff #1 through Staff #5). All of them acknowledged that Resident #1 (R1) had been hospitalized due to general weakness. Staff #2 (S2) claimed that no one from the hospital inquired about R1's diabetic diagnosis. S2 was uncertain whether there had been any miscommunication regarding R1's prescribed medications with the pharmacy. Staff members S2 through S5 were aware that R1 had been receiving diabetic medications daily since their admission to the facility. They indicated that R1 was only receiving medications prescribed by R1's physician. Staff members S3 through S5 stated that the medication technicians were responsible for monitoring R1's blood glucose levels and that there should be a chart log documenting the daily results. However, Staff #1 (S1) claimed that R1’s service plan did not include care staff to monitor R1’s blood glucose levels. On February 13, 2025, between 3:00 PM and 5:00 PM, the Department interviewed five family representatives (Witness #1 through Witness #5) regarding the allegation. One out of the five witnesses reported some discrepancies with medications being refilled, discontinued, or continued to be administered. Evaluation Report continues LIC 9099-C INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Facility staff did not safeguard resident’s personal items. The complaint alleged that the facility failed to safeguard the personal items of Resident #1 (R1). It was reported that R1's tooth retainer and hearing aids went missing, for which the facility has since provided reimbursement. However, R1's wheelchair, which was labeled with R1's name, also went missing and was replaced with a wheelchair that did not belong to R1. No further details were provided about this issue. On January 30, 2025, between 9:35 AM and 11:50 AM, the Department interviewed five staff members, identified as Staff #1 through Staff #5, regarding the allegation. Staff #1 and Staff #2 (S1 and S2) confirmed that the facility reimbursed R1 for the retainer and hearing aids. Staff #2, along with Staff #3 to Staff #5 (S3 to S5), claimed they had never seen R1 with a personalized manual wheelchair. Rather, they mentioned observing R1 with multiple wheelchairs in R1's room. Staff #5 described R1 using a walker-wheelchair combination, while Staff #2 to Staff #4 described a regular manual wheelchair. Staff #2 stated that all personal items belonging to R1 were documented on a Facility Resident Inventory List and disputed the existence of a personalized wheelchair for R1, asserting that it was never listed on R1's inventory and should have been identified by a serial number. On February 13, 2025, between 3:00 PM and 5:00 PM, the Department interviewed five family representatives, identified as Witness #1 through Witness #5, regarding the allegation. All five witnesses (W1 to W5) could not corroborate the claim, stating personal items were never reported missing or lost. They confirmed that residents completed an individual property and valuables inventory list upon admission. On February 19, 2025, between 9:00 AM and 11:00 AM, the Department interviewed five residents, identified as Resident #2 through Resident #6, regarding the allegation. All five residents indicated that they had not experienced any missing or lost items while in care at this facility. A review of R1's service records included an Inventory of Personal Effects dated January 25, 2019, which listed 19 items, including a walker wheelchair, but did not provide a serial number for description. Based on the information gathered, there is insufficient evidence to support the stated allegation. Evaluation Report continues LIC 9099-C Allegation #2: Staff did not ensure that resident's dental hygiene was met. The complaint stated that the facility staff did not ensure that Resident #1 (R1) received adequate dental hygiene. It was reported that R1 had not received brushing and cleaning for four or five months. Additionally, it was noted that the staff was unaware that R1 had a partial front tooth retainer, which had not been removed for cleaning. No further details were provided regarding this issue. On January 30, 2025, between 9:35 AM and 11:50 AM, the Department interviewed four staff members (Staff #2 to Staff #5) regarding the allegation. They indicated that R1 was assisted daily with dental hygiene. Staff members S3 and S4, who were the primary caregivers for R1, explained that R1 preferred to perform hygiene care independently but received assistance from staff through verbal cues or contact guard support. Staff members (S2 to S5) were unaware that R1 had partial retainers, only learning of this information years later. (S2) reported that R1 had been receiving home health services from August to November 2024, with weekly visits from home health staff for healthcare services. On February 13, 2025, between 3:00 PM and 5:00 PM, the Department interviewed five family representatives (Witness #1 to Witness #5) regarding the allegation. All five witnesses stated they could not support the claim, asserting that residents had never faced any oral hygiene issues or concerns. On February 19, 2025, between 9:00 AM and 11:00 AM, the Department interviewed five residents (Resident #2 to Resident #6) about the allegation. All five residents indicated that they had not experienced any issues with their oral hygiene care. Three out of five stated they received daily assistance from care staff, while the other two preferred to manage their oral hygiene independently. On February 2, 2025, between 12:02 PM and 12:29 PM, the Department interviewed the Case Manager at Home Health Plus, identified as Witness #6. They explained that R1 was receiving home health care services with weekly visits from a Licensed Vocational Nurse (LVN), although these visits did not include grooming or dental care. A review of R1's Physician's Report (LIC 602A) dated January 24, 2019; January 11, 2020; January 27, 2021; and January 19, 2022; as well as the Facility Service Plan dated November 6, 2024; and the Preplacement Appraisal Information dated January 25, 2019, revealed that R1 required assistance with personal hygiene. Medical assessment reports indicated that R1 did not have dentures or retainers until 2022. The facility decisively failed to maintain progress notes for Resident #1, resulting in a significant gap in their care documentation. Based on the information gathered, there is insufficient evidence to support the stated allegation. Evaluation Report continues LIC 9099-C Allegation #3: Staff did not ensure that resident was adequately fed. The complaint states that the staff did not ensure that Resident #1 (R1) is adequately fed. It is reported that R1 lacked nutrition due to not eating enough, which is attributed to R1's recent hospitalization. Further reports indicated that after hospitalization, the physician ordered R1 to be given Ensure drink supplement twice daily. However, an inventory surplus showed that this was not carried out according to the doctor's orders. Los Alamitos Medical Center Medical Records indicated that on November 2, 2024, R1 was hospitalized with altered mental status due to hypoglycemia. An Unusual Incident Report dated November 6, 2024, noted that R1 was observed at 8:30 PM on November 2, 2024, in the dining area, feeling lightheaded just minutes before. On January 10, 2025, between 9:15 AM and 10:20 AM, the Department interviewed five staff members (Staff #1 - Staff #5). None of them could corroborate the complaint. They stated that R1 was on a mechanical soft diet and received three meals and snacks in between. According to Staff #1 to Staff #5, the nutritional drink Ensure was provided to R1 twice daily, as prescribed by the physician after hospitalization. Staff #2 reported that R1 was under home health services, receiving weekly visits from a Licensed Vocational Nurse (LVN), and there were no concerns regarding R1's nutrition. Staff #3 and Staff #4 indicated that the meals served to residents meet health standards, are of good quality, and provide adequate portions. They further noted that the facility offers meal substitutes and can accommodate residents with special dietary restrictions. They observed that R1 was a "light eater" who consumed smaller portions of food. On February 13, 2025, between 3:00 PM and 5:00 PM, the Department interviewed five family representatives (Witness #1 – Witness #5) regarding the allegation. All five witnesses attested that the residents enjoyed an ample selection of nutritious meals that fully met their dietary requirements. They reported no concerns whatsoever regarding the quality or appropriateness of the food provided. On February 19, 2025, from 9:00 AM to 11:00 AM, the Department interviewed five residents (Resident #2 - Resident #6) about the allegation. Evaluation Report continues LIC 9099-C They expressed that they had no issues with the meals provided, stating that the portions were sufficient and that there was no shortage of food, including ample snacks. On February 2, 2025, between 12:02 PM and 12:29 PM, the Department interviewed the Case Manager at Home Health Plus (Witness #6). The witness confirmed that there were no notable medical concerns regarding R1's nutritional status. (W6) elaborated that R1 was currently taking a variety of multivitamins, along with prescribed medications, which could potentially diminish appetite. The Department reviewed R1's Physician's Report (LIC 602A) dated January 24, 2019, January 11, 2020, January 27, 2021, and January 19, 2022; the Facility Service Plan dated November 6, 2024; and the Preplacement Appraisal Information dated January 25, 2019. These documents revealed that R1 can self-feed and is on a mechanical soft diet. Records from Home Health Plus Services dated August 13, 2024, through November 2, 2024, showed no observations of R1 being undernourished. R1 is prescribed 18 medications and nine out of 18 had side effects for causes of loss appetite (ref: National Institute of Health). Based on the gathered information, there is insufficient evidence to support the stated allegation. The Department could not conduct an interview with Resident #1 because R1 was unwilling to participate. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are deemed unsubstantiated. An exit interview was conducted with Marcus Falanai, and copies of the reports were provided. All five witnesses concurred that the facility faced significant communication challenges with the authorized parties involved. On February 19, 2025, from 9:00 AM to 11:00 AM, the Department interviewed five residents (Resident #2 through Resident #6) about the same allegation. The residents collectively stated that they had no issues with their medications and that medications were being administered in a timely manner as prescribed. On February 2, 2025, between 12:02 PM and 12:29 PM, the Department interviewed the Case Manager at Home Health Plus (Witness #6). This witness indicated that the LVN nurse was aware of Resident #1's prescribed medications and followed the physician's orders. Witness #6 stated that there were no issues with the facility's administration of medications and that the care staff was monitoring Resident #1’s glucose levels. According to this witness, the LVN nurse it was not needed to monitor during visits since the facility staff had already completed the necessary procedures. An examination of R1's medical documentation, including the Physician's Reports (LIC 602A) dated January 24, 2019, January 11, 2020, January 27, 2021, and January 19, 2022, along with the Facility Service Plan dated November 6, 2024, and Preplacement Appraisal Information from January 25, 2019, was conducted. Additional records from Los Alamitos Medical Center covering the period from November 2, 2024, to November 5, 2024, were also reviewed. Noteworthy documents included an Incident Report LIC 624 dated November 6, 2024, Physicians’ Medication Orders spanning from January 26, 2019, to December 2, 2021, a Medication Administration Record from January 26, 2019, to March 1, 2019, and further Physicians’ Medication Orders dated January 17, 2024, along with the Residential Admission Agreement dated January 25, 2019. The analysis revealed that R1 is diagnosed with a range of diabetic health issues, necessitating careful management. Since admission in 2019, R1 has been consistently prescribed diabetic medications, specifically "Glipizide 5mg & 10mg," to be taken twice daily. However, it was concerning to note that the service care plan did not incorporate any monitoring for blood glucose levels, which is critical for effective diabetes management. A significant deficiency in record-keeping was identified, as vital Medication Administration Records (MAR) were absent for the entire duration from 2020 through 2024. Evaluation Report continues LIC 9099-C Furthermore, R1 had been prescribed PRN (as needed) medications, yet there were no accompanying (MAR) Physician Medication Orders recorded for the years 2022 and 2023. There were no detailed charts available to monitor the ups and downs of blood sugar levels, which raises significant concerns about proper care. Furthermore, the absence of staff notes, or progress reports left important gaps in R1’s care documentation, making it difficult to understand their health changes over time. The Department could not conduct an interview with Resident #1 because R1 was unwilling to participate. Based on observations, interviews, and record reviews, there is substantial evidence indicating that "Neglect and Lack of Care and Supervision" has been substantiated. This finding is cited under California Code of Regulations, Title 22, Division 6, Chapter 8, as noted on the attached LIC 9099-D. An exit interview was conducted with Marcus Falanai, the Resident Care Coordinator, during which a hard copy of the report and information on appeal rights was provided.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 11-AS-20250124134130

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

87465(a)(4) Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care... When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observations and a review of records, the licensee failed to comply with the aforementioned section. The LPA observed inconsistencies and gaps in the medication administration records, which posed a potential risk to the health, safety, or personal rights of the individuals in care.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: The licensee will ensure that facility staff consistently use medication administration records (MARs) accurately. As part of the correction plan, a retraining program will be implemented to reinforce proper documentation procedures. Proof of this training will be submitted to the License Program Analyst (LPA) before the deadline for the plan of correction (POC). *CIVIL PENALTY ISSUED*

Allegation investigated: Staff do not report incidents to residents' responsible parties.

On 12/31/24 the department conducted a subsequent complaint visit regarding the allegations above. LPA met with Resident care coordinator Marcus Falanai as the purpose of the visit was explained. The investigation consisted of the following: On 07/31/2024 at 9:30 am Licensing Program Analyst (LPA), David España conducted an initial complaint visit. On 07/31/2024 as part of the LPA España investigation, LPA requested documents for Resident #1-#6 (R1-R6), Staff #1-#6 (S1-S6), and a staff and resident roster. On 12/04/24 LPA Villegas obtain copies of the staff and resident rosters, and between 9:30am-1pm LPA conducted interviews with residents #3-5 (R3-R5), Staff #1 (S1), and Witness#1 (W1). On 07/31/2024 as part of the LPA España interviewed staff 5-7 (s5-s7) . On 12/19/24 between 9:30am-11:30 am LPA Villegas conducted interviews with S2-S4. On 12/31/24 LPA Villegas conducted a medication review for 4 residents, and a review of trainings for 3 caregivers, and 3 med-techs. The investigation revealed the following: Unsubstantiated Allegation: Staff do not report incidents to residents' responsible parties. It is being alleged that the facility consistently fails to report fall incident or notify families of their loved ones' deteriorating conditions. On 12/04/24 between 9:30am-1pm LPA conducted interviews with (R3-R5) regarding the allegation above, 3 of 3 residents interviewed denied the allegation and denied experiencing a fall or injury while in care. On 12/04/24 LPA Villegas was unable to interview R1 as R1 is no longer receiving care at Brittany House. On 12/04/24 LPA conducted over the phone interview with POA for R1, per POA facility did notify POA of fall as R1 was being transported to hospital by ambulance. On 12/04/24 LPA Villegas was unable to interview R2 due to communication barrios. On 12/04/24 LPA interviewed S1 regarding the allegation above, 1 of 1 staff interviewed denied the allegation above and reported S1 will review the written report before faxing it to CCLD and obtaining a fax confirmation number. On 07/31/2024 and 12/19/24 between 9:30am-11:30 am LPA Villegas interviewed S2-S7 regarding the allegation above, 3 of 6 staff interviewed denied the allegation above and reported documenting when responsible parties are notified in the communication folder, 3 of 6 staff interviewed stated being unaware of the reporting procedures are after incidents are reported to the med room staff on shift. 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 conducted, and a copy of this report was provided. Allegation: Staff do not administer medications as prescribed. It is being alleged medications are frequently administered late or improperly. On 12/04/24 LPA Villegas interviewed S1 regarding the allegation above, 1 of 1 staff interviewed denied the allegation above and reported documenting if there is a medication error. On 07/31/2024 and 12/19/24 between 9:30am-11:30 am LPAs Espana and LPA Villegas interviewed S2-S7 regarding the allegation above 3 of 6 staff denied the allegation above, 3 of 6 staff interviewed reported they do not assist with medication therefore are unaware of the medication administration process. On 12/04/24 between 9:30am-1pm LPA conducted interviews with (R3-R5) regarding the allegation above, 2 of 3 residents interviewed denied the allegation above, 1 of 3 residents interviewed reported not taking any medications. On 12/04/24 LPA Villegas was unable to interview R1 as R1 is no longer receiving care at Brittany House. On 12/04/24 LPA conducted over the phone interview with POA for R1, per POA facility did not administer antibiotics are prescribed to R1. On 12/04/24 LPA Villegas was unable to interview R2 due to communication barrios. On 12/31/24 at 11:30am LPA Villegas conducted review of MAR for 4 residents, LPA Villegas observed that the MARs weren’t checked off and observed med tech was checking off meds that were passed during the AM during the review. On 12/31/24 1 of 7 overall staff interviewed disclosed medications errors are currently being worked on in order to correct discrepancies previously cites by LPA Brown on 12/10/24 and LPA Iniguez on 12/16/24. Allegation: Staff are not properly trained. It is being alleged that the facility has staff members who fail to complete mandatory annual training. On 12/04/24 LPA Villegas interviewed S1 regarding the allegation above, 1 of 1 staff interviewed denied the allegation above and reported training is ongoing. On 07/31/2024 and 12/19/24 between 9:30am-11:30 am LPA Villegas interviewed S2-S7 regarding the allegation above, 1 of 3 staff denied the allegation above and reported shadowing for 2 weeks, 1 staff reported shadowing for 1 week, 1 staff reporting not having much training, and 3 of 6 staff reported training is upon hire with in-services as needed. On 12/04/24 between 9:30am-1pm LPA Villegas conducted interviews with (R3-R5) regarding the allegation above, 3 of 3 residents interviewed denied the allegation above and reported feeling safe when assisted by staff. On 12/04/24 LPA Villegas was unable to interview R1 as R1 is no longer receiving care at Brittany House. On 12/04/24 LPA conducted over the phone interview with POA for R1, per POA all the “good caregivers” are no longer employed at the facility. On 12/04/24 LPA Villegas was unable to interview R2 due to communication barrios. On 12/31/24 LPA Villegas conducted a review of training records for 3 caregivers and observed completed required trainings in the personnel file. On 12/31/24 LPA requested copies of training for 3 meds techs however, LPA was not provide with training and was informed there is not documented training's for med techs on file. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8)are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 31, 2024 · control 11-AS-20240725125526

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6)(A-H) · Plan of correction due date: Jan 14, 2025

87465 Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored: The licensee shall be responsible for assuring that a record of centrally stored prescription medications.... The name of the resident for whom.... Based on interviews and record reviews, the licensee and Administrator did not comply with the section cited above as medications passes were not properly documeted which is a potential a potentila health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Dec 31, 2024

Plan of correction: Licesee and Administrator will develope a plan detailing how the facility will ensure all medications are properly administered and documented. Plan to be submitted to LPA by POC due date. Lizeth.villegas@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c)(1-2) · Plan of correction due date: Jan 14, 2025

87412 personnel records Licensees shall maintain in the personnel records verification of required staff training and orientation. The following staff training and orientation shall be documented: For staff who assist with personal activities of daily living.... Based on interviews and record reviews, the licensee and Administrator did not comply with the section cited above as there was no documentation confirming Staff 5-7 have obtained and passed required training(s).the state’s words, verbatim · CDSS document, Dec 31, 2024

Plan of correction: Licesee and Administrator will enure all staff have required training by an appropriate skilled professional and provide the department with training sign in sheets, and instructures contact info and crendials by POC due date. LPA provided a copy of section 87412 for refrence.

Allegation investigated: Residents are forced to using facility's medical care provider. Facility does not appropriately provided enough staff to meet the residents' needs. Staff falsify records.

On 12/19/24 at 9am the department conducted a subsequent complaint visit regarding the allegations above. LPA met with (S1) Marcuc Falanai as the purpose of the visit was explained. The investigation consisted of the following: On 07/31/2024 at 9:30 am Licensing Program Analyst (LPA), David España conducted an initial complaint visit. On 07/31/2024 as part of the LPA España investigation, LPA requested documents for Resident #1-#6 (R1-R6), Staff #1-#6 (S1-S6), and a staff and resident roster. On 12/04/24 LPA Villegas obtain copies of the staff and resident rosters, and between 9:30am-1pm LPA conducted interviews with residents #3-5 (R3-R5), Staff #1 (S1), and Witness#1 (W1). On 12/19/24 LPA Villegas conducted a tour of the facility, there were no immediate health or safety concerns. On 12/19/24 between 9:30am-11:30 am LPA Villegas conducted interviews with S2-S4. The investigation revealed the following: Unsubstantiated Allegation: Residents are forced to using facility's medical care provider. It is being alleged that residents are denied their right to choose healthcare providers and are being compelled to use a preferred agency contracted by the licensee. On 12/4/24 between 9:30am-1pm LPA conducted interviews with (R3-R5) regarding the allegation above, 1 of 3 residents interviewed confirmed the allegation above, 2 of 3 residents interviewed reported having no recollection if they were provided with options upon admission. On 12/4/24 LPA Villegas was unable to interview R1 as R1 is no longer receiving care at Brittany House, On 12/4/24 LPA Villegas was unable to interview R2 due to communication barrios. 12/4/24 LPA interviewed S1 regarding the allegation above, 1 of 1 staff interviewed denied the allegation above and reported that some residents come in with a medical provider and report wanting to keep them and if not, the facility has a lot of pamphlets for medical providers, home health and hospice agencies to chose from. On 12/19/24 between 9:30am-11:30 am LPA Villegas LPA interviewed S2-S4, regarding the allegation above, 3 of 3 staff interviewed denied the allegation above and reported having no knowledge of the admission process. Allegation: Facility does not appropriately provide enough staff to meet the residents' needs. It is being alleged that the turnover rate among staff is high. On 12/4/24 between 9:30am-1pm LPA conducted interviews with (R3-R5) regarding the allegation above, 1 of 3 residents denied the allegation above, 2 of 3 residents interviewed reported the facility is short staff at times. On 12/4/24 LPA Villegas was unable to interview R1 as R1 is no longer receiving care at Brittany House, On 12/4/24 LPA Villegas was unable to interview R2 due to communication barrios. 12/4/24 LPA interviewed S1 regarding the allegation above, 1 of 1 staff interviewed denied the allegation above and reported that there are 7 caregivers per shift. On 12/4/24 LPA conducted a review of the staff roster and per staff roster, there are (11) caregivers scheduled between 6:30am-5pm, (2) med techs scheduled between 6:30 am-2:30pm, (6) caregivers scheduled between 2:30pm--10:30pm, (1) LVN scheduled between 2:30pm--10:30pm, (2) caregivers scheduled between 10:30pm- 6:30am. On 12/19/24 between 9:30am-11:30 am LPA Villegas LPA interviewed S2-S4, regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. Allegation: Staff falsify records. It is being alleged that the facility is attempting to modify physician's report to remove a dementia diagnosis to facilitate transfer to assisted living. On 12/4/24 between 9:30am-1pm LPA conducted interviews with (R3-R5) regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. On 12/4/24 LPA Villegas was unable to interview R1 as R1 is no longer receiving care at Brittany House, On 12/4/24 LPA Villegas was unable to interview R2 due to communication barrios. On 12/4/24 LPA interviewed S1 regarding the allegation above, 1 of 1 staff interviewed denied the allegation above and reported that if the allegation above was observed it would be report to supervisor for further investigation. On 12/19/24 between 9:30am-11:30 am LPA Villegas LPA interviewed S2-S4, regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. 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 conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 11-AS-20240725125526

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

Allegation investigated: Staff did not dispense resident’s medication as prescribed.

On 12/16/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Mandy Taylor/ Executive Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (S#1-S#4) and Resident’s interviews (R#1-R#5). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#5) Identification and Emergency Information, (R#1-R#5) Physicians Assessment or LIC 602A, (R#1-R#5) Inventory List or LIC 621, (R#1-R#5) Medication Administration Record (MARs) from October, November, and December 2024… Evaluation Report continues LIC 9099-C Substantiated Evaluation Report continues LIC 9099-C Allegation: Staff did not dispense resident’s medication as prescribed. The details of the complaint alleged that facility staff is not dispensing residents’ medications as prescribed by their physician. During the records review, LPA Iniguez reviewed (R#1-R#5) Medication Administration Records (MARs) from October through November 2024; LPA Iniguez observed discrepancies During the records review, LPA Iniguez examined the Medication Administration Records (MARs) for residents (R#1-R#5) from October to November 2024. LPA Iniguez identified discrepancies in the medication documentation for all five residents.in all (5) residents' medication documentation. In addition, LPA reviewed (R#1-R#5) Physicians assessment or LIC 602A, LPA noted that all (5) residents are not able to administer their own medications. During this investigation, LPA found sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D. ) An exit interview was conducted, and a copy of the Complaint Report was given to Mandy Taylor/Executive Director. Investigation Revealed the Following: Allegation: Staff spoke to resident in an inappropriate manner. The details of the complaint alleged that facility staff spoke to a resident in care in an inappropriate manner. During an interview with the administrator (A#1), she and other facility staff never spoke inappropriately to a resident in care. Also, (A#1) stated that facility staff, including her, treat residents with dignity and respect. During interviews with residents (R#1-R#5), (4) out of (5) stated that they have never spoken inappropriately. During interviews with staff (S#1-S#4), (4) out (4) stated that they have never inappropriately spoken to residents in care and they treat all residents with dignity and respect. Allegation: Staff did not allow resident to have private phone calls. The details of the complaint alleged that facility staff is not allowing residents in care to have private phone calls. During a health and safety check of the facility, LPA Iniguez observed that the telephone is located in one of the common areas. The place has the ability to close the door for more private conversations. During an Interview with the Administrator (A#1), she stated that the residents can make and receive private phone calls, and she and the facility staff have never listened to their private conversations. During interviews with residents (R#1-R#5), (4) out of (5) stated that they can have private phone call conversations. Evaluation Report continues LIC 9099-C During interviews with staff (S#1-S#4), (4) out of (4) stated that the residents are able to have private phone conversations, and they have never been listed to them. Allegation: Staff did not safeguard resident's personal belongings. The details of the complaint alleged that facility staff is throwing away resident’s personal belongings. During the records review, LPA Iniguez reviewed (R#1) 's Client/Resident's Personal Property and Valuables or LIC 621; LPA observed that (R#1) refused to have their personal belongings listed. In addition, LPA reviewed (R#1) 's Physicians Assessment or LIC 602A dated 11/3/2024; LPA noted that it is listed that (R#1) has a cognitive impairment. Moreover, LPA observed that (R#2-R#5) had their inventory list on file. During an Interview with the Administrator (A#1), she stated that the facility is safeguarding residents' belongings and is not throwing them away. During interviews with residents (R#1-R#5), (4) out of (5) stated that the facility is safeguarding their personal belongings. During interviews with staff (S#1-S#4), (4) out (4) stated that the facility is safeguarding residents' belongings and is not throwing them away. Allegation: Staff did not provide resident with prescribed medical garment. The details of the complaint alleged that facility staff is not providing prescribed medical garment to resident in care. During the records review, LPA Iniguez reviewed (R#1)’s medical file, and there was no doctor’s order for a medical garment. Evaluation Report continues LIC 9099-C During an Interview with the Administrator (A#1), she stated that they provide prescribed medical garments if a medical order (R#1) does not have one on file. During interviews with residents (R#1-R#5), (4) out of (5) stated that the facility provides the items prescribed by their physician. Allegation: Staff did not ensure facility floors were maintained in clean condition. The details of the complaint alleged that facility is not clean and sanitary. During a health and safety check of the facility, LPA Iniguez observed that it was clean and sanitary. During an Interview with the Administrator (A#1), she stated that the facility is clean and sanitary. During interviews with residents (R#1-R#5), (4) out of (5) stated that the facility is clean and sanitary. During interviews with staff (S#1-S#4), (4) out (4) stated that the facility is clean and sanitary. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Mandy Taylor / Executive Director.the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 11-AS-20241209150447

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 30, 2024

87465(a)(4) Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as during medication reviews, LPA observed discrepancies in all 5 residents medication administration records which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: Licensee will ensure facility staff use correctly medication administrator records at all time. As plan of correction, licensee will re-train facility staff on the importance on how to document properly on the resident's MARs. proof of training will be sent to LPA before POC due date.

Allegation investigated: Staff did not post notice for residents council meetings

*This finding supersedes the findings written on 10/31/24. On 12/16/24, Licensing Program Analyst, (LPA) Felisa Shirley conducted a subsequent unannounced visit to this facility. LPA was met by Administrator, Mandy Taylor and explained the purpose of the visit is to deliver amended findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 10/31/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA Shirley requested and received copies of the following: Staff Roster, Resident Roster, Activity schedules, and reviewed client’s facility files and admission agreements. The investigation revealed the following: Con'd on 9099-C Substantiated Allegation: Staff did not post notice for resident council meetings On 10/31/24, LPA Shirley reviewed facilities activity board and observed that there is no Resident Council information, meeting dates nor locations. LPA Shirley interviewed facility Administrator, Mandy Taylor and learned that this facility formerly only focused on Memory Care and just recently began offering services in July of 2024 to residents for Assisted Living. LPA Shirley spoke with the Activities Director who is new to the position who stated that she is in the process of curating a calendar of events, which includes a Resident Council. The Activities Director stated that she will meet with residents and inform them that they have a right to form a committee. Resident Councils meetings are not posted as Brittany House does not have a Resident Council. There should’ve already been a Resident Council in place. LPA Shirley interviewed staff-1 thru staff-7 (S-1 thru S-7). LPA asked, does staff post notices for Resident Council meetings? Of those interviewed, 6 out of 7 answered no. One employee stated that they did not know. LPA interviewed Client-1 thru Client-6 (C-1 thru C-6). LPA asked, does staff post notices for Resident Council meetings?” Of those interviewed, 6 out of 6 did not know anything about the Resident Counsel. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. An exit interview was conducted, and a copy of this report was provided to Receptionist, Stephanie Rubio.the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 11-AS-20241022210327

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87221 · Plan of correction due date: Dec 30, 2024

87221 Resident Councils The facility shall permit the formation of a resident council by interested residents, provide space and post notice for meetings, and provide assistance in attending meetings for those residents who request it. In order to permit a free exchange of ideas, at least part of each meeting shall be allowed to be conducted without the presence of any facility personnel. Residents shall be encouraged, but shall not be compelled to attend. The purpose of such an organization shall be to work with the administration in improving the quality of life for all residents by enriching the activity program and to discuss the services offered by the facility and make recommendations regarding identified problems. This requirement was not met as evidenced by: Based on interviews and record reviews, facility staff did not assist residents in the formation of a resident council. This poses a possible personal rights violation to all residents in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: Please provide provide proof that there is a Resident Council in place by Plan of Correction date of 12/30/24. Please send to LPA Felisa Shirley at felisa.shirley@dss.ca.gov or fax to 424-544-1016 by POC date.

Type of visit: Required - 1 Year

On 12/10/2024 at 8:18am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one- year inspection (due February 2025). LPA met with Marcus Falanai, Resident Care Coordinator and the purpose of the visit was discussed. Facility is licensed to serve age range 60 and over which is approved for 170 non-ambulatory of which 24 may be bedridden (bedroom 301 - 303, 307 - 308, 311-314 may have 2 bedridden) and bedroom #304-306 and 309 may have 1 bedridden only with a waiver granted for hospice care for ten (10). There are (50) residents are diagnosed with dementia, (9) residents receiving home health, (10) residents receiving hospice care services and (1) resident receiving palliative care. The last fire inspection was completed on 05/08/2024. The facility does not handle any of the residents’ money. The facility annual fee is $$2,311.00 which is due on 02/09/2025. LPA provided pin #773699 if facility choose to make facility annual payment online. The facility a single story building consisting of: (142) resident bedrooms, (43) Full bathrooms, kitchen, (4) dining area, laundry room, medication room and (10) outdoor shaded patio areas. LPA toured the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 108.0F -112.3.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Report continues on LIC 809-C A review of (10) residents service files, (10) staff personnel files and (10) Medication Administration Records (MAR) and did observe discrepancies at the time of visit. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. -Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8); LPA observed the following deficiencies: On 12/10/2024 at 1:45 pm while LPA was conducting a tour of the physical plant, LPA reviewed and observed: 4 out 10 staff (Staff #1, Staff #4 - Staff #6) with no CPR/First Aid Certification. 8 out of 10 staff did not have a LIC 503 Health Screening with TB Test results. 10 out of 10 residents medication was not listed on the MAR, empty and or not check off by staff on consecutive days. LPA conducted a file review of the 5 out of 10 residents files and did not observe an Needs and Services Plan within 30 days after admission date. An exit interview was conducted, and a copy of Report and Appeal Rights provided.the state’s words, verbatim · CDSS document, Dec 10, 2024

Allegation investigated: Staff are not properly reporting incidents involving the residents.

On 11/06/24, at 9:30am, Licensing Program Analyst (LPA) Perry Scott conducted an initial complaint visit to the facility and was greeted by Mandy Taylor, Executive Director, and Marcus Falanai, Service Coordinator. LPA explained the purpose of this visit is to conduct interviews, gather facility files, and render findings in the complaint. The investigation consisted of the following: LPA investigated the allegation mentioned in this complaint and conducted interviews with staff (S1-S8). Additionally, LPA obtained the following documents: Resident Roster (No Date), Staff Roster (Dated: 10/28/2024), and Incident Reports (Dated: 09/14/24, 09/16/24, 10/14/24, 10/15/24, 10/18/24, 10/21/24, 10/22/24, 10/28/24, 11/6/24) from the facility. The investigation revealed the following: Staff are not properly reporting incidents involving the residents. The details of the complaint alleged that the facility does not send in incident reports for residents when they are injured or pass away at the facility. Complaint Investigation Report Continued on LIC9099-C Unsubstantiated On 11/06/24, from 09:20am-2:00pm, LPA interviewed staff (S1-S8) regarding the allegation. 8 of 8 staff (S1- S8) denied the allegation that the facility Staff are not properly reporting incidents involving the residents. All staff (S1-S8) stated that the facility does send in timely incident reports. S1 stated that since S1 has been in charge, the facility has sent in all reports involving a death or an injury. Staff (S3-S8) further state that when an injury or death occurs, they alert the med-Techs, caregivers, and the nurses and they either report it to the hospice agency, the family, call 911 and then write an incident report. The department reviewed the Incident reports for the residents dated 09/14/24, 09/16/24, 10/14/24, 10/15/24, 10/18/24, 10/21/24, 10/22/24, 10/28/24, and 11/6/24 for the residents and did not observe any discrepancies in the reports or when they were sent. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are not properly reporting incidents involving the residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No citations were issued for this complaint. An exit interview was conducted with Marcus Falanai, Service Coordinator, and a copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Nov 6, 2024 · control 11-AS-20241031111836

Allegation investigated: Staff did not post notice for residents council meetings

On 10/31/24, Licensing Program Analyst, (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Administrator, Mandy Taylor and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 10/31/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA Shirley requested and received copies of the following: Staff Roster, Resident Roster, Activity schedules, and reviewed client’s facility files and admission agreements. The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Staff did not post notice for resident council meetings On 10/30/24, LPA Shirley reviewed facilities activity board and observed that there is no Resident Council information, meeting dates nor locations. LPA Shirley interviewed facility Administrator, Mandy Taylor and learned that this facility formerly only focused on Memory Care and just recently began offering services in July of 2024 to residents for Assisted Living. LPA Shirley spoke with the Activities Director who is new to the position who stated that she is in the process of curating a calendar of events, which includes a Resident Council. The Activities Director stated that she will meet with residents and inform them that they have a right to form a committee. Resident Councils meetings are not posted as Brittany House does not have a Resident Council. LPA Shirley interviewed staff-1 thru staff-7 (S-1 thru S-7). LPA asked, does staff post notices for Resident Council meetings? Of those interviewed, 6 out of 7 answered no. One employee stated that they did not know. LPA interviewed Client-1 thru Client-6 (C-1 thru C-6). LPA asked, does staff post notices for Resident Council meetings?” Of those interviewed, 6 out of 6 did not know anything about the Resident Counsel. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not post notice for Resident Council meetings,” therefore the allegation is unsubstantiated. A copy of this report is being signed and copies given to Administrator, Mandy Taylor.the state’s words, verbatim · CDSS document, Oct 31, 2024 · control 11-AS-20241022210327

Allegation investigated: Staff do not report incidents to Community Care Licensing.

On 10/02/24 at 9:00 am, Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegation above. LPA met with Executive Director (ED) Mandy Taylor as the purpose of today’s visit was explained. The investigation consisted of the following: On 10/02/24 LPA obtained copies of staff and resident rosters, and the following documents for R1: Emergency ID from, facesheet, admission agreement, durable power of attorney, physicians report, POLST, and needs and service plan. On 10/02/24 LPA conducted interviews with ED and staff #1 (S1). The investigation revealed the following: Allegation- Staff do not report incidents to Community Care Licensing. It is being alleged that the facility does not submit incident reports for the death of R1. Substantiated On 10/02/24 LPA conducted interview with Executive Director (ED) regarding the above allegation, ED confirmed the allegation above. Per ED, an employee who is no longer employed at the facility was in charge of submitting SIRs and ED is unsure why the SIR was not submitted. On 10/02/24 LPA conducted interview with staff #1 (S1) regarding the allegation above, 1 of 1 staff interviewed confirmed that there was no incident report submitted for the death of R1 as a previously employed staff who was in charge of submitting reports to the licensing department did not complete the required report. S1 continued to report that S1 is now the employee responsible for submitting incident reports to the licensing department. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 2, 2024 · control 11-AS-20240924105844

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(B)(D) · Plan of correction due date: Oct 16, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department...(B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety, or health of any resident...This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report associated with the death of (R1) . The facility did not have proof of certified confirmations LIC 624 was faxed to CCL. This violation poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: Licensee/Administrator will review Title 22 Sec. 87211 and agreed to provide training to staff pertaining to CCL Reporting Requirements. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC date Lizeth.villegas@dss.ca.gov

Type of visit: Case Management - Incident

On October 2, 2024 at 9:40am Licensing Program Analyst (LPA) Zina Brown and Licensing Program Manager (LPM) Janae Hammond conducted an unannounced case management to follow up on a incident that occurred on September 20, 2024 between Resident #1 and Resident #2 that engaged in inappropriate sexual activity. During today visit we met with Mandy Taylor, Administrator and explained the purpose of the visit. During today's visit, LPA conducted a tour of the physical and reviewed residents file, conducted interview with Administrator, Staff #1 - Staff 3, Resident #1 - Resident #2. Due to insufficient information at this time, a further investigation is needed at this time. LPA Brown will return at a later date to complete further investigation. A exit interview was conducted with Mandy Taylor, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 2, 2024

Allegation investigated: Staff did not notify authorized representative of incident.

Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Med-Ted (S6:Laurie Riffel). LPA stated the purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation. The investigation consisted of the following: A health and safety visit was conducted 08/21/24 and 08/23/24. A toured the facility’s physical plant. A review of documents: Residents’ Roster (dated: 08/21/24); Staff Roster & Work Schedules (dated: 08/21/24); Admissions Agreement (dated: 08/10/20); Physicians Report LIC 602A (dated: 07/30/20 and 08/29/23); Resident Pre-Assessment (dated: 07/20/20); Resident Assessment (dated: 08/07/20); Admission Body Check (dated: 08/10/20 and 12/18/21); Service Plans (dated: 08/10/20); Functional Assessment Stating Tool (dated: 08/07/20); and (Evaluation Report continues LIC 9099-C) Substantiated Nurses Notes (dated: 08/10/20 – 11/12/23); Shower Scheduled (dated: 08/01/24-08/231/24); Vital Sings Records; Weight Records; and Podiatric Evaluation and Treatment (dated: 11/02/20 – 06/21/23); Los Alamitos Medical Center Medical Records (dated: 08/26/24), and other documents associated with this complaint. INVESTIGATION REVEALED THE FOLLOWING: Allegation #2: Resident sustained injury while in care. The details of the complaint alleged resident #1 (R1) sustained injury while in care. Information provided claimed while (R1) was examined at Los Alamitos Medical Center it revealed (R1) had pressure ulcers. On 08/21/24 between 09:30 am to 03:56 pm, the Department interviewed (6) out of (6) administrator #1 (A1) and staff #1-#5 (S1-S5) who denied (R1) had pressure injuries. (A1) stated when (R1) was admitted on 08/10/20 an examination of the body was performed and it indicated that old scars on the buttocks, otherwise skin was clear and intact. Whatever sore that (R1) had from the skilled nursing facility Broadway by the Sea had healed. (S3-S5) who had direct contact with (R1) as primary caregivers refuted this claim. (S3-S5) claimed body checks are performed daily and there were no indications of skin tears, lacerations, or bed sores during (R1) care at this facility. (A1-S1-S5) verified that (R1) did not have any injuries due to falls or accidents. On 08/23/24 and 08/29/24 between 01:15 pm - 03:05 pm, the Department interviewed (3) out of (6) residents #1-#6 (R1-R6) who verified to have had no pressure injuries while being cared for at this facility. On 08/23/24 and 08/29/24 between 01:35 pm to 04:45 pm, the Department interviewed (4) out of (6) witnesses #3-#6 (W3-W6), claimed that residents have not sustained pressure injuries while in care at this facility. (W1) claimed Los Alamitos Medical Center made no mention of a bed sore on (R1), however, Kaiser Permanente did specify (R1) had pressure injuries. A review of the Los Alamitos Medical Center Medical Records (dated: 08/26/24) (R1) was examined and it indicated skin had no rashes or redness. There was no indication of pressure ulcers in the gluteal region. Medical records indicated examination consisted of the gluteal area for a colonic diverticulosis procedure that may have later been attributed to a skin tear in the gluteal region. (Evaluation Report continues LIC 9099-C) A result of the Department review of (R1’s) service records included: Physicians Report LIC 602A (dated: 07/30/20 and 08/29/23); Resident Pre-Assessment (dated: 07/20/20); Resident Assessment (dated: 08/07/20); Admission Body Check (dated: 08/10/20 and 12/18/21); Service Plans (dated: 08/10/20); Functional Assessment Stating Tool (dated: 08/07/20); and Nurses Notes (dated: 08/10/20 – 11/12/23) made no mention of an active pressure ulcers were being treated. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Allegation #3: Staff did not provide a safe environment for resident. The details of the complaint alleged the facility staff did not provide a safe environment for resident #1 (R1) while in care. Information provided indicated on 06/06/24, (R1) was left in bed asleep in the room while the area was cleared of residents for construction. The result of the construction left an overwhelming smell of tar and construction noises taking place near (R1’s) room. On 08/21/24 between 09:30 am to 03:56 pm, the Department interviewed (6) out of (6) administrator #1 (A1) and staff #1-#5 (S1-S5) verified that some type of remolding was being constructed in unit 4 where (R1) had a room. (A1) S1-S5) all indicated that all residents were moved to the unit 5 area on time. (A1) indicated that all current residents and their representatives were notified Units 3 and 4 were being repurposed for assisted living and memory care will remain in units 1, 2, and 5 in writing. (S1) verified to have notified authorized representatives of the move from unit 4 to unit 5 and construction of unit 4. (S1-S5) said that (R1) remained in the room while the other residents were moved to unit 5. (S1-S4) claimed on 06/06/24, (R1) refused to cooperate and did not want to be relocated to another room. (S1-S5) claimed that (R1) was left in the room for no more than an hour between 11:30 am to 12:30 pm. (R1) eventually agreed to be relocated into a room in unit 5. (S1-S5) stated that (R1) was not abandoned and was not left in unit 4 for more than an hour. (S1-S5) stated the renovation consisted of securing several protections plastic covered to prevent noise, smell, and dust as barriers. (S1-S5) claimed that the renovation of the facility was intended to ensure the safety and health of all residents. On 08/23/24 and 08/29/24 between 01:15 pm - 03:05 pm, the Department interviewed (3) out of (6) residents #1-#6 (R1-R6) able to recall some of the remolding and were removed from the area timely. (R4-R6) claimed they did feel safe and did not feel any discomfort during the renovation. (Evaluation Report continues LIC 9099-C) On 08/23/24 and 08/29/24 between 01:35 pm to 04:45 pm, the Department interviewed (4) out of (6) witnesses #3-#6 (W3-W6) verified notification from staff was received by telephone. (W3-W6) reported not having any concerns for the health and safety of residents while reconstruction was conducted. Based on the information collected, there is insufficient evidence to corroborate the allegation mentioned above. Allegation #4: Staff left resident in soiled clothing/bedding. Allegation #5: Staff are not ensuring resident's hygiene needs are met. The details of the complaint alleged the facility staff were negligent in resident #1 (R1’s) care. It was reported the attention (R1) receives is a concern. (R1) has been seen in dirty and stained clothing. (R1) does not appear clean and unkempt. On multiple occasions, (R1) has been seen in wet clothing and bedding. On 08/21/24 between 09:30 am to 03:56 pm, the Department interviewed (6) out of (6) administrator #1 (A1) and staff #1-#5 (S1-S5) stated these allegations are not accurate. (S1-S5) who have direct care with (R1) reported, (R1) is monitored for repositioning and diaper changes every two hours or as needed. All three shifts regularly perform incontinent services after meals. (R1) is scheduled to shower weekly on Sunday and Thursday. (S3-S5) are primary caregivers to (R1), denied (R1) has been left in stained or soiled clothing and bedding. According to (S1-S5), maintaining good personal hygiene is vital to prevent ill health, and (R1) was provided the care and services daily. (S1-S5) claimed that there were occasions when it was challenging to care for when (R1) refused to receive assistance with hygiene and grooming care services from staff. The staff will attempt to redirect the (R1) or return with a different staff to assist with basic care services. (S1-S5) claimed they are respectful of (R1’s) rights and (R1) has the right to refuse services as well. (S1) stated Progress Notes (aka Nurses Notes) were used to document and track the progress of the resident’s condition over time. (S1) claimed progress notes were only available for (R1) from 08/10/20 – 11/12/23. The Brittany House's new management has not mandated the facility to continue with Progress/Nurse charting and does not have current records. On 08/23/24 and 08/29/24 between 01:15 pm - 03:05 pm, the Department interviewed (3) out of (6) residents #1-#6 (R1-R6) claimed not to have concerns with their clothing appearance nor have been left in soiled diapers or bedding. (Evaluation Reports continue LIC 9099-C) On 08/23/24 and 08/29/24 between 01:35 pm to 04:45 pm, the Department interviewed (4) out of (6) witnesses #3-#6 (W3-W6) reported having no issues or concerns with the resident’s hygiene. The residents were found in presentable conditions and appearance in clothing when visits were conducted at the facility. A result of the Department review of (R1’s) service records included: Physicians Report LIC 602A (dated: 07/30/20 and 08/29/23); Resident Pre-Assessment (dated: 07/20/20); Resident Assessment (dated: 08/07/20); Admission Body Check (dated: 08/10/20 and 12/18/21); Service Plans (dated: 08/10/20); Functional Assessment Stating Tool (dated: 08/07/20); and Nurses Notes (dated: 08/10/20 – 11/12/23); Shower Scheduled (dated: 08/01/24-08/231/24); Vital Signs Records; Weight Records; and Podiatric Evaluation and Treatment (dated: 11/02/20 – 06/21/23) revealed that hygiene practices were included in daily living activities and services. Based on the information collected, there is insufficient evidence to support the allegations mentioned above. Between 08/23/24 - 08/29/24, the Department made several attempts to interview resident #1 (R1) by telephone who is now recovering at Heritage Rehabilitation Center. (R1) refused to engage in full conversation. Based on the evidence gathered interviews conducted, and analysis of records, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations of NEGLECT/LACK OF CARE AND SUPERVISION: “Resident sustained injury while in care", “Staff did not provide a safe environment for resident", “Staff left resident in soiled clothing/bedding”, and “Staff are not ensuring resident's hygiene needs are met” are found to be UNSUBSTANTIATED. An exit interview was conducted with Laurie Riffel, and a hard copy of the report was provided. Nurses Notes (dated: 08/10/20 – 11/12/23); Shower Scheduled (dated: 08/01/24-08/231/24); Vital Signs Records; Weight Records; and Podiatric Evaluation and Treatment (dated: 11/02/20 – 06/21/23); Los Alamitos Medical Center Medical Records (dated: 08/26/24), and other documents associated with this complaint. INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not notify authorized representative of incident. The details of the complaint alleged facility staff failed to notify the authorized representative of an incident involving resident #1 (R1) on 08/05/24. Information provided stated (R1) was transported by Emergency Medical Services (EMS) to Los Alamitos Medical Center at 06:00 pm. (R1's) authorized representatives were notified by the hospital's medical physician at 9:30 pm that (R1) needed a medical procedure. Investigation revealed resident #1 (R1) was admitted at Brittany House on 08/10/20, according to the Admission Agreement (dated: 08/10/20). (R1) was a former resident at Broadway by the Sea. (R1) remained as a resident at Brittany House from 08/10/20 through 08/21/24. On 08/05/24, (R1) was admitted to Los Alamitos Medical Center through 08/08/24 and was transferred to Kaiser Permanente South Bay Medical Center and then to Heritage Rehabilitation Center where (R1) is currently a resident. On 08/21/24 between 09:30 am to 03:56 pm, the Department interviewed (6) out of (6) administrator #1 (A1) and staff #1-#5 (S1-S5) who verified to know about (R1’s) emergency admission at Los Alamitos Medical Center. Four (4) out of six (6) admitted (R1’s) hospitalization on 08/05/24 did not account for notifying the authorized representatives. (2) two out of six (6) admitted to the facility failed to notify Community Care Licensing (CCL) with an Unusual Incident/Injury Report LIC 624 of (R1’s) hospitalization on 08/05/24. (S1) claimed the staff responsible for dispatching (EMS) was a new staff and unintentionally failed to follow proper procedures. On 08/23/24 and 08/29/24 between 01:15 pm - 03:05 pm, the Department interviewed (3) out of (6) residents #1-#6 (R1-R6) who verified that they were informed of any changes in health condition. (Evaluation Report continues LIC 9099-C) On 08/23/24 and 08/29/24 between 01:35 pm to 04:45 pm, the Department interviewed (4) out of (6) witnesses #3-#6 (W3-W6), confirmed to have received notice of any changes in the resident’s condition. Based on the evidence gathered interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION resulted in " Staff did not notify authorized representative of incident" is found to be SUBSTANTIATED. Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted with Laurie Riffel, and a hard copy of the report along with appeal rights.the state’s words, verbatim · CDSS document, Aug 31, 2024 · control 11-AS-20240816151317

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(1) · Plan of correction due date: Sep 14, 2024

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia…(1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator…when a resident’s behavior or condition changes. This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to notify the responsible person/conservator for (R1) when (R1) was hospitalized on 08/05/24. This violation poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 31, 2024

Plan of correction: Licensee/Administrator will review Title 22 Sec. 87705 and agreed to provide training to staff pertaining caring for resident with dementia. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC date via email: ernand.dabuet@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(B)(D) · Plan of correction due date: Sep 14, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department...(B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety, or health of any resident... This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report associated with an incident with (R1) change in condition and hospitalization on 08/05/24. The facility did not have proof of certified confirmations LIC 624 was faxed to CCL. This violation poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 31, 2024

Plan of correction: Licensee/Administrator will review Title 22 Sec. 87211 and agreed to provide training to staff pertaining to CCL Reporting Requirements. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC date via email: ernand.dabuet@dss.ca.gov

Allegation investigated: Licensee is not isolating COVID positive resident(s).

**This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 7/15/24. On 7/15/24 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit. LPA met with the Resident Services Director, Neil Chandra and explained the purpose of today's visit and was granted entry. The investigation consisted of the following: On 7/15/24 LPA Shirley toured first floor of facility for resident interviews. LPA also requested and reviewed copies of the following records: Staff Roster, Resident Roster, Resident file, Face Sheet, Id and Emergency Info, Id card & Medical ID info, Preplacement Appraisal, Physician’s Report, MAR’s, Physician’s Orders, ActiveCare Living – admissions Disclosure Statement, House Rules, Emergency In-House Doctor Authorization, and Order Summary Report. Investigation revealed the following: Con’d on 9099-C Unsubstantiated Allegation: Licensee is not isolating COVID-19 positive resident(S) It is being reported that this facility is not properly isolating Covid-19 positive residents. There were visitors to this facility on 7/4/24 who later tested positive for Covid –19. Facility staff was notified on 7/5/24. During visit on 7/15/24 LPA Shirley interviewed residents who were exposed to the visitors and observed that they were masked, in their room and learned that they had been asked to remain in their room and not to join other residents in the dining room until their PCR test results were returned and reviewed. LPA observed that the exposed residents were more than 6 feet apart. LPA Shirley learned that they had been in their room for at least a week. The Resident Services Director stated during interviews that their protocol was to isolate the resident, notify the family and follow the physician’s orders. LPA Shirley interviewed staff 1-8 (S1-S8), and asked, does this facility staff isolate covid-19 positive resident(s)? Of those interviewed, 5 out of 8 answered yes. LPA Shirley interviewed residents 1-7 (R1-R7). R-8 was not available for interview. LPA ask, does this facility staff isolate Covid-19 positive residents. Of those interviewed, 2 out of 7 answered No. Based on information gathered, the department did not find sufficient evidence to support allegation of, "License is not isolating COVID-19 positive resident(s)”. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of the LIC 9099 was provided to Receptionist, Stephanie Rubio.the state’s words, verbatim · CDSS document, Jul 15, 2024 · control 11-AS-20240711155146

Allegation investigated: Staff did not safeguard resident's personal belongings.

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 7/10/24. On 07/10/24 Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent complaint visit to the address listed above. LPA was greeted by Office Manager, Yessica Martinez. LPA was granted access to the facility. The investigation consisted of the following: On 6/13/24, LPA toured the facility to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. LPA requested copies of the following records: Staff Roster, Resident Roster, Staff and Resident interviews, reviewed resident files, and a copy of a delivery receipt from Ideal Home Care, dated 4/25/24. The investigation revealed the following: Con'd on 9099-C Substantiated Allegation: Staff did not safeguard resident’s personal belongings This facility recently moved residents from one unit to another unit and management received notice that a resident was transferred without their personal belongings. LPA Shirley reviewed the copy of delivery receipt that was provided for missing items and learned that a medical bed, Inner Spring mattress, half bedrails, hoyer lift and wheelchair were delivered to the Brittany House facility on 4/25/24 and was accepted by staff at 7:38pm. On 6/13/24, LPA Shirley went to the resident’s room and took pictures of the equipment that was there. A standard bed, walker, a wheelchair with a pedal leaning against the wall and the other pedal missing, and no hoyer lift. LPA Shirley checked residents closet to verify that the correct clothing were in the residents closet. LPA Shirley checked the laundry room to confirm labeling for residents clothing and was told that the clothes are labeled by families or representatives before the resident moves in. Labeling prevents residents clothing and personal belongings from being separated from the resident or in other residents rooms. LPA spoke with S-1 on 6/17/24. LPA discussed the delivery and acceptance by staff. S-1 stated that they would look into the matter and get back to me. On 6/17/24, S-1 forwarded a video of all of the missing equipment that was now in R-1’s room. LPA was told that missing items were in the storage room #211 and were not being used by another resident. LPA Shirley interviewed staff S1-S5, (S-1 – S-5.) LPA ask, Does the staff here safeguard the resident’s personal belongings? Of those interviewed, 5 out of 5 answered, yes. LPA interviewed residents R-1 – R-7, (R-1 – R-7.) LPA ask, does staff here safeguard your personal belongings. Of those interviewed, 6 out of 7 answered, yes, there was 1 resident whose response did not answer LPA’s question. Based on interviews, the preponderance of evidence has been met therefore the allegation is Substantiated. Deficiencies were issued for this allegation. An exit interview was conducted and plans of correction developed with the Administrator Susie Fuentes. A copy of this report and appeals rights was reviewed and left with the Office Manager, Jessica Martinez.the state’s words, verbatim · CDSS document, Jul 9, 2024 · control 11-AS-20240611084549

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Jul 24, 2024

87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement is not as evidenced by: Based on document review and interviews, facility staff did not take appropriate measures to safeguard residents belongings. This poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 9, 2024

Plan of correction: The Office Manager shall submit in writing a better plan and training for all staff to safeguard residents personal belongings and provide receipts for all such articles to CCLD via fax or email by POC due date of 7/24/24. Proof of correction can be emailed to felisa.shirley@dss.ca.gov.

Allegation investigated: Staff does not have adequate staffing to meet resident's needs. Staff does not ensure resident's are provided quality food. Staff does not ensure facility is free of odor. Staff moved resident's out of facility without notifying resident's responsible party.

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Monday, July 01, 2024, Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Executive Director (ED) Mandy Taylor. LPA Bunker explained the purpose of today's visit. LPA Bunker conducted interviews with staff members 1-3 (S1-S3) and residents 1-4 (R1-R4), asking questions relevant to the nature of the complaint. S1-S3 and R1-R4 stated the facility has adequate staffing to meet residents' needs, residents are provided quality food, staff ensures the facility is free of odor and does not move residents out of the facility without notifying the resident's responsible parties. S1-S3 and R1-R4 stated that the building offers a comfortable living environment for residents. During the visit, ED Mandy Taylor and LPA Bunker toured the facility, receptionist area, lobby, executive office, kitchen, 2 dining rooms, and the memory care unit. The following rooms were also observed 101, 107, 114, 204, 210, 215, 302, 304, 307, 308, 310, 311, 312, 313, 314, 407, 408, 410, 412, 413, 414, and 415. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 LPA Bunker reviewed staff and residents' records and requested copies of Identification and Emergency Information, Personnel Reports, Resident's Roster, Monthly Food Menus, and Ongoing In-Service Training. Allegation #1: Staff does not have adequate staffing to meet resident's needs. Staff members 1-3 (S1-S3) and residents 1-4 (R1-R4) interviewed stated the facility is fully staffed and staff is always available to provide assistance to residents. S1-S3 stated this is a 24-hour care facility that operates, 7 days a week, 365 days a year. Residents are never left at the facility alone without supervision. The facility operates in three shifts 6:00 A.M. - 2:30 P.M., 2:00 P.M.- 10:30 A.M.; and 10:00 P.M. – 6:30 A.M., Sunday through Saturday. S1 stated the Executive Director and Resident Services Director are on call 24 hours a day. S1-S3 stated several residents were not screaming and were confused about their whereabouts. S1-S3 stated this is a memory care facility where residents have Dementia. S1-S3 ensures sufficient and competent staff are available to provide the necessary services to meet residents' needs. S1-S3 and R1-R4 denied the allegation. Allegation #2: Staff does not ensure residents are provided quality food. Staff members 1-3 (S1-S3) and residents 1-4 (R1-R4) interviewed stated residents are provided with a variety of quality food to eat. S1-S3 and R1-R4 stated the residents receive an ample supply of perishable and non-perishable food, including three (3) meals and 3 snacks per day, breakfast, lunch, dinner, and snacks daily. The staff serves well-balanced meals with a variety of food options to choose from each week. R1-R4 stated that they had no complaints about the food. S1-S3 stated every day the food menu changes and residents can select something different if they prefer. S1-S3 stated residents are not served the same food every week. The food menu for weeks 1-4, reviewed by the LPA, shows a variety of food choices. S1-S3 stated residents' food is not served on inexpensive styrofoam plates or with plastic utensils. S1-S3 and R1-R4 denied the allegation. Allegation #3: Staff does not ensure the facility is free of odor. Staff 1-3 (S1-S3) and residents 1-4 (R1-R4) interviewed stated the facility is free of odor. S1-S3 stated the facility does not smell like urine or feces and is cleaned, sanitized, and disinfected daily. S1 stated the facility has scent air throughout the facility. S1-S3 denied the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Allegation #4: Staff moved residents out of the facility without notifying the resident's responsible party. Staff members 1-3 (S1-S3) interviewed stated residents were never moved out of the facility without notifying the resident's responsible parties. S1 stated residents' responsible parties are always notified of any changes. S1-S3 denied the allegation. Investigation revealed the following: Staff members 1-3 (S1-S3) interviewed stated the facility is fully staffed and staff is always available to provide assistance to residents. S1-S3 ensures sufficient and competent staff are available to provide the necessary services to meet residents' needs. S1 and LPA Bunker observed the food in the kitchen refrigerators, freezers, kitchen cabinets, and pantry. The facility had plenty of meat, chicken, beef, steak, ground beef, hamburger patties, pork loins, pork roast, meatballs, fish, ground turkey, hot dogs, pizza, sausages, lunch meat, cold cuts, variety of frozen vegetables, green beans, sweet potatoes, chili beans, mixed vegetables, stir fry vegetables, peas, corn, French fries, variety of canned vegetables, fruit mix, diced beets, fruit cups, apple sauce, peanut butter, jelly, milk, eggs, cheese, variety of breads, white & wheat bread, hot dog buns, hamburger buns, cereals, rice, noodles, pasta, macaroni & cheese, potatoes, fresh fruits, oranges, bananas, watermelons, tomatoes, fresh vegetables, onions, garlic, potatoes, carrots, sweet potatoes, broccoli, lettuce, celery, red peppers, bell peppers, variety of canned fruits, cookies, chips, crackers, desserts, cake mix, sugar, flour, coffee cream, beverages, coffee, juice, milk, sodas, water, a variety of seasoning and sauces, ketchup, mustard, mayonnaise, tomato sauce, ripe olives, mushrooms, and etc. LPA Bunker observed an ample supply of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. S1-S3 stated residents are getting enough food to eat. During the visit, LPA Bunker observed residents in the dining room who were not eating from styrofoam plates or using plastic utensils. There was no foul odor detected throughout the facility, and it did not smell of urine or feces. Staff members 1-3 (S1-S3) also stated that residents were never moved out of the facility without notifying the resident's responsible parties. S1-S3 denied all the allegations. See continued LIC9099-C page 4 Continued LIC9099-C page 4 Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. Copies of the Complaint Investigation Report LIC9099 and LIC9099-Cs were provided to Executive Director Mandy Taylor. There were no deficiencies cited Exit interview conductedthe state’s words, verbatim · CDSS document, Jul 1, 2024 · control 11-AS-20240624084818

Allegation investigated: Staff violated residents' personal rights. Staff did not provide a safe and comfortable environment .

On 06/14/24, at 10:00am, Licensing Program Analyst (LPA) Perry Scott conducted a 10-day complaint visit to the facility and was greeted by Yessica Martinez, Office Manager. LPA explained the purpose of this visit is to gather information about the complaint and deliver findings for the allegation mentioned above. The investigation consisted of the following: LPA investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S7), (W1-W3) and residents (R1-R5). Resident Roster (No Date), Staff Roster (Dated 06/10/2024), Admission Record for all residents (Dated 06/14/2024) and Call Sheet (No Date) were obtained from the facility. The investigation revealed the following: Allegation #1- Staff violated residents' personal rights. The details of the complaint alleged that staff are moving residents from two units in the facility to unit 1 without notifying the residents or the family beforehand of the move; thereby violating their personal rights, leaving them confused and upset. Report continued on LIC 9099-C Substantiated On 06/14/24, from 10:00am-2:00pm, LPA interviewed staff (S1-S7) witnesses (W1-W3), and residents (R1-R5) regarding the allegation. 3 of 7 staff denied the allegation that the Staff violated residents' personal rights. 3 of 7 staff interviewed stated that the residents and family members were notified that the residents would be moved to another unit because of construction. They state that the family members were notified by phone or email. Whereas 4 of 7 staff were not sure if the residents’ or family were notified but received complaints from family members that they were not notified. LPA interviewed W1-W3 about the allegation and 3 of 3 witnesses denied that the facility reported to them or the residents of the relocation to another unit. Witnesses state that their family members were confused and upset about the move and did not know what was going on in the facility. LPA interviewed R1-R5 about the allegation and 4 of 5 residents that were interviewed corroborated the allegation that Staff violated residents' personal rights. A majority of the residents interviewed stated that they and their family members were not notified of the move and felt confused about it and did not know why they were moving. They further state that some of the residents that were moved into their room were not compatible with them. They complained that some of the residents kept screaming that they didn’t know what was going on. LPA reviewed the call sheet provided (No Date) but it did not specify the date, time, or who was notified and that either the resident or family member acknowledged the notification. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation: Staff violated residents' personal rights, is found to be Substantiated. California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. Deficiencies are issued and plans of corrections were discussed. The investigation revealed the following: Allegation #2- Staff did not provide a safe and comfortable environment. The details of the complaint alleged that because of construction and relocation of the residents with no attempt to make sure the residents are compatible and knowledgeable of what’s going on in the facility. It has become very crowded and chaotic, and it appears they are warehousing the residents, with no regard for their feelings, their emotional well-being, or their safety. Report continued on LIC 9099-C On 06/14/24, from 10:00am-2:00pm, LPA interviewed staff (S1-S7), witnesses (W1-W3), and residents (R1-R5) regarding the allegation. 3 of 7 staff denied the allegation that the Staff did not provide a safe and comfortable environment. 3 of 7 staff stated that the residents and their family members were notified about the construction that would take place in the facility causing the residents to be relocated. Whereas 4 of 7 staff stated that they were not sure if the residents or their family members were notified that construction would be taking place in the facility. They further state that some family members and residents were upset and confused that construction was taking place causing the residents to be subjected to loud noises, chemical smells, and overcrowded spaces. LPA interviewed W1-W3 about the allegation and 3 of 3 corroborated that Staff did not provide a safe and comfortable environment. They state that no one notified them that construction would be taking place and when they visited, they found the facility had strong odors from construction, too many residents in a small place with not enough caregivers to provide effective care, and they feared that the residents would be hurt in this environment. LPA interviewed R1-R5 about the allegation and 4 of 5 corroborated that Staff did not provide a safe and comfortable environment. They stated that no one advised them that construction was going to take place. They further state that during construction there were loud noises, dust, debris, and chemical smells that caused some to wear masks because of the fumes and they did not want to get sick. They state that it was very chaotic and could have been handled better. Based on interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation: Staff did not provide a safe and comfortable environment, is found to be Substantiated. California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * Deficiencies are issued and plans of corrections were discussed. An exit interview was conducted with Yessica Martinez, Office Manager, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 11-AS-20240607142431

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 28, 2024

87468.1(a)(2) Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews conducted, the administrator failed to ensure a resident's personal rights due to the facility not letting them know that they would be relocated to a different unit in the building, causing confusion and feeling unsafe in the facility, which posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jun 20, 2024

Plan of correction: Administrator to review Personal Rights of Residents 87468.1(a)(2) and submit a statement acknowledging understanding of Title 22 Regulations by POC due date of 6/28/24 and email it to LPA Perry Scott at perry.scott@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Jun 28, 2024

87468.1(a)(8) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations... This requirement is not met as evidence by: Based on interviews conducted and records reviewed the administrator failed to inform the responsible parties about the construction of the facility and movement of the residents. Which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jun 20, 2024

Plan of correction: Administrator to review Personal Rights of Residents 87468.1(a)(8) and submit a statement acknowledging understanding of Title 22 Regulations by POC due date of 6/28/24 and email it to LPA Perry Scott at perry.scott@dss.ca.gov

Allegation investigated: Staff are not administering resident's medications as prescribed. Staff are mismanaging resident's medications.

On 05/22/2024, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint visit to this facility to conclude complaint investigation and deliver findings. LPA met with Resident Services Director Neio Chandra, and the purpose of today’s visit was explained. The investigation consisted of the following: On 03/25/24, LPA Gonzalez conducted a tour of the medication room, interviewed staff #1-#5 (S1-S5), reviewed resident files, received documents pertinent to the investigation, and requested additional documents which were provided to LPA via email on 03/28/24. On 04/09/24, LPA Gonzalez interviewed residents #2-#7 (R2-R7), LPA was unable to interview resident #1 (R1) due to medical conditions. LPA also reviewed resident file and requested copies of documents. On 05/22/24, LPA interviewed staff #6-#8 (S6-S8). Continued on LIC9099-C Substantiated The documents received and reviewed are the Staff Roster, Resident Roster, resident’s Physician’s Reports, Residents Physicians Orders, and Resident Appraisals, and residents MARs (Medication Administration Records). INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff are not administering resident's medications as prescribed. It is alleged that staff failed to administer medications to a resident as prescribed. It is also alleged that a resident has had extended times without vital medications which have led to the resident experiencing extreme anxiety and hallucinations. 0n 05/22/24, the department audited residents MAR (dated: 02/01/24 - 02/29/24 and 03/01/24 - 03/31/24) and revealed that a Not Applicable note was noted for 18 out of 29 days in February and 11 out of 31 days in March. On 05/22/24 at 10:30 AM, (1) out of (8) staff that were interviewed by the Department were aware of the error. S8 admitted to knowing about the medication not being dispensed as prescribed to the resident. LPA Gonzalez asked S8, what happened on 03/15/24 and 03/16/24 with R1? S8 stated they couldn’t give the resident their medication those days because they were waiting on the refills. S8 stated that they wrote not applicable on the QuickMAR note section but forgot to note the reason for not applicable. LPA then asked S8 if the not applicable noted on the rest of the days in the MAR meant the same thing, and S8 stated that it did mean that the resident was not given their medication(s) as prescribed and said this won’t happen again. On 04/09/24, LPA Gonzalez interviewed residents #2 - #7 (R2 -R7). Five (5) out of six (6) residents interviewed stated that the staff at this facility dispense their medication as prescribed by their physician, and (6) out (6) residents interviewed stated they have not missed any medication dosage. Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Continued on LIC9099-C Allegation: Staff are mismanaging resident’s medications. It is alleged that staff are mismanaging resident’s medications. It is also alleged that a resident had not had their Memantine medication in a week, because the medication was ordered but it had not arrived yet. On 04/09/24 LPA interviewed witness #1 (W1), R6’s daughter. Interview communicated that they feel there is not enough staff at this facility to provide for the needs of the residents. W1 stated that R6 does not get their medications on time or when needed. W1 stated that staff has advised them on several occasions that R6 did not get their medication because of the facility waiting for the medication to be refilled. On 05/22/24 at 10:30 AM, (1) out of (8) staff that were interviewed by the Department were aware of the error. S8 stated that they are aware the resident missed their medications on numerous times because they were out of medicine and were waiting on the medication to be refilled. S8 stated that in the past they have made the mistake of advising the nurse (which is responsible for refilling the resident’s medication) last minute or when the resident did not have any more medication, and that would cause a delay in receiving the new medication timely, which would cause the resident to go days without their medication(s). Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8) the following deficiencies have been observed and citations issued (ref. LIC 9099D). An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights was provided to Resident Services Director Neil Chandra.the state’s words, verbatim · CDSS document, May 22, 2024 · control 11-AS-20240318111845

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jun 5, 2024

87464(f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This was not met as evidence by based on records reviewed and interviews, med tech failed to give medication to resident which poses a potential health, safety risk to persons in care.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: Licensee will provide a training for all med techs to attend regarding policies and procedures for medications. Licensee will send LPA Gonzalez the sign in sheet and description of the type of training given by POC due date 06/05/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jun 5, 2024

87465(a)(2) Incidental Medical and Dental Care - A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall provide assistance in meeting necessary medical and dental needs… This was not met as evidence by based on records reviewed and interviews, med tech admitted to LPA that he was notifying the nurse about refilling medications last minute and that would cause a delay, where resident would go days without medication.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: Licensee will provide a training for all med techs to attend regarding policies and procedures for medications. Licensee will send LPA Gonzalez the sign in sheet and description of the type of training given by POC due date 06/05/24.

Allegation investigated: The facility admitted a resident with prohibited health condition. The facility operates beyond conditions and limitations specified on the license.

On 03/21/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced complaint visit to the facility listed above. LPA met with Administrator, Mandy Taylor, and the purpose of today’s visit was explained. During today's visit, LPA toured the facility, interviewed Staff (S1-S8), interviewed Residents (R2-R7), and received documents pertinent to the investigation. The documents received and reviewed are the Staff Roster, Resident Roster, Plan of Operation, resident Physicians Report, visitor logs, Preplacement Appraisal, and Resident Admission Agreement. The investigation revealed the following: Continued on LIC9099-C Substantiated Allegation: The facility admitted a resident with a prohibited health condition. It is alleged a resident was admitted and moved into the facility, in the beginning of March 2024, with a communicable disease prohibited health condition. During interviews with staff (S1-S8), they were asked if a resident with a prohibited condition was admitted, seven (7) out of eight (8) stated Resident R1 was admitted to the facility with a prohibited health condition. During an interview with the Administrator (S1) stated they were unsure if an exemption was submitted to Community Care Licensing (CCL). Additionally, S1 stated when they became employed at the facility, on March 18,2024, they had R1 placed on home health for the care of the condition, and since that time R1 has been cleared, by a physician, of the prohibited health condition. During an interview with S2 stated that once they found out R1 had a prohibited health condition, staff took precautions such as isolating R1, placing a PPE cart outside the room for staff to use. During file review of Resident R1, LPA observed the facility was informed of R1’s diagnosis of the prohibited health condition via fax on March 12, 2024, at 8:37AM PDT. R1 was admitted to the facility on March 12, 2024, after a diagnosis of the prohibited health condition. During interview with residents (R2-R7) six (6) out of six (6) stated they were unsure if the are any residents with a prohibited condition. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. Allegation: The facility operates beyond condition and limitations specified on the license. It is alleged a client has come to the facility and uses it as a daycare and is participating in activities and meals then is picked up at 5:30pm. During interviews with staff (S1-S8), they were asked if there is a client who comes in and participates in daily activities and has meals, four (4) out of eight (8), stated C1 has been at the facility a few times and participated in activities. During an interview with S2, stated C1 has been in the facility twice when C1’s spouse has things they need to do. Additionally, S2 stated C1 will be a resident at the facility eventually but the family is not ready to place them here yet. S2 stated C2 receives minimal assistance while here and has been charged for the days they participated in the program. During file review, LPA observed on the Visitor Log, C1 was signed in on 03/06/24 at 8:30am, and on 03/15/24 at 8:25am till 6pm. During interviews with residents (R2-R7), six (6) out of six (6) stated they have no knowledge or concern of C1 coming in to participate in activities or meals. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. Two deficiencies were cited on the attached LIC9099-D. An exit interview was conducted with Maintenance Director, Juan Talavera, and a copy of this report and the appeals rights were provided.the state’s words, verbatim · CDSS document, Mar 21, 2024 · control 11-AS-20240315115358

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(4) · Plan of correction due date: Apr 4, 2024

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not ve admitted or retained in a residental care faclity for the elderly: (4) Staphylococcus aureus ("staph") infection or other serious infection. This regulation was not met based on evidence by: Record review and interviews, the licensee failed to ensure resident R1 did not have a phohibited health conditionthe state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: Administrator will review Tittle 22, Division 6 Chapter 8 Article 11 Health Related Services and conditions. Adminsitrator will submit a signed letter to LPA upon completion stating it was reviewed. Administrator will submit an excemption request to CCL and a Care Plan for the R1 by the POC.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87204(a) · Plan of correction due date: Apr 4, 2024

87204Limitations-Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum numbe of persons who my receive sedrvice at any one time. An exceptio my be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity, This regeulation was not met based on: Interviews and file review, C1 has paid to come and stay at the faclitily during the day, meals and services are porvided.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: Administrator will review Title 22, 87204 Limitations and submit a signed letter stating it has been reviewed by POC. Administrator will ensure C1 no longer being left at the facility unless a resident.

Type of visit: Prelicensing

On 1/19/24 Licensing Program Analysts (LPAs) Socorro Leandro and Alfonso Iniguez conducted a pre-licensing evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with authorized administrator: Ruth Tistoj. The licensee has applied for a license to serve (170) elderly residents ages 60 and older. The fire clearance is approved for (146) non-ambulatory residents and (24) bedridden. A complete tour of the facility was performed: residents rooms, medication room, kitchen, patio, dinning room, public restrooms and common areas. The following was observed during this visit: MEDICATIONS There is a locked centralized storage area for Resident medications. PHYSICAL PLANT Facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 73°F. degrees. Open porches, and areas of potential hazard are well-lit. Smoke alarms operate properly. Carbon monoxide detectors operate properly. Report continues LIC 809C. BEDROOMS There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair. Mattresses and pillows are flame-retardant. There is dresser and closet space for each client that includes at least two (2) drawers or eight (8) cubic feet of dresser space per client. There is a chair and lamp for each client and at least one (1) nightstand per two (2) clients. BATHROOMS There is at least (1) toilet and washbasin per six (6) clients, family, and personnel. There is at least (1) shower or bathtub per ten (10) clients, family, and personnel. Hot water temperature is 113° Fahrenheit. Bathroom is located near client bedrooms. There are nightlights in the hallways outside non-private bathrooms. SUPPLIES There are client personal hygiene supplies to include soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths. FOOD SERVICE Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0° Fahrenheit. Refrigerator is a maximum of 45° Fahrenheit. A seven (7) day supply of non-perishable food is present. There are enough tableware, tables, dishes, and utensils. There is enough equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. Report continues LIC 809C. RECORDS There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility. ADMINISTRATION The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings. ACTIVITIES There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors. MISCELLANEOUS There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries. During this pre-licensing inspection, LPA did not find corrections are needed. LPA conducted the Component III Orientation with the Licensee and copy of this report was provided. A copy of the facility evaluation report will be available to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with their assigned CAU Analyst. Exit interview conducted with Ruth Tistoj/Administrator.the state’s words, verbatim · CDSS document, Jan 19, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 170 Census (if any clients in care): 69 Interview Method: Telephone interview On 11/16/2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Nov 16, 2023