Brookdale Brookhurst

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Hanna Fuller made an unannounced visit to the facility to conduct a case management health and safety check on residents in care. LPA was greeted and granted entry by staff. LPA met with Business Office Manager (BOM) Danielle Chairez and discussed the purpose of the visit. The Orange County Regional Office (OCRO) received an incident report for Resident #1 (R1) dated August 4, 2026, stating that on July 31, 2026, R1 was seen by staff walking unsupervised on the main street towards the grocery store due to missing the community outing. Staff found R1 and continued walking with them to the grocery store and then escorted them back to the facility on the community bus. No injuries were noted. LPA reviewed R1s LIC602 Physicians Report dated February 28, 2025, stating that R1 is unable to leave the facility unassisted due to their cognitive decline. This report was signed by a medical professional on the same date. LPA toured the facility and observed residents eating dinner and participating in activities. LPA spoke with R1 and they stated they were okay and have no injuries from leaving the facility unassisted. Based on today's observations a deficiency and $250 civil penalty were noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with LIC809D, Civil Penalty and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Aug 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 18, 2026

87464(f)(1) Basic Services (f) (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Based off record review and interview, R1 eloped from the facility when their physicians report states they cannot leave unassisted. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 17, 2026

Plan of correction: Licensee stated they will conduct an in service with staff by POC due date and do a routine check on assisted living residents that are not allowed to leave the facility unasssited by September 18, 2026. A civil penalty was assessed.

Allegation investigated: Staff did not ensure resident was provided medical attention after having a fall Staff did not reassess resident for changes in his health condition

On July 29, 2026, Licensing Program Analysts (LPAs) Brandon Lopez and Tran Nguyen made an unannounced visit to the facility to deliver the complaint findings. LPAs were greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director John Goodwin and Health and Wellness Director Putri Tarigan were present and assisted on today's visit. During the course of the investigation, the Department conducted staff interviews, reviewed and obtained pertinent documents for this complaint. Regarding the allegation, staff did not ensure resident was provided medical attention after having a fall, the following has been concluded: It was alleged that staff did not ensure Resident #1 (R1) was provided medical attention after a fall. The Department conducted a file review for R1, including progress notes for R1 between the dates of May 8, through July 2, 2026. Per the facility's progress notes, on June 22, 2026, R1 called for staff assistance and was found laying on the floor. R1 stated that he fell out of his bed. R1 stated that he was not in any pain or discomfort. CONTINUED ON LIC9099-C Unsubstantiated The facility staff checked on R1 seven hours later and noted R1 to be in good spirits and tolerating well. The Department was unable to conduct an interview with R1 for this complaint due to R1 passing away on July 18, 2026. The Department conducted four staff interviews. The four staff interviewed confirmed that R1 sustained a fall while at the facility on June 22, 2026. However, the staff reported that R1 did not sustain any obvious injuries as a result of the fall and that R1 did not complain of any pain. Therefore, immediate medical attention was not required for R1. The staff interviewed reported that R1 was continuously checked on to determine if R1 needed any further treatment after the fact. Regarding the allegation, staff did not reassess resident for changes in his health condition, the following has been concluded: It was alleged that staff did not reassess R1 for changes in his health condition. The Department reviewed the facility's progress notes for R1 between the dates of May 8, through July 2, 2026. Per the facility's progress notes, on June 23, 2026, R1 complained of soreness, body aches, and a cough. Staff then notified R1's Responsible Party who stated that they would have R1's Nurse Practitioner check him out. Approximately seven hours later, R1 again complained of generalized body aches and a cough. Staff also noted R1 with a decreased appetite during dinner. On the following day, June 24, 2026, staff noted R1 to be dry heaving. Staff asked R1 if he wanted to be sent out to the hospital but R1 refused. A visitor for R1 then called 9-1-1 due to their concerns about R1's condition. However, R1 refused the paramedics once they arrived to assess him. On June 25, 2026, staff noted R1 to not be eating well and that R1 vomited a dark output during lunch. 9-1-1 was then called for R1 who agreed to be transferred to the hospital. The Department was unable to conduct an interview with R1 for this complaint due to R1 passing away on July 18, 2026. The Department conducted four staff interviews. One staff was unable to provide any information into this allegation. However, the three other staff denied the allegation. The staff reported that 9-1-1 was offered to R1 when he first displayed his symptoms, however, R1 declined to be assessed by the paramedics. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the two allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director John Goodwin and Health and Wellness Director Putri Tarigan. A copy of the report was provided at time of visit.the state’s words, verbatim · CDSS document, Jul 29, 2026 · control 22-AS-20260625141247

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Hanna Fuller made an unannounced visit to the facility to conduct a case management visit. LPA was greeted and granted entry by staff. LPA met with Business Office Manager (BOM) Danielle Chairez and discussed the purpose of the visit. LPA toured the facility and observed the freezer was operational with an internal temperature of 0 degrees Fahrenheit and the freezer truck was no longer needed. BOM informed LPA that the freezer temperature has been stable and keeping the food frozen since the unit had been repaired. LPA observed the food inside the freezer to be frozen. Based on today's inspection no deficiencies were noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 24, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Hanna Gough and Ruth Martinez made an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry by staff. LPAs met with Administrator (AD) John Goodwin and discussed the purpose of the visit. The facility is a three story building with resident bedrooms, bathrooms, activity rooms, dining room, staff offices, medication rooms, laundry rooms, memory care unit and outside courtyard with pond. The facility appears clean, safe and sanitary. LPAs toured the facility and observed all resident bedrooms had the required components and furnishings. LPAs observed the restrooms to be stocked with toilet paper, paper towels and textured shower flooring. The water temperature was tested to be between 105.3 and 118.2 degrees Fahrenheit. LPAs toured the kitchen and observed it to be clean and free of vermin. LPAs observed a two day perishable and seven day non perishable food supply on hand. LPAs observed the freezer to be at 40 degrees Fahrenheit with the Administrator already ordering a new freezer that is to be delivered the night of July 16, 2026, and be at the facility until the current one has been repaired. LPAs observed the activities being conducted with residents. LPAs observed the toxins and chemicals to be in locked closets throughout the facility. The housekeeping carts are locked in a closet located in the locked laundry room when not in use. LPAs observed a completed first aid kit at the facility. LPAs observed the Assisted Living medication room to be on the second floor with locked medication carts that are made inaccessible to residents. LPAs observed the memory care unit to have operational delayed egress doors. The memory care medication room was locked and made inaccessible to residents. LPA observed the memory care unit to have a dining room that connects to the main facility kitchen by a locked door. LPAs observed an outdoor gated shaded seating area for resident use that is accessible to the memory care residents and is free of debris and obstructions. Continue on LIC809C An outdoor shaded seating area was observed and accessible to the assisted living residents with a koi pond that is surrounded by a 5ft 8in wrought iron fence. LPAs observed the signal system to be operational. All fire extinguishers were charged with a service date of June 9, 2026. LPAs observed the facility to have evacuation chairs in all staircases of the facility. LPAs reviewed staff files and no discrepancies were observed. LPAs reviewed resident files and no discrepancies were observed. LPAs reviewed the last disaster drill was conducted on April 16, 2026. LPAs reviewed an annual report dated January 9, 2026, from James Gollner Services Inc. on a fire inspection report stating that all systems passed. LPAs reviewed resident medications in the memory care and assisted living medication rooms and no discrepancies were observed. Based on today’s inspection a technical violation and advisory were noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 16, 2026

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: - Resident sustained multple unstageable pressure injuries due to neglect

Licensing Program Analyst (LPA) Michael Tea arrived on this day for the purpose of delivering findings regarding the above allegation. LPA met with Executive Director (ED) John Goodwin. On October 27, 2025, the Orange County Adult and Senior Care Regional Office received a complaint alleging that Resident 1 (R1) sustained multiple unstageable pressure injuries due to neglect. During the investigation, the Department reviewed facility records, hospice records, and hospital records and conducted interviews with facility staff and other pertinent witnesses. The Department attempted to interview R1; however, at the time of the initial investigation, R1 had been hospitalized and was unavailable for interview. LPA later learned that R1 passed away in March 2026. Therefore, an interview with R1 could not be completed. Complaint Investigation Report continued on LIC9099-C Unsubstantiated Records reviewed showed that R1 had a history of multiple chronic medical conditions, including diabetes, vascular disease, severe anemia, and poor circulation. Medical records indicated these conditions significantly affected the resident's ability to heal and increased the risk of developing pressure injuries. R1 was admitted to the hospital on October 21, 2025, due to abnormal laboratory results, severe anemia, weakness, and ongoing wound concerns. Hospital records reviewed showed that multiple unstageable pressure injuries were identified during the hospitalization. Hospice records further documented that, prior to the hospitalization, hospice had been providing wound care treatment to R1 for Stage II and Stage III pressure injuries. Hospice records contained physician orders, regular nursing visits, wound assessments, and ongoing monitoring of the resident's skin condition. Facility staff were responsible for monitoring R1's condition, reporting changes, and following medical recommendations. LPA interviewed R1's hospice case manager, who stated that R1's wounds were not caused by a lack of repositioning and that R1's chronic medical conditions played a significant role in the development and healing of the wounds. The hospice nurse reported that facility staff regularly communicated changes in the resident's condition, reported concerns when dressings became soiled, and contacted hospice as needed. The hospice nurse stated there were no concerns that the facility neglected the resident's care. LPA also reviewed hospital records. While hospital staff documented multiple pressure injuries and expressed concern regarding the severity of the wounds, the records did not conclude that the wounds were caused by neglect by facility staff. The records showed that R1 was already receiving wound care services prior to hospitalization. During a screening documented in the hospital records, R1 denied being abused, neglected, or mistreated by the facility. Although the investigation confirmed that R1 had multiple pressure injuries, the evidence obtained did not establish that facility staff caused or contributed to the wounds through neglect. The evidence showed that R1 had significant underlying medical conditions affecting wound healing and was receiving ongoing treatment from hospice and other medical providers. (Report continued on LIC9099-C) Based on the information obtained during the investigation, the allegation is deemed UNSUBSTANTIATED, meaning that although the allegation may have happened or be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report and the Confidential Names List were provided to the facility.the state’s words, verbatim · CDSS document, Jun 11, 2026 · control 22-AS-20251027143540

Allegation investigated: - Staff did not distribute resident's medication as prescribed

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conduct a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the reason for the visit. Executive Director (ED) John Goodwin arrived shortly to assist with the visit. The department received a complaint on June 1, 2025, and LPA Tea conducted the initial 10-day visit on June 11, 2025. LPA Tea spoke to residents and facility staff and reviewed and collected pertinent documents and information. It was alleged that staff did not distribute a resident's medication as prescribed. During the investigation, LPA reviewed records and conducted interviews with residents, staff, and facility management. Interviews revealed that Resident 1 (R1) received medication intended for another resident. R1 reported (Complaint Investigation continued on LIC9099-C) Substantiated experiencing symptoms and was sent to the hospital for evaluation. ED Goodwin confirmed that Staff 1 (S1) self-reported the medication error and acknowledged that the wrong medication had been given to R1. Staff 2 (S2), who was present at the time, confirmed that S1 did not follow the facility's medication administration procedure and administered medication to the wrong resident. Resident 2 (R2), whose medication had been mistakenly given to R1, also confirmed that the error was discovered after questioning the medication they received. Based on LPA’s interviews and information obtained during the investigation, the Department determined that staff failed to administer medication as prescribed. Therefore, the allegation mentioned above has been determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with Executive Director (ED) John Goodwin and a copy of this report and appeal rights were provided to the facilitythe state’s words, verbatim · CDSS document, Jun 11, 2026 · control 22-AS-20260601123459

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 12, 2026

87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall ... (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews, records reviewed, and observations made, the facility failed to ensure Resident 1 received proper assistance with self-administered medications when staff administered medication intended for another resident, resulting in a medication error. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2026

Plan of correction: Facility will sign a statement of understanding for the regulation cited and will conduct an in-service training for medtech staff regarding proper medication administration procedures, including verifying the correct resident, medication, dosage, and time before administering medications. Training shall include review of the facility's medication error policy and procedures. Facility will submit proof of training, including the training materials, staff signatures, and date of completion, to LPA by POC due date by COB.

Allegation investigated: Facility did not ensure resident was repositioned causing bruising Facility is charging for services not provided Facility did not ensure resident received food and water resulting in a change of condition Facility did not address change of condition in resident

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit. The Department received the complaint on January 7, 2026 and LPA Mendivil conducted initial 10 day visit on January 15, 2026. During the visit LPA Mendivil obtained copies of records including resident admission record, physician report LIC 602, care plans for Resident 1 (R1) , and staff schedules. LPA Mendivil interviewed staff and residents. Regarding the allegations Facility did not ensure resident was repositioned causing bruising ,Facility is charging for services not provided, Facility did not ensure resident received food and water resulting in a change of condition, Facility did not address change of condition in resident the investigation revealed the following: R1 lived at the facility since May 07, 2021 and moved out on December 30, 2025. Based on physician’s report LIC 602 dated January 21, 2025 indicated R1 was 100 years old and was diagnosed with Mild Cognitive Impairment. Per LIC 602 R1 was able to feed themselves and was non-ambulatory. R1 was placed on hospice on January 21, 2025. Unsubstantiated It was alleged that facility did not ensure resident was repositioned causing bruising. Per interviews with 5 out of 5 staff stated that R1 was repositioned. Per review of care notes bruising was noticed on R1’s heel which was notated by hospice. Interviews with staff stated they would not notate in care plans when a resident was repositioned. Staff stated they only chart issues out of the norm for the resident. It was alleged that facility is charging for services not provided. Interviews with 5 out of 5 staff stated they were providing all services for R1. Interviews with 6 out of 6 residents stated all needs are being met and all services are being provided. It was alleged that Facility did not ensure resident received food and water resulting in a change of condition. Per interviews with staff, staff stated that R1 was able to feed themselves until December 2025. 5 out of 5 staff deny that R1 was not provided with food and water. Per interviews with Executive Director John Goodwin stated that R1 was refusing food even with staff assistance around December 25, 2025 and hospice was notified. 6 out of 6 residents stated when they have received tray service they did not have issues receiving their food. It was alleged the Facility did not address change of condition. Per interviews with 5 out of 5 staff stated that all change of conditions are brought up to med-techs or management. Per interviews with staff, it was stated that R1’s hospice was notified when R1 was refusing food and then R1 was moved a few days after their change in condition. Therefore based on the preponderance of evidence through records reviewed and interviews the allegations Facility did not ensure resident was repositioned causing bruising ,Facility is charging for services not provided, Facility did not ensure resident received food and water resulting in a change of condition, Facility did not address change of condition in resident are determined to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies are being cited in today's visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 21, 2026 · control 22-AS-20260107153606

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today's visit was to conduct a case management. LPA Tea was greeted and granted entry into the facility by Executive Director (ED) John Goodwin. On this day LPA Tea amended LIC809 and LIC809D dated 10/28/2025. LPA reviewed amended report with ED Goodwin. An exit interview was conducted with Executive Director John Goodwin. A copy of this report and amended LIC809 and LIC809D along with LIC9102TV were provided to the facility.the state’s words, verbatim · CDSS document, Apr 23, 2026

Allegation investigated: - A resident sustained multiple falls and sustained serious injuries

On this day, Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit to the facility to conclude the complaint investigation and deliver the findings. LPA Tea was greeted by staff, allowed entry, and explained the purpose of the visit. Executive Director (ED) John Goodwin arrived shortly after to assist. The Department received a complaint on August 9, 2022. The complaint was reassigned to LPA Tea. LPA Tea spoke to facility staff and other witnesses and reviewed and collected pertinent documents and information. Resident 1 (R1) was initially assessed as largely independent and was not identified as a fall risk by the facility and physician reports despite having a history of falls. The physician report dated March 4, 2022, noted R1 was independent with activities of daily living, able to bathe, toilet, and self-administer (Complaint investigation continued on LIC9099C) Unsubstantiated medication. Although R1 had complex medical conditions, including liver cirrhosis, anemia, interstitial lung disease, and later hepatic encephalopathy, there was no physician designation indicating R1 was a fall risk. Facility records such as staff progress notes show that R1 experienced a significant and progressive decline in medical condition, including confusion, disorientation, weakness, and repeated hospitalizations. Documentation reflects that R1’s condition worsened following hospital discharges, particularly after episodes related to elevated ammonia levels and liver disease complications. The facility appropriately updated R1’s Personal Service Plan (PSP) multiple times (05/13/22, 05/18/22, and 05/23/22) in response to their changing condition. These updates included added assistance with medication management, dressing, grooming, and toileting. Although escort mobility assistance was briefly implemented and later removed, documentation supports that services were adjusted based on observed needs and condition changes. Incident reports indicate that R1 experienced multiple falls, many of which were unwitnessed or occurred while attempting to act independently, such as trying to get into bed or ambulate without assistance. Injuries documented were generally minor with skin tears and bruising, and staff responded appropriately by providing first aid and seeking medical evaluation when necessary. Medical records from Orange Coast Memorial indicate that at the time of hospitalization, R1 was alert, oriented, well-developed, and non-toxic appearing, with no signs of neglect. After the fall, a brain bleed was suspected, but R1’s decline was mainly caused by pneumonia, respiratory failure, and septic shock, which led to their death. The medical records review does not indicate or specify correlation between R1’s falls and her overall medical deterioration or death. Instead, documentation supports that their decline was primarily due to underlying chronic and acute medical conditions. In the medical records, it was also notated that R1’s family expressed satisfaction with the facility’s care and denied any concerns regarding staff. LPA conducted interviews with current facility staff who worked when R1 was present at the facility. All staff interviewed consistently reported that R1 experienced a noticeable decline in condition, including increased confusion, weakness, and frequent hospitalizations. Staff indicated that R1 preferred to maintain independence and often attempted tasks without assistance, which contributed to their falls. Staff also stated that R1 did not like to ask for help. All interviewed staff reported that they provided appropriate care and (Complaint investigation continued on LIC9099C) supervision, monitored R1’s condition, and responded to incidents as they occurred. Staff further indicated that R1’s sister expressed appreciation for the care provided and felt reassured by staff support. Although R1 experienced multiple falls while residing at the facility, the evidence supports that these incidents were largely associated with R1’s declining medical condition and attempts to remain independent, rather than neglect or lack of care by facility staff. The facility responded appropriately by updating care plans, monitoring R1’s condition, and ensuring medical attention when needed. Therefore, based on the records reviewed and interviews conducted, there is insufficient evidence to conclude that the facility’s actions directly caused or contributed to serious injuries resulting from the falls. The allegation mentioned above has been determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies cited at this time and an exit interview was conducted with the facility. A copy of the report and confidential names list were provided to the facility.the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 22-AS-20220809153159

Allegation investigated: - Resident not receiving medications in timely manner - Facility has not eradicated the cockroach problem

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the reason for the visit. Executive Director (ED) John Goodwin arrived shortly to assist with the visit. The Department received a complaint on July 21, 2023. The complaint was reassigned to LPA Tea. LPA Tea spoke to residents, facility staff and other witnesses and reviewed and collected pertinent documents and information. It was alleged a resident is not receiving medications in a timely manner. Facility progress notes document an instance where medications were not available on hand and staff contacted Resident 1(R1)’s daughter. Admission orders indicate R1 was able to determine and clearly communicate the need for PRN medications. (Complaint investigation continued on LIC9099C) Unsubstantiated The Physician’s Report dated June 15, 2023, states R1 was unable to administer own prescription medications but was able to self-administer PRN medications and safely store medications. The “Medication Release When Resident is Absent from the Residence” form indicates R1 and the daughter handled medications independently. The Personal Service Plan dated July 21, 2023, states R1 self-manages medications, including administering, ordering, coordinating, and storing medications safely. A witness reported concerns that the facility charged for medication management services while allegedly not providing adequate assistance and believed R1’s health decline was related to poor medication management. The witness also expressed concern that the facility delayed reassessing R1’s medication needs. However, the witness’s statements were not supported by facility records or corroborated by other interviews. LPA interviewed the facility’s Long-Term Care Ombudsman, who stated she regularly attends resident council meetings and has not received complaints or concerns regarding medication mismanagement. She indicated the most common concern is residents wanting medications administered exactly on time, noting the one-hour allowable window for medication administration. LPA interviewed eight residents. Most residents reported they manage their own medications. One resident reported medication management services were satisfactory initially but later experienced delays and forgetfulness. Two residents reported receiving medication management services and stated they had no issues. One resident receiving medication management services expressed a preference to self-manage medications due to cost; however, facility staff were following a nurse practitioner’s order requiring facility-managed medications. It was alleged that facility has not eradicated the cockroach problem. Upon investigation staff consistently reported the presence of cockroaches, sometimes referred to as water bugs, as a seasonal issue rather than an infestation. Staff stated the facility is located near a canal and that pests may enter through drainage systems. Staff reported the facility has taken proactive measures, including installing additional mesh barriers on drains to prevent pests from entering. Pest control records from Ecolab document monthly pest maintenance services, bait trap monitoring, and on-call services as needed. The Maintenance Director, Cristian Hernandez confirmed Ecolab services the (Complaint investigation continued on LIC9099C) facility monthly and that the facility maintains in-house pest control products for immediate response. He stated the facility avoids toxic chemicals due to concerns about water supply safety and emphasized ongoing pest management rather than complete eradication. LPA also spoke to the facility ombudsman stating there were no complaints or concerns related to cockroaches or pest infestations during resident council meetings. LPA interviewed eight residents, all of whom denied experiencing cockroach or pest issues and stated the facility responds appropriately to pest concerns. Therefore, based on record review and interviews, there is insufficient evidence to substantiate that R1 was not receiving medications in a timely manner due to facility noncompliance. Records consistently indicate R1 self-managed medications or shared responsibility with the daughter, and there is no documentation showing a failure by the facility to administer medications when responsible. Based on interviews and documentation reviewed, the facility has implemented ongoing and reasonable pest control measures and there is no evidence of an unresolved cockroach infestation. The facility demonstrated consistent pest management efforts and resident reports did not corroborate the allegation. The allegations mentioned above has been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with Executive Director John Goodwin. A copy of the report and confidential names list were provided to the facility.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 22-AS-20230721104609

Allegation investigated: - Resident sustained unexplained bruising - Staff did not administer resident’s medication

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the reason for the visit. Executive Director (ED) John Goodwin arrived shortly to assist with the visit. The Department received a complaint on January 15, 2025. LPA Tea was reassigned to this complaint. LPA Tea spoke to residents, facility staff and other witnesses and reviewed and collected pertinent documents and information. It was alleged that resident sustained unexplained bruising. LPA reviewed Facility Progress Notes documented R1’s skin condition throughout their short stay. Records indicate the family was informed of R1’s condition and that R1 was taken to the hospital for evaluation. Progress notes further reflect that R1 frequently denied pain. The Facility Personal Services Assessment and pre-admission assessment (Complaint investigation continued on LIC9099C) Unsubstantiated completed prior to move-in indicate that R1 bruises easily and required a high level of assistance. Four out of four facility staff interviewed stated that R1 had visible bruising prior to admission. Three staff reported observing R1’s private caregiver handling R1 roughly during transfers. Staff also reported observing the same private caregiver handle R1’s great-grandson, who has special needs, in a rough manner during visits to the facility. All staff interviewed stated they handled R1 with care, particularly due to frequent family monitoring. Two witnesses expressed concerns regarding R1’s care and believed R1 did not require a two-person assist; however, facility records and assessments completed prior to admission indicate R1 required extensive assistance. Witnesses interviewed corroborated that one staff member initially expressed discomfort assisting R1 alone and requested additional assistance, consistent with the documented care plan. Emergency department discharge paperwork from Kaiser indicates the treating physician believed R1’s elbow bruising and swelling were not related to infection or other emergent conditions and were most consistent with a minor injury expected to improve within two weeks. It was alleged that staff did not administer resident’s medication. Four out of four staff interviewed stated that R1 did not have complete or valid physician orders for several medications during their stay. Facility Progress Notes document multiple instances where medications brought in by the family or private caregiver did not match physician orders, including incorrect medication strength and missing orders. On January 22, 2025, records indicate that medication was delivered by the family without a corresponding physician order for essential medication, including Carbidopa/Levodopa for Parkinson’s disease. Progress notes reflect the facility made ongoing efforts to obtain appropriate physician orders, including attempts made up to R1’s move-out date of February 22, 2025. Documentation indicates the family was aware that physician orders were required for medication administration. Staff consistently stated they could not legally administer medication without a valid physician order and were required to follow Title 22 requirements. The Physician’s Report dated December 30, 2024, completed by a Physician Assistant, indicates medication (Complaint investigation continued on LIC9099C) management responsibilities were handled by R1’s private caregiver. The LPA also interviewed the Ombudsman, who attends resident council meetings and reported no known complaints regarding medication mismanagement at the facility. Resident interviews revealed varied experiences with medication management; however, these statements were general in nature and not specific to R1. Two residents reported satisfaction with medication services, and no residents provided information corroborating medication mismanagement related to R1. Therefore, based on documentation, medical evaluation, and consistent staff statements, there is insufficient evidence to conclude the bruising occurred as a result of facility staff actions or neglect. Based on documentation showing the absence of required physician orders, the facility’s documented efforts to obtain orders, and staff adherence to regulatory requirements, there is insufficient evidence to conclude the facility failed to administer medication improperly. The allegations mention above has been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with Executive Director John Goodwin. A copy of the report and confidential names list were provided to the facility.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 22-AS-20250130111502

Allegation investigated: - Resident sustained multiple pressure injuries due to neglect

This is the final report of the investigation completed by the Department. LPA met with Executive Director (ED) John Goodwin and Health & Wellness Director (HWD) Suzette Paige. On June 11, 2025, the Orange County Adult and Senior Care Regional Office received a complaint alleging that a resident sustained multiple pressure injuries due to neglect. The investigation determined as follows: Resident 1 (R1) was admitted to the facility on February 16, 2018. Per physician report dated November 06, 2024, R1 has some motor impairment/paralysis and is considered non-ambulatory with no history of skin breakdowns. The facility completed an assessment of R1 on March 08, 2023, in which it was noted R1 had fallen within the last 12 months. Universal fall precautions were put in place including orienting resident to environment & familiarizing them with the facility call system. (Complaint Investigation Report continued on LIC9099-C) Substantiated On June 08, 2025, R1 was found by MedTech 1 (MT1) lying on their bedroom floor at approximately 9:30 AM after staff reported not seeing R1 at breakfast. Per facility policy, staff are to check on residents when they do not show up for meals. Emergency services were contacted and R1 was transported to UCI Medical Center where he was treated for pressure injuries, abrasions and signs of prolonged immobility. Per records obtained, EMS report confirms a call at 9:23 AM, with arrival at 9:30 AM. The EMS report noted pressure ulcer to left check, abrasions to chest and knee and stable vital signs. Per UCI Medical Records R1 was admitted on June 8, 2025, for trauma and sepsis secondary to gangrenous cholecystitis. The medical notes document that R1 was found down after approximately 24 hours in which large pressure ulcer was found on the left cheek; an abrasion to chest and right knee; strong smell of urine; clothes soiled; and soft tissue trauma consistent with prolonged immobility. UCI medical documents and EMS report corroborate that injuries resulted from prolonged immobility. Per interview with Health & Wellness Director (HWD) Suzette Paige, R1 was independent and typically attended all meals. She received a call from MT1 that R1 was found on the floor because they had missed breakfast. HWD Paige stated that the night shift failed to perform required checks despite policy requiring one per shift. From records obtain, Brookdale Senior Living has a Night Check Policy – CS-100-16 Effective April 1997 where resident care staff should make night checks of the residents. Interviews with MedTech and Caregiver confirmed that there was no overnight welfare checks completed on June 7th & 8th. Facility did not follow or practice the policy of verifying the independent residents’ well-being during night shifts which contributed to the prolonged delay in discovery of R1 in their apartment. Per interviews, two staff interviewed mentioned there was a facility informal rule, to wait for two consecutive missed meals before checking on residents. This informal rule practiced by facility staff demonstrates neglect with delayed responses and violation of the facility procedures. The facility failed to provide adequate supervision and neglected to ensure the health and safety of residents in care. Based on interviews conducted and records reviewed, Resident sustained multiple pressure injuries due to neglect. The following is cited by the California Code of Regulations, Title 22, Division 6. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f) (Complaint Investigation Report continued on LIC9099-C) An exit interview was conducted and a copy of this report, LIC809-D, appeal rights and confidential names list was provided to Executive Director and Health & Wellness Director.the state’s words, verbatim · CDSS document, Oct 31, 2025 · control 22-AS-20250609112449

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Nov 3, 2025

87464(f)(1) Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Based on interviews with staff and witnesses, as well as records reviewed, it was determined that Resident 1 (R1) sustained pressure injuries resulting from a lapse in supervision. Evidence indicates that R1 was found on the floor and remained there for an extended period of time. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 31, 2025

Plan of correction: Facility agrees to sign a statement of understanding for the regulation. Facility also agrees to conduct an in-service on wellness checks and Facility's Night Check Policy and forward proof to LPA by POC due date.

Allegation investigated: - Staff did not seek medical attention for a resident in care

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the reason for the visit. Executive Director (ED) John Goodwin arrived shortly to assist with the visit. The Department received a complaint on October 3, 2025, and LPA Tea conducted the initial 10-day visit on October 9, 2025. LPA Tea spoke to facility staff and reviewed and collected pertinent documents and information. It was alleged that facility staff failed to seek timely medical attention for a resident in care. The investigation determined the following: Photographic evidence provided to the Department depicted Resident 1 (R1) with significant bruising along the shoulder area and lighter bruising above the left eyebrow extending from the (Complaint Investigation continued on LIC9099-C) Substantiated hairline. A police report obtained by the Department included a witness statement describing that upon touching the bruised area of R1’s shoulder, distinct welts could be felt. The witness indicated that the bruising pattern appeared consistent with the shape of a hand, suggesting that R1’s shoulder may have been forcefully grabbed or yanked. The photographs and police report collectively demonstrate the presence of extensive and severe bruising that, based on its visibility, should reasonably have been observed earlier in the day. Accordingly, medical evaluation should have been sought immediately upon discovery. Interviews conducted by LPA Tea with current facility staff, former staff members, and witnesses revealed that six out of nine interviewees confirmed the bruising was ultimately identified by R1’s daughter in the evening, prompting the facility to seek medical attention at that time. One staff member reported that earlier that morning, a caregiver had informed a medtech about the bruising; however, the information was not relayed to facility management. Another staff member stated that while they had noticed the lighter facial bruising, they were unaware of the more severe bruising on R1’s body. That staff member further confirmed that the facial bruising had been reported to management. Despite these internal reports, there is no evidence indicating that timely medical attention was sought by facility staff prior to the discovery by R1’s daughter later that evening. It was not until R1’s daughter’s discovery of their bruising that R1 was transported to the hospital emergency department for evaluation. A witness confirmed that diagnostic imaging, including a CT scan and blood work, revealed no fractures or internal bleeding and serious or severe injuries. Therefore, based on LPA Tea's observations, interviews conducted, and documents obtained, the allegation mentioned above has been determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with Executive Director (ED) John Goodwin and Health & Wellness Director (HWD) Suzette Paige and a copy of this report and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 22-AS-20251003170854

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Oct 29, 2025

87465 Incidental Medical and Dental Care... The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents This requirement was not met as evidenced by: Based on documents obtained and interviews, the facility did not ensure R1 received proper assistance and medical care in a timely manner which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Facility will sign a statement of understanding for the regulation cited and will conduct an inservice training about the regulation and reporting requirements in which they will send proof of POC to LPA by email by COB.

Type of visit: Case Management - Deficiencies

On today's date, Licensing Program Analyst (LPA) Michael Tea conducted this case management in conjunction with the continued Complaint visit Control #: 22-AS-20251003170854. LPA Tea met with Executive Director (ED) John Goodwin and discussed the purpose of today's case management visit. During the course of the complaint investigation, LPA Tea verified through interviews that seven out of nine interviewees reported the facility was inadequately staffed at the time of the incident. Several staff members stated they were responsible for an excessive number of residents, with some indicating they were assigned to an entire floor independently. It was further reported that during the nocturnal shift in the Memory Care unit, only one care staff member was on duty. Insufficient staffing levels were described as negatively affecting the quality of care, timeliness of assistance, and overall supervision provided to residents. The LPA’s own observations during the investigation supported these accounts, indicating that the number of staff present was insufficient to meet residents’ needs. However, it was also noted that following the incident, the facility increased staffing levels across various shifts to provide more consistent coverage throughout the day. Based on documents reviewed and interviews conducted, no deficiencies are being cited at this time. However, the LPA provided a technical advisory regarding inadequate staffing. An exit interview was conducted with Executive Director John Goodwin. Copies of LIC809 and LIC9102TV were provided at exit. *** THIS IS AN AMENDED REPORT ***the state’s words, verbatim · CDSS document, Oct 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 29, 1987

Deficiency issued in error. Deficiency issued in error.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: *** This is an AMENDED report ***

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Michael Tea conducted a case management incident visit to follow up on an incident report received by Community Care Licensing Division (CCLD) on Oct 8, 2025, submitted by Health and Wellness Director (HWD) Suzette Paige. LPA was greeted and allowed entrance into the facility by Executive Director (ED) John Goodwin. LPA explained the reason for the visit. The department received an incident report regarding elopements of a memory care resident, Resident 1 (R1) that happened on October 1, 2025 and October 7, 2025. During the visit, LPA and ED Goodwin toured the facility and inspected Clare Bridge Memory Care unit and R1's room. LPA conducted a health and safety check on R1 and observed no health and safety issues. Based on LPA's observation and review of records, despite R1 having a diagnosis of Alzheimer's, R1 is very cognitive, high functioning and very alert. LPA toured and observed the rest of the facility and found no health and safety issues. LPA requested and reviewed copies of R1’s resident file. LPA Tea spoke to staff and management regarding R1's care and the elopements. One of the delayed egress on the doors in the memory care unit in which R1 has exited out of, has an alert that is not loud enough for staff to hear. The alert does go to the front desk and 2nd floor of the facility, and staff has caught the alerts in time during each elopement. Currently the facility has fixed the annunciator alert for the delayed egress in the memory care unit to be more audible and louder and added additional siren alert as of yesterday, Oct 8, 2025. R1 is very quick and can run fast but each elopement they were able to bring him back to the facility within in a short matter of time, no more than 20 mins and less than a mile away from the facility. The facility did follow elopement protocols and contacted local law enforcement. They contacted the family and R1's primary care physician. Facility was was able to redirect him to the facility and ensure that he (Report continued on LIC809-C) was safe. Facility management believes R1 needs a higher level of care. With proper mitigation, the facility has been keeping a close observation on R1 and since the last elopement the facility has had the family hire a one to one personal caregiver from 7:00 AM to 7:00 PM for R1. After the hours of the personal caregiver, the facility has assigned a facility caregiver staff to be with R1 till bedtime and monitoring throughout the night. Based on the observations made during today’s inspection, no deficiencies are being cited at this time. An exit interview was conducted with Executive Director John Goodwin and Health and Wellness Director Suzette Paige and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Oct 9, 2025

Allegation investigated: - Staff are not ensuring resident is accorded privacy - Staff inappropriately removed resident's door

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the reason for the visit. Executive Director (ED) John Goodwin arrived shortly to assist with the visit. The Department received a complaint on July 15, 2025, and LPA Tea conducted the initial 10-day visit the following week on July 24, 2025. LPA Tea spoke to residents and facility staff and reviewed and collected pertinent documents and information. It was alleged that staff are not ensuring resident is accorded privacy. LPA interviewed residents who live in shared suites and asked them about their privacy. Eight out of nine residents interviewed agreed that the facility tried their best to afford their privacy despite having to have a roommate. If something bothered them, the facility was willing to accommodate and seek solutions. There are no complaints about privacy Complaint Report continued on LIC9099-C Unsubstantiated among the seven residents interviewed. LPA spoke to two residents who shared a room together. One resident, Resident 1 (R1) interviewed, felt the facility did not do anything enough and felt their privacy was violated. The resident complained that their roommate played the television 24 hours non-stop. The facility had made both residents come to an agreement but R1 did not feel the roommate did not follow the agreement and remained unresolved. Two staff interviewed felt the facility did their best to accommodate their privacy with residents who shared an apartment together. They offered solutions with residents but with R1, they did not like the options and had made up their mind of leaving the facility. It was alleged that staff inappropriately removed resident’s door. Staff explained to LPA that residents who share an apartment together share the entire space together. There are no designated spaces for any of the residents in the shared apartment. Residents are fully aware when they move in that the entire space of the room is shared. Some shared resident rooms have a door because if not shared, the apartment is a one-bedroom apartment. When it is shared the apartment is called a semi-private or companion suite and residents can decide if they want to keep the door or remove it. If the door remains in the shared apartment, the staff remind the residents to be mindful of sharing the entire space together and that the facility can remove the door if needed when issues occur between residents. With two of the nine residents interviewed, residents had an issue with each other where one resident closed the door not allowing the air conditioning to come through the entire apartment. The other resident had problems with the television noise. As a result of them having issues, the staff removed the door. Two of the staff interviewed did say that both residents agreed to have the door being removed. R1 said they did not agree to it. One staff member said after the agreement was made between R1 and their roommate, R1 said the noise was better and gave permission to remove the door. Since the entire space of the apartment is shared all residents have access to any part. Residents signed the admission agreement in where the section, “Alterations” acknowledges that the facility may make alterations to meet the requirements of any applicable law or regulation. In this case both residents are not afforded equal access to the shared space, so the facility made the decision to take the door down. Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegations staff are not ensuring resident is accorded privacy and staff inappropriately removed resident’s door has been determined to be unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Complaint Report continued on LIC9099-C No deficiencies cited at this time and an exit interview was conducted with Executive Director John Goodwin. A copy of the report and confidential names list were provided to the facility. The residents share the bathroom, closet, kitchenette and the rest of the suite, it is accounted for as one shared space. Two facility staff interviewed said residents who sign up for these rooms are aware before moving into these shared suites that everything is shared and there is no room or part of the room given to a resident. One staff member explained that residents were explained and shown the configurations of the suites prior to moving in during a room tour. The residents accepted and were aware that everything in the suite space must be shared and all residents have equal access to the space. 8 out 9 residents confirmed they were aware about moving into a shared space and the nature of the space prior to moving in. Therefore, based on LPA Tea's observations, interviews conducted, and records reviewed the allegation that staff did not ensure resident’s room was not used as a passageway to the bathroom has been determined as UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies cited at this time and an exit interview was conducted with Executive Director (ED) John Goodwin. A copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 22-AS-20250715155510

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to the facility today to conduct a continuation of the annual required inspection. LPA was greeted and granted entry by the facility staff and explained the reason for the visit. Executive Director (ED) John Goodwin arrived shortly after to assist with the continued annual inspection. During today’s visit, LPA Tea reviewed medication storage and administration. Medications are stored in locked carts on different floors of the facility. Medications are being administered per physician’s order. LPA spoke to staff that were present regarding care provided. During the visit LPA Tea observed residents having breakfast and lunch in the dining area. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with ED John Goodwin and a copy of this report was given to the facility.the state’s words, verbatim · CDSS document, Jul 15, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by front desk staff and explained the reason for the visit. Executive Director (ED) John Goodwin and Business Operations Manager (BOM) Danielle Chairez arrived shortly to assist with the visit. Facility is licensed for 148 non-ambulatory residents, of which 22 may be bed-ridden, but limited to the first and second floor, and a hospice waiver for 22 residents. Currently there are 113 residents and 7 are on hospice during today's visit. LPA Tea reviewed twelve resident files and six staff files. Resident files and staff files contained all the required documentation. ED Goodwin’s administrator certificate expires on July 24, 2025. ED Goodwin completed and submitted all course work to renew his certificate and is pending approval. The last disaster drill was conducted on June 6, 2025. LPA Tea along with ED Goodwin toured the facility at 2:10 PM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a three-story building, with a memory care wing, called “Clare Bridge” on the first floor. In the middle of the building is a courtyard with shaded patio seating and a fenced in water fountain with koi fishes swimming. Memory Care unit has a garden sitting area of its own in the back that is secured. LPA tested delayed egress around the memory care garden to be operational. The fire alarm system of the facility is monitored and maintained by a third-party company. Fire extinguishers are fully charged throughout the facility. LPA observed evac chairs in every stairwell in the facility for emergencies. 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, and shower was free of mold/mildew. Water temperature measured between 118.4 to 110.6 Fahrenheit degrees. LPA pulled emergency pendants in resident’s bathrooms. The first test, the Annual inspection report continued on LIC809C emergency pendent was not working properly. The facility did not receive a signal or notification. ED Goodwin will check to make sure all emergency bathroom pendants are operating. The second time it was tested, staff came within in 15 minutes. LPA tested the resident push pendant and staff came within in less than 10 minutes to respond to the call. Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen and dining room were inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed emergency food and water supplies stored in storage areas in the facilities. During the visit, LPA observed residents having lunch and early dinner. LPA also observed residents playing card games and partaking in activities in the activity room. LPA interviewed clients regarding their quality of care. Due to time constraints, LPA will return to the facility at a later time this month to finish the annual inspection. At this time, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations An exit interview was conducted with ED John Goodwin and a copy of this report was given to the facility along with a copy of the LIC 858, 858C; and 859.the state’s words, verbatim · CDSS document, Jul 11, 2025

Allegation investigated: - Facility staff is verbally threatening resident with eviction - Facility staff is spreading lies about the resident

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conduct a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the reason for the visit. Executive Director (ED) John Goodwin arrived shortly to assist with the visit. The department received a complaint on June 2, 2025, and LPA Tea conducted the initial 10-day visit a week later on June 10, 2025. LPA Tea spoke to residents and facility staff and reviewed and collected pertinent documents and information. It was alleged that facility staff is verbally threatening resident with eviction. The investigation determined the following: Per investigation, LPA spoke to ED Goodwin in regard to resident evictions. ED Goodwin stated that he has always been transparent with resident evictions and discusses evictions with licensing before issuing or notifying residents about evictions. With one resident he has address the concerns of Complaint Report continued on LIC9099-C Unsubstantiated living with other residents and how the resident does not get along with their paired roommates. He gave the resident notice that the options are starting to be limited, either they must get along or they will have to pay the price for a private room which the resident can not afford. Another staff interviewed said there has never been any staff or management to their knowledge giving verbal threats of eviction to residents. Also, the staff said it could be a miscommunication about staff addressing concerns to a resident about their living situations or issues. Per interviews with residents, two out of three residents interviewed have address that they never heard the facility verbally threatened residents with an eviction. One resident has heard rumors or hearsay about some residents that will be evicted from residents in the community. One witness said that a resident feels that they are going to be evicted. It was alleged that facility staff is spreading lies about resident. The investigation determined the following: ED Goodwin stated the facility staff does not talk about resident evictions or any issues with residents. If it pertains to a resident who is being evicted, it would be addressed directly to the resident who is being evicted in a formal professional manner. Another staff has stated that there would be no facility staff spreading lies about resident, it is very unprofessional. The staff believe that residents would be spreading lies in the community, some would lie and make up stories. Per interviews with residents two out three have agreed that they never heard the facility staff spread lies about resident. A witness addressed that a resident likes all the staff here and that they do not spread lies but is disappointed in one staff who feels they are making up a story about them. The witness explained that resident likes living here and gets along with everyone and is well liked. Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegations that facility staff is verbally threatening resident with eviction and facility staff is spreading lies about resident has been determined to be unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with Executive Director John Goodwin. A copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 10, 2025 · control 22-AS-20250602140822

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Michael Tea conducted a case management incident visit to follow up on an incident report regarding medication error received by Community Care Licensing (CCL) on May 21, 2025, submitted by Health and Wellness Director (HWD) Suzette Paige, LVN. LPA was greeted and allowed entrance into the facility by facility staff. Executive Director (ED) John Goodwin and HWD Suzette Paige arrived shortly to assist with the visit. LPA explained the reason for the visit. During the inspection, LPA and ED toured the facility and checked on Resident 1 (R1). R1 was observed to be fine and was using the oxygen machine when LPA came to check on them. LPA conducted health and safety checks on residents present and confirmed they were doing well and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA requested and reviewed copies of R1's resident file. Based on the report received the following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Executive Director, John Goodwin and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Jun 10, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 24, 2025

87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall ... (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on LPA's interview, documents reviewed and observations made, the facility did not ensure Resident 1 received assistance with self-administered medications due to medication not given as prescribed, resulting in a medication error. This poses as a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jun 10, 2025

Plan of correction: After incident Health and Wellness director went over what happened with Med Tech and retrained as well. Also conducted a mini inservice with the other Med Tech staff. Facility will provide the proof of training of corrective action to LPA by POC due date.

Allegation investigated: Resident sustained multiple pressure injuries due to neglect

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit on this day for the purposes of delivering findings into the above allegation. On this day, LPA was greeted and met with Executive Director John Goodwin. On July 9, 2024, the Department received a complaint alleging a resident sustained multiple pressure injuries due to neglect. A health and safety visit was conducted by the Department on July 11, 2024, and an investigation initiated. The investigation determined as follows: Resident 1 (R1) was admitted to the facility on April 12, 2024. Per Physician Report dated June 05, 2024, R1 is able to self manage activities of daily living (ADLs) such as bathing, toileting, and dressing and is not able to communicate their needs. R1’s personal service plan dated May 18, 2024, also notates facility’s assessment that resident is independent in ADLs. On July 02, 2024, R1 was found bleeding on their bathroom floor by Caregiver 1 (C1). C1 called for assistance from facility Med Tech 1 (MT1 and 9-1-1 was activated by Wellness Director Suzette Paige. CONTINUED ON LIC 9099C DATED 02/20/2025 Substantiated R1 was admitted to UC Irvine Medical center where they were admitted with multiple signs of trauma to their face and wounds to their shoulder and knee. Per UCI medical records obtained and interviews conducted with UCI Irvine Medical staff, upon admittance R1 was received covered in urine and feces which R1 appeared to have stayed in for a while. Upon testing and evaluation, R1 was diagnosed with Rhabdomyolysis and an intracranial hemorrhage. Resident was further diagnosed to have pressure wounds to the right maxilla; right deltoid; bilateral knees; and right hand. During interviews, UCI Medical staff reported R1’s wounds were suspected to have been caused from being on the ground for two days. Per interview with facility Health and Wellness Director Suzette Paige, MT1 reported seeing R1 sometime mid-morning on July 02, 2024. However, interview with MT1 denied seeing R1 the morning of. Despite interviews stating facility policy was to check on residents if they did not show up to meals, interviews with six of six staff could not confirm who checked in on R1 after not showing up to breakfast on July 02, 2024. Interviews with staff reported conflicting statements as to when R1 was last seen. During an interview, R1 reported they had tripped and fell on their own footing. When asked approximately how long they had been on the floor before being found, R1 stated maybe a day or two. Per interviews with R1’s Designated Power of Attorney (DPOA), R1 was discharged back to the facility following a stay at a Skilled Nursing Facility, however R1 continued to decline due to esophageal conditions and the wound on R1’s knee becoming infected. R1 passed away on August 16, 2024. At the time of interview, Administrator Goodman reported there was a total of 97 residents and routinely three caregivers, one Med Tech, and one Licensed Vocational Nurse (LVN) to assist 97 residents. Based on interviews conducted and records reviewed, Resident sustained multiple pressure injuries due to neglect. The following is being cited per California Code of Regulations, Title 22, Division 6. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f) An exit interview was conducted and a copy of this report, LIC809-D, appeal rights and confidential names list was provided to Executive Director.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 22-AS-20240709135536

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 21, 2025

87464(f)(1)- Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Based on interviews conducted with staff, residents and records obtained, R1 sustained pressure injuries as a result of having an unwitnessed fall and being left on the floor for approximately one to two days. This poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Feb 20, 2025

Plan of correction: Licensee agrees to conduct an in-service on wellness checks and forward proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Michael Tea made an unannounced visit on this day for the purposes of delivering findings into allegations of sexual abuse. On this day LPA was greeted and met with Business Office Manager (BOM) Danielle Chairez. Executive Director (ED) John Goodwin arrived shortly after. On August 9, 2024, the Department received a self reported incident of suspected sexual abuse from the facility regarding Resident 1 (R1) and Staff 1 (S1). A health and safety visit was conducted by the Department on August 12, 2024, and an investigation initiated. The investigation determined as follows: R1 moved into the facility on May 26, 2024. Per Physician Report dated May 10, 2024, R1 is able to self manage activities of daily living (ADLs) such as bathing, toileting, and dressing and is able to communicate their needs. R1’s personal service assessment dated May 06, 2024, also notates facility’s assessment that resident is independent in ADLs and has an intact cognitive response. Per incident report received, R1 reported S1 engaged in sexually explicit conversations with them on multiple occasions over a period of approximately two months. In addition to engaging in sexually explicit conversations, R1 reported S1 showed them sexually explicit images on their personal phone including nude photographs of individuals they were dating and images of S1’s genitalia. Sometime in early August, R1 reported to a facility Med Tech (MT1) that S1 entered their room without knocking. R1 requested S1 not enter their room as they did not request any services and did not want assistance from S1. MT1 spoke with S1 and instructed them not to provide services to R1. The following day MT1 heard R1 yelling from their room at S1. S1 was observed leaving R1’s room. Interviews with three of three residents confirmed R1 had disclosed to them inappropriate interactions between themselves and S1. Per interview with R1, S1 would often enter their room without knocking including when R1 was in the shower. R1 reported S1 would ask to help dress R1 despite R1 being assessed independent in that ADL. R1 further disclosed they had awoken once (date unknown) to S1 watching them sleep and informing them they had taken photos of R1 while they sleep because they look so pretty. Case management report continued on LIC 809-C On August 1, 2024, Westminster Police Department conducted a visit to the facility to look into the allegations listed. Per review of records obtained, S1 when interviewed by police admitted making inappropriate comments and showing sexually explicit photographs to R1. S1 denied touching or attempting any sexual acts with R1. On August 07, 2024, the facility determined S1’s actions warranted termination for violation of facility harassment policies. The day of S1’s termination, S1 emailed ED Goodwin resigning from their position. Based on interviews conducted and records reviewed, S1 engaged in behavior which violated R1’s personal rights. The following is being cited per California Code of Regulations, Title 22, Division 6. An exit interview was conducted with Executive Director (ED) John Goodwin and a copy of this report, LIC809-D, appeal rights and confidential names list was provided to ED Goodwin.the state’s words, verbatim · CDSS document, Dec 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Dec 27, 2024

87468.1(a)(1)- Personal Rights of Residents in all facilities. To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidence by: Based on interviews with residents, staff and documents reviewed, S1 engaged in inappropriate conversations and showed sexually explicit photographs to R1 and repeatedly entered their room without knocking which poses an immediate safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 24, 2024

Plan of correction: Management staff will provided written statement of understanding for regulation that was cited and emailed to LPA. And will conduct an inservice training on personal rights and provide proof to LPA by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today's visit was to conduct a case management. LPA Tea was greeted and granted entry into the facility by Executive Director John Goodwin. On this day LPA Tea amended LIC809, LIC809C dated 08/12/2024. LPA reviewed amended report with Executive Director. An exit interview was conducted with the executive director . A copy of this report and amended LIC809, LIC809C was provided to the facility.the state’s words, verbatim · CDSS document, Aug 13, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Michael Tea conducted a case management incident visit to follow up on an incident report received by Community Care Licensing (CCL) on August 9, 2024, submitted by Health and Wellness Director (HWD) Suzette Paige, LVN. LPA was greeted and allowed entrance into the facility by Executive Director (ED) John Goodwin. LPA explained the reason for the visit. During the inspection, LPA and ED toured the facility and inspected R1’s room. LPA conducted health and safety checks on residents present and confirmed they were doing well and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA checked perishable and non-perishable food supply and it was adequately stocked at time of visit. The electricity and water were running, the facility had soap and paper towels, and the medications, sharps, and toxins were properly stored. LPA interviewed ED Goodwin and requested and reviewed copies of R1’s resident file and S1’s staff file. On August 7, 2024, facility management concluded their investigation, S1 emailed their resignation before receiving investigation results. Facility management concluded they were going to terminate S1 employment. In Guardian, S1 has been shown to be separated on August 7, 2024. There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited at this time. An exit interview was conducted with Executive Director, John Goodwin and a copy of this report was provided at exit. **THIS IS AN AMENDED REPORT** This page was created in error. **THIS IS AN AMENDED REPORT**the state’s words, verbatim · CDSS document, Aug 12, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:15 AM, LPA Tea was greeted and granted entry into the facility by Business Operations Manager, Danielle Chairez and explained the reason for the visit. Facility is licensed for 148 non-ambulatory residents, of which 22 may be bed-ridden, but limited to the first and second floor, and a hospice waiver for 22 residents. Currently there are 110 residents during today's visit. The Executive Director (ED), John Goodwin arrived shortly after to assist during the visit. LPA Tea along with ED Goodwin toured the facility at 9:27 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a three-story building, with a memory care wing, called “Clare Bridge” on the first floor. In the middle of the building is a courtyard with shaded patio seating and a fenced in water fountain with koi fishes swimming. Memory Care unit has a garden sitting area of it's own in the back that is secured. LPA tested delayed egress around the memory care garden to be operational. Staff came immediately within minutes when the alert for delayed egress went off. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. The fire alarm system of the facility is monitored and maintained by a third-party company. Fire extinguishers are fully charged throughout the facility. LPA observed evac chairs in every stairwell in the facility for emergencies. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. In the memory care unit in the dining room area and one resident room, LPA observed cleaning supplies and disinfectants accessible to residents in care, after the observation was made ED had staff secured the toxins away from residents. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 110.6 F degrees and 117.5 F degrees. LPA pulled emergency pendants in resident’s bathrooms; staff came in the room in a matter of one to two minutes in response. Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen and dining room was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed emergency food and water supplies stored in storage areas in the facilities. Annual inspection continuation on LIC809-C LPA Tea observed residents doing exercises and partaking in activities in the activity room. The facility provides different activities for residents daily, which are posted throughout the facility. LPA Tea reviewed ten resident files and ten staff files. resident files and staff files contained all required documentation. At 2:54 PM LPA reviewed medication storage and administration. Medications are stored in locked carts in each floor of the facility. Medications are being administered per physician order. LPA interviewed clients regarding their quality of care and spoke to staff present regarding care provided. The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with ED John Goodwin and a copy of this report was given to the facility along with a copy of the LIC 858, 858C; 859, 859C; 809-D and Appeal Rights.the state’s words, verbatim · CDSS document, Jul 19, 2024

Allegation investigated: Lack of staff supervision resulted in resident being left on the floor for an extended period of time

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) John Goodwin and explained the reason for today’s inspection. The investigation into the allegation that lack of staff supervision resulted in resident being left on the floor for an extended period of time revealed the following: During the course of the investigation, Department staff inspected the facility, interviewed AD, witnesses, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Facility Progress Notes from 2023, R1’s Physician’s Report (LIC 602A) dated October 20, 2022, R1’s Brief Interview Mental Status Screening dated June 15, 2021, R1’s Fountain Valley Hospital Medical Records dated June 13, 2023, R1’s Kaiser Medical Records dated June 28, 2023, the facility’s Resident Meal Check Record for the week of June 11, 2023, and the facility’s Progress Notes for R1. On June 13, 2023, R1’s responsible party called the facility to check on R1 because R1 had not answered their phone calls for two days, facility staff went to check on R1 and found R1 on the floor, R1 was taken to the hospital where they were diagnosed with a broken hip. Substantiated AD advised R1’s responsible party that the facility’s dining staff had not seen R1 for two days but had not informed anyone at the time. Per R1’s Facility Progress Notes from 2023, R1 resided in the assisted living section of the facility from June 18, 2021, to June 13, 2023. Review of R1’s Physician’s Report (LIC 602A) dated October 20, 2022, revealed that R1 did not have dementia or mild cognitive impairment, had no physical health impairments, was ambulatory, and could communicate their needs, leave the facility unassisted, manage and store their own medications, and independently transfer to and from bed. Facility staff had completed R1’s Brief Interview Mental Status Screening dated June 15, 2021, which assessed R1 as having moderate impairment. Interviews with AD, facility staff, and witnesses revealed that R1 lived independently, required very little assistance with daily living tasks, had no history of falls, and was not considered a fall risk. Per AD, facility staff, and witnesses, on June 13, 2023, at 4PM, R1’s responsible party called the facility to check on R1 because R1 had not answered their phone calls for two days, facility staff went to check on R1 and found R1 on the floor, and R1 was taken to the hospital. Review of R1’s Fountain Valley Hospital Medical Records dated June 13, 2023, revealed that on June 13, 2023, R1 was taken to the hospital for an unwitnessed fall and diagnosed with a hip fracture and R1’s Kaiser Medical Records dated June 28, 2023, indicate R1 required surgery for the hip fracture. When interviewed, AD stated that facility staff conduct checks on residents but that residents in assisted living do not require frequent checks because they are issued pendants to call for assistance, R1 ate in the dining room for meals and dining room staff were supposed to use the facility’s Resident Meal Check Record to monitor the residents. The dining room staff admitted they had not been using the facility’s Resident Meal Check Record and did not notice that R1 had not been coming to the dining room for their meals as R1 usually did. LPA reviewed the facility’s Resident Meal Check Record for the week of June 11, 2023, which shows the record was not completed by facility staff that week until after the incident with R1 was discovered. Facility staff interviewed stated that R1 was not seen in the dining room on June 13, 2023 and it is unknown if anyone saw R1 on June 12, 2023, that even if a resident is considered independent their assigned caregiver should know their location. When R1 was found on June 13, 2023, R1’s pendant was out of reach on the dresser and it appeared R1 had been on the floor for a period of time because their clothes were soiled and R1 appeared extremely exhausted. LPA reviewed the facility’s Progress Notes for R1 which indicate that upon being discovered on June 13, 2023, and asked when they fell, R1 stated that they had fallen two or three days ago. R1’s responsible party reported that the last time they spoke with R1 was on June 11, 2023, at 4PM and the information obtained did not reveal that anyone saw or made contact with R1 on June 12, 2023. The information obtained corroborates that lack of care and supervision resulted in R1 being left on the floor for at least 24 hours after their fall while suffering from a hip fracture. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation that lack of staff supervision resulted in resident being left on the floor for an extended period of time. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. Regarding the allegation of lack of care and supervision resulting in injury while in care: On June 13, 2023, R1’s responsible party called the facility to check on R1 because R1 had not answered their phone calls for two days, facility staff went to check on R1 and found R1 on the floor, R1 was taken to the hospital where they were diagnosed with a broken hip, and AD advised R1’s responsible party that the facility’s dining staff had not seen R1 for two days but had not informed anyone at the time. Per R1’s Facility Progress Notes from 2023, R1 resided in the assisted living section of the facility from June 18, 2021, to June 13, 2023. Review of R1’s Physician’s Report (LIC 602A) dated October 20, 2022, revealed that R1 did not have dementia or mild cognitive impairment, had no physical health impairments, was ambulatory, and could communicate their needs, leave the facility unassisted, manage and store their own medications, and independently transfer to and from bed. Facility staff had completed R1’s Brief Interview Mental Status Screening dated June 15, 2021, which assessed R1 as having moderate impairment. Interviews with AD, facility staff, and witnesses revealed that R1 lived independently, required very little assistance with daily living tasks, had no history of falls, and was not considered a fall risk. Per AD, facility staff, and witnesses, on June 13, 2023, at 4PM, R1’s responsible party called the facility to check on R1 because R1 had not answered their phone calls for two days, facility staff went to check on R1 and found R1 on the floor, and R1 was taken to the hospital. Review of R1’s Fountain Valley Hospital Medical Records dated June 13, 2023, revealed that on June 13, 2023, R1 was taken to the hospital for an unwitnessed fall and diagnosed with a hip fracture and R1’s Kaiser Medical Records dated June 28, 2023, indicate R1 required surgery for the hip fracture. However, while R1 had a fall and sustained an injury while in care, the information obtained did not corroborate that R1’s fall was caused by lack of care and supervision on the part of the facility. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegation of lack of care and supervision resulting in injury while in care occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 11, 2024 · control 22-AS-20230824151155

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 12, 2024

87464 Basic Services … (f) Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure R1 received care and supervision when R1 was left on the floor for an extended period of time after their fall while suffering from a hip fracture, which poses an immediate safety risk to persons in care. CIVIL PENALITY ASSESSED.the state’s words, verbatim · CDSS document, Jul 11, 2024

Plan of correction: The licensee stated that after the incident with R1 was discovered, staff were retrained on the meal checks and clinical staff were directed to follow up on residents’ meal check status to ensure that the residents’ whereabouts are known. The licensee stated they will submit these training records to LPA by POC due date.

Allegation investigated: Financial abuse

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose to initate the complaint investigation into the above allegation. LPA was allowed entry by Business Office Manager (BOM) Danielle Chairez and was introduced to Executive Director II (ED) John Goodwin. During the course of the investigation, LPA conducted interviews with the resident/staff and obtained copies of pertinent resident documentations. The investigation revealed the following: Regarding the allegation of financial abuse, it was determined based on the records reviewed, and three out of the three staff interviews, one resident interview, that the alleged individual in question is not a staff employed under this facility. Therefore, this agency has investigated the complaint and based on the interviews conducted and the records that were reviewed, the above allegation is deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. The Executive Director II John Goodwin authorized the exit interview to be conducted with Business Office Manager Danielle Chairez, and a copy of this report was provided at the end of the visit. Unfoundedthe state’s words, verbatim · CDSS document, Apr 24, 2024 · control 22-AS-20240416110404

Allegation investigated: A lack of care and supervision reulted in resident falling several times.

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA arrived at the facility was greeted by receptionist and granted entry. LPA met with John Goodwin, Executive Director and explained the nature of today’s visit. Based on the information obtained during this investigation the Department as concluded the investigation into the above mentioned allegation. Findings are based upon this investigation which included interviews conducted, tour of the physical plant of the facility and copy of pertinent documents (face sheet, Services plan, physicians report dates 3/06/23 and 3/20/24, and admissions agreement). It is alleged that a lack of care and supervision resulted in resident falling several times. Record review revealed that resident Continued on LIC9099 Unsubstantiated (R1) was newly diagnosed with Parkinson disease on March 20, 2024. Personal service plan dated October 05, 2023, page 4 indicates R1 ambulates with a rolling walker independently throughout the community, although R1 prefers to stay in their room or in bed most of the time. R1 has episodes of dizziness and anxiety that causes R1 to have tremors and is prone to bedsides and bathroom falls. Staff to remind R1 to use call light pendent, request and wait for staff assistance when feeling anxious or dizzy. Staff to observe environment when assisting with meds, care and remove hazards. Remind R1 to wear non-skid sole slippers/shoes while ambulating. Communicate with primary care physician regarding falls and residents’ safety. Unusual incident/injury reports submitted to the Department reflect that facility has called 911 immediately upon R1 having falls. Report also indicate that R1 has had subsequent non-injury falls due to non-compliance with use of assistive device despite staff re-orientation and reminder to use walker. Reports indicate that on March 20, 2024 R1 was admitted to hospice care and service plan to be updated and reflect current needs. Tour of R1’s bedroom LPA observed a rollator walker with seat in the bathroom. Interviews with 4 of 4 staff indicate that the facility since resident had more fall implemented safety checks about two times every hour. Staff indicated that R1 does not like carrying pendent, forgets it or simply refuses to use it. Staff indicated that R1 must be reminded to use the walker even on short distance walks. Staff constantly remind R1 the importance of the pendent and to wear it as well as the importance of using the walker for ambulation assistance. R1 has always been very independent but facility has been proactive on implanting stand assist for R1 as needed and when requested. Staff indicated that they encourage proper use of assistive devices and additional personalization for falls management based on R1’s history and diagnosis while balancing independence, dignity, and choice. Based on the information gathered during the investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. This report was reviewed with Executive Director and a copy was furnished to the facility.the state’s words, verbatim · CDSS document, Apr 16, 2024 · control 22-AS-20240411162724

Allegation investigated: Lack of care and supervision resulted in unstageable wound

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver findings. LPA arrived at the facility and explained the purpose of today’s visit, was greeted by business office manager (BOM) Danielle Chairez. The complaint was investigated by the Department which involved interviews record review. It is alleged that due to lack of care and supervision, resident resulted in getting an unstageable wound. On January 4, 2024, resident (R1) was sent to the hospital to be evaluated due to exhibiting signs of weakness and confusion. Upon R1 getting discharged from the hospital, an updated physician reported dated for January 6, 2024 stated that R1 is diagnosed with mild cognitive impairment, delirium, has weakness, bladder, visual and motor impairments, however R1 is able to use the bathroom without assistance. Unsubstantiated R1 was discharged from the hospital and returned to the facility on January 6, 2024 by R1’s family. Per R1’s discharge paperwork, R1 showed signs of delirium, but no hospital documentation indicated that R1 had skin breakdown. On January 7, 2024, R1 began home health services with Excell Home Health, and R1 was assessed by the nurse, who also did not report or observe any skin issues. On January 14, 2024, facility staff observed wounds on R1’s sacrum and buttocks while changing R1, and staff notified the home health nurse who cleaned and dressed R1’s wound the same day. On January 15, 2024, when R1 was being changed, staff observed that R1’s wounds had worsened, therefore, sent R1 out to the hospital to obtain further medical evaluation. An interview was conducted with R1’s family who stated that the facility is not to blame regarding R1’s condition and expressed satisfaction regarding the facility care given to R1. Based on interviews which were conducted, review of documents obtained, and observations, there is insufficient evidence to ascertain if the allegation occurred as reported, therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with BOM Chairez. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Apr 1, 2024 · control 22-AS-20240117162657

Allegation investigated: Resident sustained multiple falls due to lack of care and supervision

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility for the complaint and to deliver the findings. LPA De Perio explained the purpose of today's visit, and was greeted by Health and Wellness Director (HWD) Suzette Paige. During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that resident sustained multiple falls due to lack of care and supervision. 2 out of 2 staff interviews did not corroborate with the allegation by stating that upon resident (R1) sustaining a fall in room, R1 pressed their pendent button, of which 2 staff responded within 9 minutes. Upon staff responding, a body assessment was conducted on R1, and 911 was immediately contacted, of which R1 was taken to the hospital for further evaluation. R1 is currently not residing at the facility and was admitted to skilled nursing for additional monitoring for a condition unrelated to R1’s fall. Unsubstantiated Per documentation review, R1 is able to bathe, and dress self, is not diagnosed with mild cognitive impairment or dementia, is ambulatory, has a history of falls, and when R1 is anxious, R1 will engage in behavior such as placing self on the floor. Documentation revealed that R1 had one fall on January 30, 2024, and sustained no other falls the month prior and after. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with HWD Paige. A copy of this report was provided and explainedthe state’s words, verbatim · CDSS document, Feb 9, 2024 · control 22-AS-20240201085538

Allegation investigated: Staff do not respond to resident calls on the signal system. Facility’s signal system is not functioning properly.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegations and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Executive Director (ED) John Goodwin. LPA explained the reason for the visit. On today’s visit LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation that facility staff do not respond to resident calls on the signal system, the following was revealed: Three of four residents interviewed denied the allegation. At 9:35 AM LPA tour the facility and tested four pendants in four resident bedrooms. The average staff respond time range from 40 seconds to 13 minutes and 10 seconds. During the interviews with residents it was reported that staff do not respond fast and/or that staff respond within 15-30 minutes. During the course of the interviews ED stated that the average respond time is within 20 minutes and/or that staff respond timely. Continued on LIC9099-C... Unsubstantiated During the course of the investigation LPA reviewed documents including the Smartcare pendant call log dated 09/25/23 and 09/26/23. Per Smartcare pendant call log the average staff respond time ranges from one minute to 59 minutes. Regarding the allegation that facility’s signal system is not functioning properly, the investigation revealed the following: Three of four residents interviewed denied the allegation. Per interviews conducted with residents it was reported that the signal system does not always work but that if the pendant is not working properly that staff will replace it within 15 minutes. It was reported via interviews by Staff 1 (S1) that sometimes the pendants do not work properly but that it will get replaced right away. Per S1 the signal system has been working properly. Based on LPA's observation and information gathered during the investigation, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, the allegations are deemed UNSUBSTANTIATED. LPA Ramirez conducted an exit interview with ED Goodwin, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 4, 2023 · control 22-AS-20230927104948