Broadview Residential Care Center

Allegation investigated: Staff are not allowing resident to return to the facility

At 2: 15p.m., Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to complete an investigation and deliver findings of the above noted allegations. LPA met with Staff #1 (S1) and explained the reason for the visit. During initial visit on 11/24/25 at about 10:05a.m. LPA requested and received copies of the facility’s residents and staff rosters. At 10:30a.m. LPA and Office Supervisor conducted a physical plant inspection. Between 11:00a.m. - 1:00p.m. LPA conducted interviews with Licensee, eight (8) out of seventy-six (76) residents, staff #1-#2 (S1-S2) and asked questions relevant to the investigation. At the time of the investigation, resident#1(R1) was out of the facility. LPA request copies of resident #1 (R1) Identification information, Admission Agreement, Physician Report, Needs & Services Plan, Appraisal, Unusual Incident Reports, and other pertinent documents. Cont. on LIC 9099-C Unsubstantiated Cont. from LIC 9099 On 07/18/26 LPA- Alvizar-Ettima reviewed Resident #1 (R1’s) records that Administrator provided. During this visit at approximately 3:30p.m., LPA Alvizar- Ettima and Staff #1 conducted a physical plan tour and did not observe any immediate health and safety issues. Facility staff indicated that Resident #1 (R1) has not returned to the facility. Staff are not allowing resident to return to the facility It was alleged that R1 was not permitted to return to the facility following hospitalization. During the investigation, the Administrator denied the allegation and stated the facility had not refused to accept R1 back. The Administrator explained that R1 was hospitalized due to medical concerns and was subsequently admitted to a Skilled Nursing Facility (SNF) for a higher level of care. The Administrator stated the facility has maintained communication regarding R1’s status and indicated that R1’s return to the facility would depend on whether R1’s care needs could be safely met and whether the resident remained appropriate for RCFE placement. Staff interviews corroborate with the Administrator’s statement and indicate they were not aware of the facility refusing to readmit R1. Staff further stated that no written eviction notice had been issued and that R1 remained hospitalized and later admitted to a SNF due to medical needs. LPA review, R1’s facility file, including but not immitted to Admission Agreement, Physician Report, Needs & Services Plan, Appraisal, Unusual Incident Reports and other relevant records. Records reviewed did not reveal any information to support the allegation. Based on interviews and documents review there is insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues were noted. Exit interview was conducted. Copy of report was provided.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 31-AS-20251118083947

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced Required One (1) year inspection visit at this facility today. LPA met with Administrator and explained the reason for the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools. At 9:30a.m. LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The facility is fire cleared for one hundred eighty (180) residents of which sixty-five (65) may be non-ambulatory and has a hospice waiver for two (02). The facility is currently occupying seventy-five (75) residents. The facility is a two (02) story building in a residential community. The 1st floor consists of the following: a lobby area, administrative offices, dining area, activities room, kitchen, garden lounge, beauty shop, game room, tea room, indoor gardens with water fountains, TV areas, outdoor gardens, and residents’ rooms. The 2nd floor consists of activity area, TV areas, library lounge, Zen room, snack room, large lounge area, and residents’ rooms. The passageways and walkways are free of hazards and free from obstruction. The facility maintains a comfortable temperature at 74°F. There are carbon monoxide detectors installed in the facility. Fire extinguishers are located all throughout the facility and last inspected on 05/13/2025. The fire extinguishers were observed to be fully charged and in compliance. The facility is equipped with emergency fire sprinkler system. Facility Fire drill was last conducted on 12/02/2025. There is only one entrance being utilized at the facility, all required posters were posted in the hallway. During today's visit, in addition to the physical plant inspection LPA interviewed seven (07) out of seventy-five (75) residents. Cont. on LIC 809-C Cont. from LIC 809 A tour of the physical plant was conducted, and the following was noted: Kitchen: The kitchen appliances and fixtures were functional. Food supplies was sufficient amount for two (02) days of perishable and seven (07) days of non-perishable was stored in covered containers at the appropriate temperatures. Knives and sharp objects were observed to be locked and inaccessible to residents. Storage areas for cleaning solutions, toxics, knives, and hazardous items were secured and made inaccessible to residents. Walls, ceiling, and floor is in good repair, ample supply of dishes, cups, glasses and utensils for the current census. Dining Area: The dining area was observed to be neat, clean and in proper order. Walls, ceiling, tables, chairs and floor is in good repair. Laundry rooms: There are laundry rooms located on each floor of the building. All toxins such as laundry detergents and cleaning agents were observed to be inaccessible to the residents in laundry rooms. Medication: Medications are centrally stored in the locked medication stations located on the first floor. The medications were observed to be locked and inaccessible to residents. There are multiple complete first aid kits in the facility. Bedrooms: LPA randomly selected resident’s apartments on each floor. Resident bedrooms were properly furnished with appropriate bedding and linens with sufficient lighting. Hygiene supplies for residents were observed, and hallways/passageways are lit. There were enough clean linen available in the closets. Each resident’s apartment has their own closet and restroom. Bathrooms: LPA randomly selected residents’ bathrooms on each floor. The bathrooms were observed to be clean properly supplied, functional fixtures and appropriate grab bars in showers and toilets. The hot water temperature measure range was between 110.1 – 115.1 degrees Fahrenheit within Title 22 Regulations. Towels and washcloths are not shared. Common Areas: LPA observed common areas on every floor. All furnishings are in good repair, lighting is good, walls, ceiling and floors are also in good repair. Surrounding Grounds: The front grounds of the facility are well landscaped with a waterfall with Koi fish and turtles which are enclosed. All passageways were observed to be clear from obstruction. Due to time constraints, LPA had to terminate the visit and will return on a later date to complete the Required - 1 Year inspection by reviewing medication, residents and staff records. No health and safety issues noted at the time of this visit. An exit interview was conducted. A copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jan 14, 2026

Allegation investigated: Staff is wrongfully evicting resident

At 9:30a.m., Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to complete an investigation and deliver findings of the above noted allegation. LPA met with Administrator and explained the reason for the visit. Initial visit was conducted on 06/04/2025 at about 2:20p.m., LPA requested and received copies of the facility resident and staff rosters. At 2:30p.m., LPA and Administrator conducted a physical plant walk-through. At approximately 2:50p.m., LPA interviewed Administrator and asked questions relevant to the investigation. LPA request copies of Resident #1 (R1) Identification Information, Admission Agreement, Physician Report, Needs and Services Plan, Rules & Regulations, Unusual Incident Reports, and other pertinent documentations. Prior to this visit on 10/17/2025 LPA Alvizar-Ettima reviewed records and prior documentation obtained during the initial visit. Unsubstantiated Cont. from LIC 9099 During this visit at 10:10a.m., LPA and Administrator conducted a physical plan tour. Between 10:35a.m. – 12:20p.m. LPA conducted additional interviews with facility staff and Resident #1 (R1). Staff is wrongfully evicting resident It was alleged that when Skilled Nursing Facility (SNF) planned to discharge Resident #1 (R1) back to facility, the Administrator refused re-admission, citing that R1 was disruptive and a threat to staff. Interview conducted with the Administrator denied the allegation and stated that R1 was not evicted from the facility. The Administrator explained that R1 had been hospitalized for an extended period and is scheduled to return back today. Administrator further stated that R1 exhibited repeated behavioral concerns prior to hospitalization, including verbal outbursts toward staff and refusal of care. Administrator indicated that no eviction letter was issued because R1 was hospitalized and not residing at the facility at the time. The Administrator confirmed that R1’s belongings remained secure, and the facility would have accepted R1’s payment had they been readmitted through proper discharge coordination. Staff interviews indicated that R1 had previously displayed verbal aggression toward staff and residents. Staff denied that R1 was wrongfully evicted and stated that the facility was awaiting discharge coordination from SNF before determining if R1 could safely return. Staff confirmed no written eviction notice was issued. Records reviewed do not demonstrate that the facility initiated or executed an eviction process. During interview, R1 stated she has never threatened or acted aggressively toward anyone and denied that any eviction process was initiated. R1 further stated she has not received a written eviction notice, continues to reside at facility and paying rent accordingly. Based on interviews, observation and record reviewed, there is not sufficient information to support this allegation. Thus, this allegation is deemed to be UNSUBSTANTIATED at this time. No immediate health and safety issues were noted. Exit interview was conducted and copy of was provided.the state’s words, verbatim · CDSS document, Oct 24, 2025 · control 31-AS-20250603104620

Allegation investigated: Staff are not allowing residents to pass away in the facility

At 9:30a.m., Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to complete an investigation and deliver findings of the above noted allegation. LPA met with Administrator and explained the reason for the visit. During initial visit on 10/14/2025 at 9:55a.m. LPA Alvizar-Ettima requested copies of the facility resident and staff roster. At 10:30a.m. LPA and Administrator conducted a physical plant inspection. Between 11:15a.m. - 2:55p.m. LPA conducted interviews with Staff #1 (S1), Administrator, five (5) out of seventy-eight (78) residents and asked questions relevant to the investigation. LPA request copies of Resident #1 (R1) Identification Information, Admission Agreement, Physician Report, Facility & Hospice Collaboration Plan, Appraisal/Needs and Services Plan, Preplacement Appraisal, Unusual Incident Reports, and other pertinent documentations. Cont. on LIC 9099-C Unsubstantiated Cont. from LIC9099 Prior to this visit on 10/17/2025 LPA Alvizar-Ettima reviewed records and prior documentation obtained during the initial visit. During this visit at 10:10a.m., LPA and Administrator conducted a physical plan tour. Between 10:35a.m. – 12:20p.m., LPA conducted additional interviews with facility staff and three (3) residents. At the time of the investigation, resident #1 (R1) had already passed away. Staff are not allowing residents to pass away in the facility It was alleged that Administrator is not allowing Resident (R1) to pass away in the facility and instead arranges for resident to be transferred to Skilled Nursing Facility (SNF) or other setting at the end of life. Interviews conducted with facility staff revealed that R1 never expressed a desire to pass away in the facility. Administrator indicated that they discussed with R1 the need for higher level of care, and R1 reportedly agreed with the plan for transfer. Staff#1(S1) indicated that R1 had become too weak to transfer independently from bed to restroom. Staff provided continuous care until the last few days, when R1 appeared increasingly weak and immobile. Resident#2 (R2) indicated that staff will temporarily assist residents with mobility. However, all residents must be able to ambulate independently as part of the facility’s admission and retention criteria. A review of R1’s Admission Agreement dated 12/12/2022 confirmed that the agreement included a clause stating that residents requiring medical care and assistance beyond the facility’s capacity must be transferred to a higher level of care. Other residents interviewed during investigation verified that they had knowledge that anyone requiring medical care and assistance beyond the facility’s capacity must be transferred to a higher level of care. Based on interviews and records reviewed, there is not sufficient information to support this allegation. Thus, this allegation is deemed to be UNSUBSTANTIATED at this time. No immediate health and safety issues were noted. Exit interview was conducted and copy of was provided.the state’s words, verbatim · CDSS document, Oct 24, 2025 · control 31-AS-20251008082013

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Betsy Davis for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 11:00 AM and the following was noted: There is one entrance being utilized at the facility. The facility is fire cleared for one hundred eighty (180) residents of which sixty-five (65) may be non-ambulatory and has a hospice waiver for two (02). The facility is currently occupying seventy-two (72) residents. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be inaccessible to residents. The common and dining areas are neat and clean. The facility maintains a comfortable temperature at 72°F. The smoke and carbon monoxide detectors are centralized, hardwired, interconnected and checked quarterly for operation. Fire extinguishers are located throughout the facility, observed to be fully charged and last inspected 05/22/2024. (continued on LIC 809-C) LPA randomly selected six (06) rooms, and they were all adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at an average 114.5°F. Towels and washcloths are not shared. There was enough clean linen available. LPA observed medication to be inaccessible to residents. Facility maintains a complete first aid kit. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Mar 19, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced required one year annual inspection. LPA met with Administrator Betsy Davis and explained the purpose of the visit. LPA Valenzuela conducted a physical plant tour of the facility. The facility is a two-story building. Areas inspected: the front lobby, dining area, activity spaces / common lounge areas, medication room, storage/ disaster rooms, resident common restrooms, laundry room, outside gardens, residents bedrooms and kitchen area. LPA observed that the facility does not have a large body of water, small fountains were observed and were secured and fenced. All indoor and outdoor passageways were free of obstruction. There is only one entrance being utilized at the facility. LPA toured randomly selected resident bedrooms. All bedrooms were clean and furnished with required furniture. The resident's bathrooms were observed to be clean, operational and equipped with grab bars and non-skid mats. Common resident restrooms were observed. The hot water temperature was tested and measured 115 degrees Fahrenheit. Smoke detectors are present throughout the facility and in resident bedrooms. Fire extinguishers were last serviced on May of 2023 . Oxygen monoxide detectors were observed to be operable. Fire alarms are hardwired throughout the facility. The kitchen was inspected. LPA observed all kitchen equipment to be clean and in working condition. LPA observed sufficient supply of perishable and non-perishable foods, food menu was posted and no foods were expired. Common areas were observed clean and properly furnished. LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was complete. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 19, 2023