Brookdale Chanate

Allegation investigated: -Resident care needs not being met. -Facility staff do not respond to pendant call system timely.

An informal meeting was conducted today in the Santa Rosa Regional Office to deliver and discuss findings regarding allegations. Present in the meeting were Licensing Program Manager Victoria Bertozzi, Licensing Program Analyst Marisol Cuadra, facility representatives Jeannette Kinney, Executive Director/Administrator, Grace Ndomo, District Director of Operations Northern California and Samantha Small, District Director of Clinical Services. The Department received an allegation of resident care needs not being met. Per reporting party, there are multiple instances where resident (R1) has been found with their briefs not being changed at night. On 7/13/26, R1 was brought to breakfast in pajamas because staff didn’t assist them with a shower. Reporting party has concerns that R1 could develop a rash due to lack of incontinence care. In February, staff (S1) were refusing to follow R1’s care plan including shaving them. After a conversation with facility representatives and pertinent parties, S1 wasn’t allowed to provide any care to R1 anymore. Continue on LIC9099C... Substantiated Continued from LIC9099...On 7/30/26 and 8/11/26 LPA conducted a 10-day visit to the facility made observations, reviewed records and conducted interviews with staff and residents in care. Based on records review, R1’s physician report dated 3/16/26 and care plan printed on 7/30/26 confirms that R1 needs assistance care staff to ensure R1 wears clean clothing daily, stand by assistance while showering, incontinence care and escort assistance due to fall risk. Alarm responses report provided by the facility for time frame between 7/4/26 to 8/3/26 revealed that R1 waited over 20 minutes to get assistance from staff in different dates as follow: 7/4/26 announced 9 times but alert was never responded, 7/7/26 waited 27 minutes to receive a response, same day waited 23 minutes at a different time, 7/14/26 waited 37 minutes, 7/17/26 waited 29 minutes, same day 25 minutes at a different time, 7/28/26 announced 9 times but alert was never responded, same day waited 34 minutes at a different time, same day at a different time alert was announced 9 times, but it was never responded, 7/29/26 waited 22 minutes, 7/30/26 waited 28 minutes, 7/31/26 waited 21 minutes, same day at a different time alert was announced 9 times, but it was never responded, 8/2/26 waited 20 minutes, same day waited 25 minutes at a different time of day. Based on records review and interviews conducted by LPA with staff (S1, S2, S3 & S4) and residents (R1, R2, R3, R4 & R5) confirmed that residents are not receiving timely assistance from facility staff to meet their care needs by taking over 20 minutes to respond and at times they don’t respond at all. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. ***civil penalties in the amount of $250 are issued due to repeated citation within 12 months. Another allegation of Facility staff do not respond to pendant call system timely. According to reporting party, R1 needs incontinent care, fall risk and there have been times when they had to call the fire department to get help with getting R1 up from the ground. On 07/16/26, it appears that R1 had fallen at night and knocked over a table/and the lamp broke. Also, there are concerns about facility is understaffed for overnight resulting in staff not responding to the pendant calls at night; In some cases, they take the pendants away from the residents because they don’t have enough staff, so residents are not being supported with their care needs. Continued on LIC9099C.... Continued from LIC9099C... Based on records review, the facility provided LPA with facility census in the assisted living unit of 70 residents in care and staff schedule for the month of July 2026 indicates that the facility had an average of two caregivers on duty for residents in care and one med-technician. However, Alarm response reports dated 7/4/2026 to 8/3/2026 indicated that staff response times to assist residents were over 20 minutes as following: 8/3/26 there were 41 alert calls and care staff responded in between 24 to 44 minutes; 8/2/26 – 80 times and waited 20-42 minutes; 8/1/26 – 68 times and waited 20-45 minutes; 7/31/26 – 73 times and waited 20 to 37 minutes; 7/30/26 – 77 times and waited 20-38 minutes; 7/29/26 – 93 times and waited 21-39 minutes; 7/28/26 – 90 times and waited 20-40 minutes; 7/27/26 – 91 times and waited 20-43 minutes; 7/26/26 – 109 times and waited 20-41 minutes; 7/25/25 – 77 times and waited 20-38 minutes; 7/24/26 – 71 times and waited 21-41 minutes; 7/23/26 – 76 times and waited 20-43 minutes; 7/22/26 – 87 times and waited 20- 32 minutes; 7/21/26 – 87 times and waited 20-45 minutes; 7/20/26 – 88 times and waited 20-34 minutes; 7/19/26 – 78 times and waited 20-37 minutes; 7/18/26 – 80 times and waited 20-41 minutes; 7/17/26 – 73 times and waited 20-36 minutes; 7/16/26 – 63 times and waited 20-44 minutes; 7/15/26 65 times and waited 20-39 minutes; The remaining dates are same average between 20 to 45 minutes. Based on interviews conducted with the Administrator, the facility is in the process of implementing a plan of action to address the alert responses ongoing issue by hiring one new full-time employee and four new part-time employees since July 2026 to work as caregivers and med-technicians, staggered schedules to ensure coverage during cross-over meetings and weekend schedules. However, based on interviews conducted by LPA with residents (R1, R2, R3, R4, & R5) and staff (S1, S2, S3 & S4) revealed that residents are feeling frustrated due to the length of time that they must wait to receive assistance from current staffing to assist them with their care needs, which is confirmed by the response time report obtained by LPA. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Continued from LIC9099A... Based on records review, facility provided LPA with their electronic monitoring policy indicating their permission to install an electronic monitoring device if procedures are followed by signing their policy, resident or their responsible party agrees to these conditions. According to administrator, the camera is located inside of R1’s room, which is a single occupancy room, there is a sign outside of R1’s room indicating the presence of surveillance camera, even though the facility is under the impression that the position of the camera does not allows privacy for R1, their responsible party is in agreement with it, but there is no documentation on file that R1 gave consent nor agrees to have a camera in their room. Also, there are staff that do not agree about been monitored through the cameras, but administrator denies that staff have restricted the use of the camera by turning it off or blocking the device while personal care has been provided. Regarding the incident between staff and R1’s private caregiver, LPA is unable to determine if foul language or profanity was used during the argument between staff and private caregiver, because LPA has attempted unsuccessfully to speak with private caregiver. Although facility administrator and HWD believe that it could have happened, there is no supporting evidence that the incident could have escalated to the use of inappropriate language outside of R1’s room. A finding that the complaint allegation of personal rights is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Last allegation of reporting requirements. Per Reporting party, on 07/16/26, R1 had a fall at night, where supposedly knocked over a table/and the lamp broke, but the facility did not notify R1’s responsible party about R1’s fall and family heirloom broken. Also, on 12/30/25, R1’s rent and care costs increased without prior written notice to R1’s responsible party, so they requested clarification from administrator why advance notice was not provided prior to the implementation of the increased rent and care costs, itemized explanation of any changes in services, staffing or level of care, and billing adjustment for a 90-day period. Continued on LIC9099C... Continued from LIC9099C... Based on records review, LPA was provided with written communication between R1’s responsible party and administrator regarding billing issue delaying the effective date of increases as a result of their lack of appropriate notice not given as stated by regulations because the notification was sent directly from the facility home office. Regarding the fall incident not reported to R1’s responsible party, LPA was provided with progress notes from the facility confirming an un-witnessed fall on 7/2/26, but there was no record of any further fall incident after that date. Based on interviews conducted with R1’s responsible party, they were notified by the facility about R1’s falls back in January, February, April and May, but not the fall incident on 7/16/26 where the lamp allegedly broke. R1’s responsible party stated that they learned about the fall incident from R1 and their private caregiver when they visited them over the weekend, but facility did not notify them about it. According to the facility administrator confirmed that there was a fall where R1’s private caregiver broke the lamp, but they were unable to provide a date when the incident happened. LPA reviewed incident report logs and was unable to locate any incidents for R1 dated 07/16/26. Also, the facility provided LPA with R1’s personal property and valuables form (LIC621) where lamp was not disclosed in it. Based on records review and interviews conducted with pertinent parties, LPA is unable to determine whether there was a fall on 7/16/26 because there is no supporting evidence to proof that it happened. A finding that the complaint allegation of reporting requirements is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Sep 9, 2026 · control 21-AS-20260724172641

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(A)(6) · Plan of correction due date: Sep 10, 2026

1569.269 (A)(6) Type A - §1569.269 Enumerated rights (a) Residents of RCFE shall have all of the following rights: (6) To care, supervision & services that meet their individual needs & are delivered by staff that are sufficient in numbers... & competency to meet their needs. This requirement has not been met as evidence by: Based on LPA’s interviews with staff (S1, S2, S3 & S4) and residents (R1, R2, R3, R4, & R5) in care and records review were in support that the facility is short staffed to meet residents’ care needs timely, resulting in residents waiting a long period of time for assistance, which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Sep 9, 2026

Plan of correction: The Department has scheduled an informal meeting to discuss areas of concern with facility staff. Facility submitted a written plan that they have implemented to ensure call responses are been monitored and reviewed on a weekly basis to clear the citation. ***civil penalties in the amount of $250 are issued due to repeated citation within 12 months.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 10, 2026

Type A: 87411 Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers & competent to provide the services necessary to meet resident needs…This requirement has not been met as evidence by: Based on records review of alarm response reports for period time between 7/4/26 to 8/3/26, staff schedules for the month of July 2026 and interviews conducted with staff (S1, S2, S3 & S4) and residents (R1, R2, R3, R4 & R5) in care, Administrator did not ensure that staff on duty was sufficient to respond in a timely manner to assist residents in care which poses an immediate risk to the health & safety of residents in care.the state’s words, verbatim · CDSS document, Sep 9, 2026

Plan of correction: Administrator submitted LIC500 Personnel Report ensuring adequate staffing coverage according to the amount of residents in care to clear the citation.

Type of visit: Office

An informal meeting was conducted today in the Santa Rosa Regional Office to deliver and discuss findings regarding complaint allegations. Present in the meeting were Licensing Program Manager Victoria Bertozzi, Licensing Program Analyst Marisol Cuadra, facility representatives Jeannette Kinney, Executive Director/Administrator, Grace Ndomo, District Director of Operations Northern California and Samantha Small, District Director of Clinical Services. The purpose of the informal office meeting was to discuss areas of non-compliance and observe Community Care Licensing (CCL) concerns regarding the operation, including substantiated complaints # 21-AS-20260724172641 and # 21-AS-20260716114041 received by the Department. The facility representatives were informed that this informal meeting is a part of the Administrative Action process and that further and/or repeat citations may result in a formal Non-Compliance Plan. Items addressed in today's meeting include but are not limited to the following areas of concern: -Ongoing inadequate care and supervision: multiple complaints regarding call bells not being answered in a timely manner. Also, facility representatives stated that they are assessing protocols for pendant call light concerns since August 11, 2026, by continuing to maintain sufficient staff to meet their resident census, needs and preferences by reviewing all care plans to ensure accurate care is being provided to residents on a weekly basis. Additional staff are hired to meet the needs of increased care that is being provided as well as staff were retrained on call pendant responses policy on August 6th, at 2pm, August 13th, at 2pm, August 17th at 10pm and have implemented a process of reviewing call times daily with Executive Director and weekly with their regional team to ensure adequate response in a timely manner. Exit interview conducted with facility representatives and copy of this report was given.the state’s words, verbatim · CDSS document, Sep 9, 2026

Allegation investigated: -Facility does not have sufficient number of staff at all times to provide the services necessary to meet the resident's needs.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to deliver findings regarding the allegation listed above and met with Patricia Gustin, Administrator. The Department received an allegation of facility does not have sufficient number of staff at all times to provide the services necessary to meet the residents’ needs. The reporting party stated that response times have become unacceptable again, the average response time is between 20 to 30 minutes with times when it takes caregivers over an hour to assist residents with incontinence care. According to reporting party, this issue has been reported to management to compare it with the amount of money that residents are being charged, but care needs not been taken care of. Based on interviews conducted with staff and residents (R1, R2, R3, R4, R5, R6 & R7) in care revealed concerns about the amount of money that they get billed for personal services that are not been provided by the facility, where according to residents the facility don’t have enough caregivers when they call for assistance it takes them an average of 20 to 30 minutes to arrive. Continued into LIC9099C... Substantiated Continued from LIC9099... The residents expressed that there are patterns including nights, early mornings, and weekends when the number of caregivers is limited. Furthermore, residents stated that staggered shower schedules, back up staff during shift changes and busy mornings might provide help to assist residents in care. Additionally, LPA conduced interviews with staff (S1, S2, S3, S4 S5, S6 & S7) where it was revealed the following: As of 7/23/26, there are 70 residents who reside in the assisted living area where approximately 18 residents who are completely independent, 27 residents need laundry services, 22 residents need assistance with showers, 4 residents need two people assistance, 3 residents have behavioral expressions that requires additional staffing to be present when they need assistance, 15 residents need assistance with dress, grooming, incontinent cares, and escorts to dining room during mealtimes. According to interviews conducted with caregivers, they are struggling to assist residents in care due to lack of staffing during busy times, medication technicians help when medication passing is completed, but it could represent a delay in their availability to come and help with assistance to residents’ care needs. The main concern raised by staff from different shifts is the need for additional caregivers to ensure that residents are being taken care of properly, where at times they must work alone during their shifts, call responses log obtained for the last 24 hour confirmed caregiver’s statements revealing response times taking between 20 to 43 minutes. Based on records review, on 7/23/26, the facility provided itemized record of personal services provided to residents in care who reside in the assisted living area that reveals contradictory information about the amount of residents who are paying for certain services as follow: 26 residents are completely independent, 29 residents need assistance with shower services, 17 residents need incontinent care, 1 resident gets additional staffing assistance due to behavioral expressions. According to facility administrator, it acknowledges the need for additional staffing due to an ongoing issue of care staff, where the facility is in the process of hiring staff for 4 hour shifts to assist residents during the morning and additional staff to help for another four hours during the afternoon shift. Also, they are discussing the possibility of allowing staff who want to work additional hours to cover these 4 hour shifts from other departments. LPA was provided with staff schedule for the month of July 2026 indicating coverage of two care staff and one medication technician for assisted living area in the morning and afternoon shift. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. The Department will be scheduling a meeting to discuss areas of concern and non-compliance.the state’s words, verbatim · CDSS document, Aug 11, 2026 · control 21-AS-20260716114041

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(A)(6) · Plan of correction due date: Aug 12, 2026

§1569.269 Enumerated rights (a) Residents of RCFE shall have all of the following rights: (6) To care, supervision & services that meet their individual needs & are delivered by staff that are sufficient in numbers... & competency to meet their needs. This requirement has not been met as evidence by: Based on LPA’s records review of alarm response report, staff schedules for the month of June 2025 & interviews conducted with staff & residents in care, the facility did not ensure that staff on duty was sufficient to respond in a timely manner to assist residents in care which poses an immediate risk to the health & safety of residents in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: Administrator agrees to submit a plan to ensure staffing is adequate to meet residents’ needs timely. Written plan will be submitted to CCL by POC due date. The Department will be scheduling a meeting to discuss areas of concern and non-compliance.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management visit to follow up on deficiencies cited during complaint investigation #21-AS-20250602090022. During today's visit, Administrator provided information about facility policies and procedures implemented are been followed: -§1569.269 (a)(6) - written plan ensuring that the facility is following up on resident's needs timely. During today's visit, LPA learned that facility staff that performs assessments are receiving additional training to learn how to perform accurate assessments of residents' care needs. Administrator agrees that care plans for all residents will be reviewed for accuracy. - 87411(a) - Based on records review, the facility census revealed that there are five floors for assisted living residents where currently there are approximately 74 residents. The facility provided staff schedule for the month of June 2026 indicating that there are one med-technician (med-tech), two care staff for assisted living (AL) for morning and afternoon shifts; one care staff for AL and one shared med-technician who alternates between memory care and assisted living units at night. There are three care staff for memory care (MC) for morning and afternoon shift; one med-tech and two care staff (MC) for night shift coverage according to the amount of residents in care of 25 residents. -87625(b)(3) - staffing schedule for the month of June 2026 reflects current staffing got to assist residents with incontinent care needs timely. According to administrator, there are about 12 residents in AL needing assistance with incontinence care, behavioral concerns or two-people assistance, which staff are able to meet their care needs timely. No deficiencies found during today's visit. Exit interview conducted with Administrator and copy of this report was given.the state’s words, verbatim · CDSS document, Jun 16, 2026

Allegation investigated: -Facility does not have sufficient number of staff at all times to provide the services necessary to meet the resident's needs.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct to delivered findings regarding the allegation listed above and met with James Kennedy, Maintenance Director. Administrator, Patricia Gustin was not able to come to the facility, but was available by phone. The Department received an allegation of facility does not have sufficient number of staff at all times to provide the services necessary to meet the residents’ needs. Per reporting party, the facility has only two caregivers for all floors in the morning, several staff are being asked to work two shifts due to staff shortages. Furthermore, staff come to residents’ rooms to clear call buttons to reflect no delay in staff responses, but they are not assisting residents with their needs because they stated that they were on light duty which means that there will be another staff who are assigned to come and assist residents with incontinent care needs. Based on LPA’s observations, on 5/14/26 during 10-day visit, LPA conducted interviews with staff and heard the pager kept sounding alerting staff that they were needed to assist residents in care. Based on records reviews, the facility census revealed that there are five floors for assisted living residents where currently there are approximately 68 residents and one floor designated for memory care unit where there are about 23 residents in care. Continued on LIC9099C... Unsubstantiated Continued from LIC9099...The facility provided staff schedule for the month of May 2026 indicating that there are two caregivers designated to assist residents in the assisted living area on Sundays through Wednesdays and Fridays, there is an extra staff designated, but they are in light duty, which means that they are unable to assist residents with incontinence care or assist with two people assistance if needed in the mornings, three caregivers assigned on Thursdays and Saturdays and one med-technician (med-tech) assigned in the mornings and afternoons; One caregiver assigned for night shift with one med-tech. Memory Care unit schedule for the month of May 2026 indicates that there are in average of about two to three caregivers to assist residents with incontinence care, fall risk or two people assistance needs including one of the two caregivers who are in light duty that alternates between both units and one med-tech. Two caregivers and one med-tech are assigned for night shifts in memory care unit. Based on interviews conducted by LPA with staff (S1, S2, S3, S4, S5 & S6) it was revealed that facility has only two staff assigned to work on assisted living unit to assist about 68 residents including residents with incontinence and hospice care needs between all five floors, and there are about two to three caregivers including staff who are in light duty to assist about 12 residents with incontinence care or needing two people assistance. Per staff, caregivers who are in light duty are not able to assist residents with current needs due to lifting restrictions. Furthermore, staff revealed that they have been assigned to perform laundry services as well as conduct activities for residents in care without them having any experience performing this task. However, Administrator indicated that the facility has a designated responsible employee who has at least one year of experience conducting group activities according to residents’ needs as stated by regulation. According to staff interviewed, it is revealed that med-tech rarely do help them assisting residents with incontinent care or two people assistance. Based on interviews conducted with residents in care (R1, R2 & R3) revealed that when they push their pendants, there are caregivers who come clear of their pendants and say that someone will come shortly to assist them, but on average it takes between 15-20 minutes until someone comes to assist them with incontinent care. According to Administrator, there are certain residents who has preference of certain caregivers and they decline other caregiver assistance until their preferred staff is available. Based on records review and interviews conducted by LPA with involved parties reflects conflicting information resulting in LPA is unable to determine if the facility has sufficient staffing or if the current number of staff present is able to provide the services necessary to meet the residents’ needs at all times. A finding that the complaint allegation occurs of facility does not have sufficient number of staff at all times to provide the services necessary to meet the resident's needs is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, May 28, 2026 · control 21-AS-20260504083857

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Required 1 Year visit and met with Executive Director (ED)/Administrator, Patricia Gustin. Required postings observed. There are eight residents receiving hospice care services within the approved hospice waiver. Facility has an approved dementia care plan. LPA obtained staff schedules for the Assisted Living and Memory Care Units for the month of January 2026 with a census of 98 residents in care indicates that the facility had an average of two caregivers on duty for residents in care and one medication technician (med-tech). Currently, there are currently 76 residents in Assisted Living area and 22 residents in Memory Care Unit. LPA/ED observed three caregivers present in memory care, one resident care coordinator and one med-tech. There are two caregivers present in assisted living area and one med-tech, there is one caregiver present who alternates between assisted living and memory care unit to assist with showers and incontinence care. LPA/ED toured the facility which included an inspection of assisted living and memory care, all common areas, hallways, and bathrooms observed had sufficient lighting. Residents rooms are furnished per regulation. Facility's Memory Care is allocated to one floor. The facility was a comfortable temperature. Passageways were free of obstructions. Cleaning products are in locked closets or on supervised and/or locked carts. Facility has a sufficient supply of cleaners, hygiene items and paper products. Multiple first aid kits were observed. A call button is located in each bathroom, LPA tested the call system in resident's rooms and staff response time was under three minutes. Continued on LIC 809-C.. Continued from LIC809... LPA/ED observed the memory care unit is on a delayed egress system, which it was approved in their fire clearance. The units two delayed egress doors were tested. There are evacuation chairs located at each stair. The elevators were last inspected on 7/16/25 and permit expires on 7/16/26. The facility has a generator in case of any power outages. The last fire drill was conducted 12/26/25. Fire extinguishers were observed to be last charged on February 2025. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected 3/26/25 & 10/3/25. At approximately 10:25am, LPA/ED toured the kitchen area located in the second floor of the building. A tour and inspection of the kitchens and dining areas were found to be clean and sanitary except a cart containing dirty dishes had a bottle of disinfectant cleaner (technical advisory issued). Also, there were two prepared left over fruit cups and tray containing at least 38 pieces of food were observed uncover and not labeled. Per kitchen chef, the left over cups were going to be discarded and tray of food was ready to be fried, but the stove was not on. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. Refrigerators and freezers were at required temperatures. Menu includes a wide variety of foods from all of the food groups. A board in the kitchen has written instructions for residents with food allergies and restricted diets. Other cleaning products and medication carts that were observed on the floor were supervised and/or locked carts. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. During the tour, residents were observed participating in group activities in common areas. There are activities written on a board specified for both assisted living and memory care engagement. Water temperatures measured at between 107.3 and 112.1 degrees (F) which is within acceptable range of 105 to 120 degrees F. Bathrooms have non-skid surfaces and grab bars at the toilet and showers. Additionally, LPA/ED noticed that garbage cans located in some resident's bathrooms do not have lids, LPA had a conversation with ED regarding the importance of providing garbage cans with well-fit covers (technical advisory issued). Continued on LIC809C... Continued from LIC809C... At approximately 11:14am, During the walk through of the six story building including assisted living and memory care, LPA/ED observed two resident's toilets were observed dirty, one located in the assisted living and one located in the memory care unit. Based on records review, the facility provided housekeeping schedule for the month of January 2026 for both areas, which indicates that room in assisted living area is scheduled to be cleaned two times per week (Sunday & Wednesday), unless that residents call to get assistance to clean their bathroom, the staff won't come to do so, which it was agreed and signed in their admission agreement. Regarding memory care area room, the housekeeping schedule revealed that the dirty toilet should have been cleaned today by 10am. According to ED, the housekeeping staff designated to memory care area called in sick this morning, and they were expecting another staff to come and cover for them. - At 11:30 AM, LPA conducted a file review of six staff and ten residents. Residents receiving hospice services had a care plan that appears to be accurate to services being provided. All residents' care plans seems to have a person-centered approach and they are updated. Medical assessments are current and included a description of any known behavioral expression. One out of six (S1) staff did not have a current CPR/1st aid on file. According to ED, staff recently was hired as a housekeeper and they are in the process of training S1 as caregiver (Technical advisory was issued). All staff have required training hours complete. Patricia Gustin, administrator certificate 7010392740 expires on 6/8/2027. Medications and medication records were reviewed. Annual fees are current. ED agrees to submit updated documents by 2/6/26: (LIC500) Personnel Report & Liability Insurance. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with ED/Administrator and copy of report was given.the state’s words, verbatim · CDSS document, Jan 23, 2026

The state marks this report as 8 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management visit to follow up on four self-incident report dated between 10/17/25 and 10/31/25 received by the department regarding falls and met with Patricia Gustin, Administrator. -On 10/17/25, incident received dated 10/12/25 staff noted about 1:00pm that resident (R1) was lying on the floor face down next to their bed. Apparently R1 was trying to walk using their walker and may have tripped over their own legs. R1 was observed confused and tearful, and complained of having pain in their head. Staff called 911 to transport R1 to the hospital for further evaluation, where they were diagnosed with a fractured hip. Responsible parties were notified. During today's visit, LPA learned that R1's responsible parties decided that R1 will be continuing to receive hospice services. -On 10/23/25, incident dated 10/18/25 reported that resident (R2) was observed by med-technician while walking by their residence at about 4:15pm when a "moaning" sound was heard coming from R2's apartment. Upon entering the apartment, R2 was noted to be standing in their living room and stated that they had fallen. There was a small cut noted above their right eyebrow, R2 was complaining of right knee pain and staff determined to call 911 to transport R2 for further evaluation, where they were diagnosed with bacterial urinary tract infection and closed non-displaced fracture of the right patella. Responsible parties were notified. Based on records review of R2's care plan dated 6/18/25 did not have any updates, because there were no change of condition to increase level of care. Continue on LIC809C... Continued from LIC809... The last two incident reports received on 10/23/25 and 10/31/25 30/25 involving resident (R3) regarding two falls. The first fall occurred on 10/21/25 at about 4:30pm, R3 pressed their pendant to alert staff about their fall from their wheelchair after "fallen asleep" and complained about head and back pain, the med-technician called 911 to transport R3 for further evaluation, resident's responsible parties were notified, imaging tests indicated that there were no injuries and R3 returned to the facility same day with no new orders. On 10/28/25 at about 10:20pm, R2 pressed their pendant after falling on their back in their kitchen. After staff assessed R3, it was determined to call 911 due to R3 was complaining of pain in their left hip, R3 was taken to the emergency room for further evaluation. Responsible parties were notified. Today, LPA was informed that R3 was diagnosed with hip fracture and they had surgery. The facility is currently in the process of obtaining updated physician report to update their care plan prior to R3's discharge back to the facility. No citations were issued during today's visit. Exit interview conducted with Administrator and copy of this report was given.the state’s words, verbatim · CDSS document, Nov 7, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management visit to follow up on SOC341 submitted to the department on 9/24/25 of suspected adult/elder financial abuse. LPA met with Marissa Vargas (BOM) and Patricia Gustin, Administrator. During this Case Management-Incident visit, LPA learned that the suspected abuser is an outside party and does not involve the facility nor their staff, and Licensing does not have jurisdiction over an outside party actions, but LPA confirmed that the pertinent parties including law enforcement and Ombudsman were cross reported. No deficiencies were observed or cited during today's case management visit. Exit interview was conducted and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Oct 2, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management visit to follow up on five self-incident report and one death report dated between 8/25/25 & 9/5/25 received by the department regarding falls in assisted living unit and met with Patricia Gustin, Administrator. Death report received on 8/27/25 indicates that on 8/25/25 the facility was notified by an outside party that resident (R1) passed away on 8/25/25 while in the hospital. Previously, on 8/12/25 the department received a self-incident report notifying CCL about R1's hospitalization on 8/7/25 due to altered mental status and weakness. During today's visit, LPA requested death certificate because R1 was not receiving hospice services at the time of their passing. According to death report, R1 had a diagnosis of cirrhosis of the liver, kidney failure and hypertensive heart disease. -On 8/29/25, incident received dated 8/20/25 resident (R2) called for assistance due to a fall after returning from the hospital, staff called 911 to transport R2 back to the hospital for increased falls and change of condition, responsible parties were notified. Today, LPA learned that R2 was transferred to a rehabilitation facility for treatment and there is no date for them to return to the facility. -On 8/29/25, incident dated 8/27/25 reported that resident (R3) was observed by med-technician while passing their medications that R3 was lying on the floor in a prone position with their walker positioned on their back. Continues on LIC809C... Continued from LIC809... R3 could not tell staff how the incident occurred, no injuries were noted, but staff determined to call 911 to transport R3 for further evaluation, responsible parties were notified. During today's visit, LPA reviewed R3's records including care plan updated on 8/30/25 that reflects the change of condition alerting staff of heightened risk for falling. -On 8/29/25, third incident report dated 8/27/25 indicates that resident (R4) pressed their call alert pendant at about 1:15pm, upon staff arrival, family member was present in their room and told staff that R4 had fallen while arising from off the toilet and reported that R4 struck their head, staff assessed R4, but there were no visible injuries noted and R4 denied any acute pain nor discomfort, and staff followed the facility protocol to call 911 to transport R4 to the hospital for further evaluation. R4 was diagnosed with a closed heads injury and no new orders were issued. R4 was placed on increased round checks to be monitored for any further effects from the fall. On 9/5/25 another incident report was submitted to CCL notifying that on 9/1/25 at approximate 3pm, staff entered R4's apartment and noticed that R4's recliner had tipped over, R4 was seated on the floor next to the chair, and they were unable to recall what happened, R4 appeared confused, staff assessed them and called 911. Emergency team determined that R4 had a very slow and irregular heartbeat and they transport them to the emergency room for further assessment. Responsible parties were notified. R4 returned to the community same day and have been placed on alerting chart. Today, LPA was provided with updated care plan dated 8/27/25 including increased assistance needed in the bathroom to reduce fall risk considering a review of current medications with their physician to reduce the possibility of side effects. The last incident report received on 9/2/25 it was dated 8/30/25 indicating that resident (R5) was noticed by staff wandering in the hallways which was unusual for the resident. R5 could not remember when was the last time that they ate nor even if they had a recent bowel movement. Staff assessed the resident and did not observe any signs of injury, but they called 911 and resident was taken to the emergency room for further evaluation. Responsible parties were notified. LPA was informed that the facility is currently in the process of obtaining updated physician to update their care plan. No citations were issued during today's visit. Exit interview conducted with Administrator and copy of this report was given.the state’s words, verbatim · CDSS document, Sep 9, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management inspection of this licensed senior care facility and met with Patricia Gustin, Administrator. The purpose of this case management inspection is to follow up on uncleared deficiencies cited during complaint investigation #21-AS-20250602090022 on 7/17/2025. As of today's inspection citations §1569.269 (a)(6) with POC date 7/18/2025, 87411(a) with POC date 7/18/2025 and 87625(b)(3) with POC 7/18/2025 are outstanding. LPA contacted Administrator on two occasions to follow up on POC's. During today's visit, Administrator provided proof of correction for citations: -§1569.269 (a)(6) - written plan ensuring that the facility is following up on resident's needs timely. - 87411(a) - staffing schedule for the months of July and August 2025 as follow: one med-technician, two care staff for assisted living (AL) and three care staff for memory care (MC) for morning and afternoon shift; one med-technician, one care staff (AL) and two care staff (MC) for night shift coverage according to the amount of residents in care of 19-20 residents in MC and AL mainly resident's care needs are based on medication management. Written plan obtained ensures staffing is adequate to meet residents needs timely. -87625(b)(3) - staffing schedule for the months of July and August 2025 reflects additional hired staffing to assist residents with incontinent care needs timely. Deficiencies cleared from 7/17/2025. Copies of documents obtained. Exit interview conducted with Administrator and copy of this report was given.the state’s words, verbatim · CDSS document, Aug 13, 2025

Allegation investigated: -Staff not keeping an accurate record of resident’s payments.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver the findings regarding the above allegation and met with Administrator Patricia Gustin. The Department received an allegation of staff not keeping an accurate record of residents’ payments. Per Reporting Party when resident (R1) receives a bill for the month, R1 writes a check and walk it down to facility bookkeeper (S1) timely, but no receipt or acknowledgement is given to R1. However, the following month R1 would receive a late fee of $250.00, when R1 inquiries about it with S1 who instructs R1 to ignore it. Last month (May 2025), R1’s bill was $6,784.00 then receives a bill the following month for $13,985.52, and the responsible party doesn’t believe the facility is keeping an accurate record of R1’s payments resulting in late fees continuing to be added along with additional fees. Based on confidential interviews conducted with S1, last month (May 2025), there was a glitch in the system resulting in the rejection of checks submitted in-person and the system automatically generates by the 10th day of each month outstanding fees in the amount of $250 for those residents who do not submit a payment prior to the 10th of the month. Continue on LIC9099C... Unsubstantiated Continued from LIC9099... S1 was made aware of the system been down, so S1 notified R1 to ignore the late fees charges because the charges for late fees were going to be removed. Regarding additional fees, R1 was referred to the clinical department to address their concerns around them, because those charges are named “PSR”, which are based on R1’s needs, which fluctuates each month depending on different levels of care provided that are not determined by S1, the facility has a clinical department that evaluates resident’s level of care. Based on records review, the facility provided an account history report from 1/8/25 through the present are consistent and supporting the agreed amount of $6784 with late fees reversal in the amount of $250. A finding that the complaint allegation of staff not keeping an accurate record of resident’s payments is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 21-AS-20250603083138

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management visit to follow up on a self-incident report dated 4/7/25 received by Community Care Licensing (CCL) regarding a medication error and met with Daniela Oseguera, Business Office Manager (BOM). Per incident report: "On 4/4/25 at about 10am the staff (S1) telephoned pharmacy to obtain clarification around an order written by resident's (R1) neurologist to input it into the facility electronic medication records (MARs). It was reviewed that it was populating on the MARs was on 3/20/25 Namenda 5mg once per day per one week and on 3/21/25 Namenda 10mg 2x/day was also started, which then overlapped with the other Namenda dosage and continued to overlap until the morning on 3/30/25. Namenda 5mg 2x/day for one week began on 3/28/25 when the 1x/day dosing was completed. No further Namenda was given as it had run out and a supply reorder was pending with the pharmacy. Responsible parties were notified. R1 was placed on alert charting and monitored for any side effects of the medication overdosing, but R1 has not complained about any discomfort and no further incidents have occurred. According to incident report, R1's care plan has been updated and medication technicians will be re-trained on checking all resident's medications orders prior to begin assisting them with their medications". During today's visit, LPA requested R1's updated care plan, physician's report, medication administration records and staff training records. Per BOM, the facility agreed to submit requested documents to by not later than 4/22/25. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. **Civil penalty assessed for repeat violation within 12 months** Exit interview conducted with BOM and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 22, 2025

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met by: Based on self-incident report the licensee did not comply with section above by not properly assisting R1 with their prescribed medication Namenta 5mg and 10mg resulting in overdosing resident in care, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 21, 2025

Plan of correction: Facility to review all resident's medication and will contact an outside vendor to conduct medication training with all med techs. Facility to submit proof of training to CCL by POC due date. **civil penaltiy assessed for repeat violation within 12 months**

Allegation investigated: Staff does not respond to pendant call system timely Staff left resident in soiled incontinence briefs for an extended period of time

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility deliver complaint findings on the above allegation. LPA met with Administrator Robert Alvarado. Complaint alleges staff does not respond to pendant call system timely. Complaint alleges that facility is short-staffed and so do not provide timely care. Per California Title 22, RCFEs do not have staffing ratios and staffing is dependant on residents' needs, so a determination that a facility is short-staff is determined by whether or not residents' needs are being met. At this facility, the method by which residents alert staff that they need help with care or require assistance is through a pendant call button system. Each resident is assigned a pendant. When a resident needs help or assistance with a care need, they push the button on their pendant in order to alert staff to their need. During investigation, LPA review of pendant log shows that between 2/9/25 and 2/13/25 residents pushed their pendant call buttons 192 times. Continued on 9099C... Substantiated Continued from 9099... Of those 192 times, the wait time until someone arrived to help were: · 41 waited between 15 minutes and 30 minutes, · 17 waited between 30 minutes and 44 minutes, and · 42 never got a response Additionally, on average, the residents pressed their pendant call button between 4-9 times on each occurrence of pressing it. Administrator advised they are actively working with staff to bring response times down and address the needs of residents in a timely manner. Based on LPA interview and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Complaint alleges staff left resident in soiled incontinence briefs for an extended period of time. During investigation, LPA interviewed eight [8] residents. Of the eight residents interviewed, two [2] residents wear incontinence briefs and require staff assistance to manage and change their briefs. Both residents report that they have have to wait long periods of time before staff arrives to change their briefs. Both residents report that on least two occasions they waited over an hour for staff to arrive, after they notified staff they needed to be changed. Based on LPA interview, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 5, 2025 · control 21-AS-20250127104841

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269 · Plan of correction due date: Mar 12, 2025

§1569.269 Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by: Based on LPA record review of facility's pendant call button system log, the licensee did not comply with the section cited above in that between 2/9/25 and 2/13/25 residents pushed their pendant call button at least 192 times. Of those 192 times at least 42 never got a response, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 5, 2025

Plan of correction: Facility to ensure that pendant call button system is in good repair and operational, staff is sufficient to answer calls in a timely manner, when residents are in need of assistance. Facility to submit three day pendant call button system log to CCL showing all calls answered within a timely manner by plan of correction due date. Admin agrees that within 10-12 minutes can be defined as within a timely manner.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Mar 26, 2025

87625 Managed Incontinence (b) In addition to Section 87611... the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met by licensee as evidenced by: Based on LPA interviews of facility's pendant call button system log, the licensee did not comply with the section cited above in that two [2] out of [2] residents that require staff assistance to manage and change their briefs waited long periods of time before staff arrived to change them, on least two occasions they waited over an hour, hich poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 5, 2025

Plan of correction: Facility to conduct resident rights training for all care staff providing direct care to residents. Training to be at least one hour in duration and completed no later than 3/26/25.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct the continuation of the Annual inspection conducted on 2/19/25 and was greeted by Administrator Robert Alvarado. On 2/19/25 LPA conducted annual inspection and completed the annual inspection, However, LPA had computer printing errors which caused the 809D pages not to print the respective deficient practice statement language nor the respective plan of correction language. LPA has amended all related 809D pages to now include the completed respective deficient practice statement language and the respective plan of correction language. LPA reviewed with Admin the respective 809D pages and plans of correction. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 5, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Christi Coppo and Ali Deniz arrived unannounced to conduct a required Annual inspection and was greeted by receptionist. Administrator Robert Alvarado arrived later. Facility contact information was reviewed. At approximately 9:45am LPAs toured the building and grounds. LPAs toured main kitchen and found it to be clean and organized. LPAs observed speed rack of sandwiches and salads that were not covered with plastic. LPAs and Director of Food Services (DFS) discussed getting a cover/tarp for the speed rack. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner but many open items not covered with tight fitting lid, such as ice cream and veggie burger patties. LPAs and DFS discussed ensuring all items that are open or pre-made must be wrapped or covered with a lid. LPAs toured emergency food and water supply room, facility has supply within regulation. LPAs measured temperature of water in main kitchen to be 148 degrees F but did not have a caution hot water sign above sink; however, a caution sign was observed on ancillary sink in kitchen. LPAs and DFS discussed putting a caution sign above main sink. LPAs measured temperature of water in kitchen by Activity Director's office to be 109 degrees F, which is within the allowable range of 105 to 120 degrees F Fire extinguishers were last inspected both on 2/12/24 and 4/10/24. Fire extinguishers last inspected 2/12/24 were charged and arrow showing in the green. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired and serviced by a vendor. Director of Maintenance (DOM) explained to LPAs that a vendor came to the facility that DOM thought was the vendor that served the fire panel but DOM was mistaken and company tampered with fire panel box such that it was rendered to not working properly. Vendor that actually does service came on 2/11/25 and the Automatic Sprinkler System failed inspection. Deficiencies found were listed as: riser pressure gauges are over 5 years old and need to be replaced, four Continued on 809C... Continued from 809... in total; the water flow switch for the 1st and 2nd floor sprinklers didn't activate into alarm when tested. A purchase order was placed for the risers and another 5 year inspection will be conducted with a date yet to be determined (deficiency cited, see 809D). Facility’s last quarterly disaster drill was conducted 1/29/25. Facility has a backup generator for use during a power outage. LPAs toured Memory Care unit and found the unit to be at a comfortable temperature with residents engaged in activity or watching T.V. LPAs measured temperature of water in Memory Care kitchen to be 110.4 degrees F which is within the allowable range of 105 to 120 degrees F. LPAs observed trash, food scraps and pieces of discarded food items, cup with black substance and white substance, and used paper towels to be discarded and piled up underneath sink (deficiency cited, see 809D). LPA observed notable urine smell coming from room next Sauna room in Memory Care (deficiency cited, see 809D). At approximately 11:00am LPAs conducted review of 7 staff records. Staff (S1, S2, S3, and S4) did not have the total required hours of training completed (deficiency cited, see 809D). Seven staff (S5, S6, S7, S8, S9, S10, and S11) were listed on staff roster but did not have fingerprint clearance (deficiency cited, see 809D and civil penalty assessed). LPA, Admin, and Business Operations Manager Danielle Oseguera (BOM) discussed those staff not having fingerprint clearance. BOM concerned as she remembers waiting for the clearance before putting them on the floor; however per Gaurdian S5-S11 do not have any applications and do not have clearance. Additionally two [2] staff listed on staff roster were not associated to the facility. LPA and Admin discussed staff not present on Guardian roster that were listed as current staff on facility roster. Admin advised that for some reason these employees are listed as separated in Guardian but are not actually separated. Admin and BOM showed LPA on Guardian site the separation dates of this staff. Admin agrees to go back in and re-associate each one. At approximately 12:00pm LPAs conducted a review of 7 resident records. All documentation present. Continued on 809C(2)... Continued from 809C... At approximately 3:00pm LPAs and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies At approximately 4:15pm LPA walked facility grounds. No obstructions found. Evacuation chair present in stairwell. Robert Alvarado Administrator Certificate 7017266740 is currently expired. LPA called Administrator Certification Bureau and was told by the representative that the certificate was in renewal status but was subsequently removed from pending status due to not having enough training hours completed and required forms not submitted (deficiency cited, see 809D). Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with BOM and a copy of this report was given. ***Due to computer problems citations and civil penalties not printing. LPA obtained signatures for 809 and 809C pages and will return at a later date to complete issuing of citations and civil penalties as part of annual inspection.***the state’s words, verbatim · CDSS document, Feb 19, 2025

The state marks this report as 25 pages; the online copy we transcribed has 10. You can request the full file from the county licensing office.

Allegation investigated: Facility did not provide resident's authorized representative with the correct refund Facility billed resident's authorized representative after resident's departure from facility for incontinence items

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings for the above allegations. LPA met with Robert Alvarado, Administrator. Compliant alleges facility did not provide resident's authorized representative with the correct refund. Per R1’s admission agreement, the agreement will terminate upon death. The estate will be responsible for all outstanding fees due at the time of death until personal property is removed from the Brookdale apartment, within 15 days after the personal property is removed from the apartment, R1’s estate will receive a refund of any fees paid in advance. LPA review of Brookdale’s account history for R1 shows that on 7/3/24 R1’s responsible party paid the full amount of rent covering the period of 7/1/24-7/31/24. During investigation, LPA received proof of the removal of R1’s personal belongings on 7/10/24 as evidenced by the paid invoice from removal company. R1 passed away on 7/13/24. Continued on 9099C... Substantiated Continued from 9099... Therefore, the refund provided to R1’s responsible party should have been from 7/11/24-7/31/24, or at least 7/14/24-7/31/24. However, per review of R1’s account history report, the refund issued was for the period covering 7/21/24-7/31/24. So, based on LPA’s record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. *Per LPA interview with Admin additional 7 rent days in question has been refunded to the responsible party as of 1/7/25.** Complaint alleges facility billed resident's authorized representative after resident's departure from facility for incontinence items. On 5/27/24 R1 was hospitalized and subsequently never returned to Brookdale. During investigation, LPA reviewed R1’s account history report. Review shows that on 7/16/24 R1’s responsible party was billed three [3] charges of $102.50 for the dates of 6/15/24, 7/2/24, and 7/16/24. Per LPA interview with Administrator, these billings were in error and on 1/2/25 Brookdale refunded R1’s responsible party $307.50 for the aforementioned “personal solutions” fees. So, based on LPA’s record review and interview the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given. Continued from 9099A... However, neither the Apria centralized billing department nor the local branch had a signed SRA on file, nor could either provide the serial number of the wheelchair dropped off on 5/26/24. Facility claims that Apria never dropped off any wheelchair, to the best of their knowledge. Apria retrieved a wheelchair from facility as of 11/19/24. However, per the Apria local branch customer service representative, the wheelchair returned may not be the property of Apria as no serial number is present. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 21-AS-20241114141725

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Jan 16, 2025

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met by licensee as evidenced by: Facility did not provide resident's authorized representative with the correct refund and facility billed resident's authorized representative after resident's departure from facility for incontinence items, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Facility to submit LIC9098 self-certifying they will, to the best of their ability, mitigate billing errors by reviewing all billing statements before issuing to residents and/or their responsible parties, by plan of correction due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management - Incident visit. LPA met with Robert Alvarado, Administrator. On 12/23/24 facility submitted to CCL an Incident Report indicating that on 12/21/24 facility received reporting that resident (R1) was missing $500-$600 dollars in cash from their wallet. R1 reported to facility that they had last seen their money in their wallet when leaving the hospital on 12/19/24. R1 also reported the missing money to their family at an unknown date and time. Per Incident Report submitted, upon receiving the report of missing money, the acting Admin was notified immediately by facility receptionist. R1's room was subsequently searched by Resident Care Coordinator (RCC); however, no money was recovered/found. Facility then notified Santa Rosa Police Department (SRPD) of the missing money and the issued case number was provided to CCL. The local ombudsman was also notified of the incident on 12/21/24. Additionally, facility RCC self reported the incident on a SOC341 to CCL on 12/23/24. No deficiencies cited for this incident. On 1/6/25 CCL received an Incident Report regarding a medication error for resident (R2). R2 was given another resident's medications: Acyclovir, Metformin, and Pravastatin. Facility notified Emergency Medical Services (EMS) and R2 was taken to the hospital for evaluation. All required partied were notified by facility. Continued on 809C... Continued from 809... Per Incident Report, R2 was diagnosed with non-toxic accidental ingestion and returned to the facility the same day. Resident placed on 72 hour alert charting (deficiency cited, see 809D). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jan 9, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 17, 2025

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met by licensee in that another resident's medication was administered to R2, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Facility to conduct medication training and administer written medication test (as outlined in HSC 1569.69(a)(5)) with staff (S1), Med Tech responsible for the error. Facility to submit proof of training to CCL by plan of correction due date. **civil penaltiy assessed for repeat violation within 12 months**

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to amend 9009D issued on 12/27/24. LPA met with Robert Alvarado, Administrator. On 12/27/24 LPA delivered complaint findings for complaint 21-AS-20241217154914. During this visit it was evidenced that an Incident Report relating to the substantiated allegation of the complaint was not received by CCL. Therefore, a citation was issued on the 9099D for deficiency of regulation 87211(a)(1)(D). However, this deficiency should not have been cited on a 9099D, rather it should have been cited on an 809D and 809 Case Management- deficiencies. The 9099D has been amended and the deficiency is now being cited on today’s case management-deficiencies (see 809D). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jan 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jan 10, 2025

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports...: (1) A written report shall be submitted to the licensing agency...for the resident within seven days of the occurrence of any of the events...(D) Any incident which threatens the welfare, safety or health of any resident...This requirement was not met by licensee as evidenced by: CCL did not receive an Incident Report for R1's medication error, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Facility to submit LIC9098 self-certifying that facility will submit to CCL an Incident Report in compliance with regulation, by plan of correction due date. (Facility has already satisfied plan of correction, deficiency cleared) **citation is being issued as a result of amendment of 9099D of complaint 21-AS-20241217154914**

Allegation investigated: Licensee failed to administer medications as prescribed by physician

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to open an investigation into the above allegations. LPA met with Robert Alvarado, Administrator. Complaint alleges licensee failed to administer medications as prescribed by physician During investigation, LPA reviewed resident's (R1) physician's orders, electronic MAR (eMAR), and Medication Administration Audit report. R1's medication list as of 11/25/24 listed Sevelamer Carbonate 800mg 1 tablet 3 times per day. R1 was discharged from a hospital stay on 12/6/24. LPA review of 12/6/24 discharge papers have medication orders for Sevelamer 800mg 1 tablet 3 times per day. Continued on 9099C... Substantiated Continued from 9099... However, review of facility's Medication Administration Audit report and eMAR system indicates R1 had been receiving Sevelamer Carbonate 800mg 3 tablets 3 times per day from 11/27/24 through 12/16/24. On 12/17/24 R1's Sevelamer dosing was changed to 800mg 1 tablet 3 times per day. LPA review of facility's eMAR shows that on 12/16/24 the Sevelamer Carbonate 800mg 3 tablets 3 times per day was discontinued. However, CCL was never informed of the medication error and has never received an Incident report for the medication error (deficiency cited, see 9099D). LPA's review of R1's discharge papers, medications list of current prescriptions, and facility's eMAR all show that R1 received the incorrect dose of Sevelamar between the dates of 11/27/24 and 12/16/24. Therefore, based on LPA's record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was giventhe state’s words, verbatim · CDSS document, Dec 27, 2024 · control 21-AS-20241217154914

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

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met by licensee as evidenced by: Based on LPA record review, R1 received the incorrect dosing of Sevelamer from 11/27/24 through 12/16/24, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 27, 2024

Plan of correction: Facility has discontinued incorrect prescription dose for R1 and implemented dosing that matches physician's orders for R1. Facility to submit plan to conduct training for all Med Techs on ensuring the reisdent's current medications on eMAR match respective residents' physician's orders by plan of correction due date. Proof of training to be submitted to CCL no later than 1/3/25

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to open a compliant investigation at this facility. Upon LPA arrival LPA was informed that there was not an Administrator present at the facility. The Administrator of record, Kelly Ording is no longer employed by Brookdale but LPA was advised there is an Interim Administrator (IA), Jannluy Trevino. LPA reached IA by phone to advise of LPA's visit to facility and to inquire as to the status of an Administrator. IA advised that there are candidates being considered. IA advised that they work remotely as they live out of state, but that they are also present in-person at the facility. LPA contacted CCL Santa Rosa Regional Office (RO) to confirm IA has an active current Administrator certificate. All three Administrator certificate databases were searched: Active certificates, Pending initial certificates, and Pending renewal certificates, IA was not found. Additionally, fingerprint clearance and association to the facility could not be confirmed. Per RO, IA does not show as having fingerprint clearance and is not currently present on the facility roster (deficiency cited, see 809D **civil penalty assessed**). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Sales Manager. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Sales Manager and a copy of this report was given.the state’s words, verbatim · CDSS document, Nov 15, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(d) · Plan of correction due date: Nov 18, 2024

Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted. Licensee did not meet this requirement as evidenced by; interim administrator does not have fingerprint clearance. This poses an immediate Health, safety or personal rights risk to residents*civil penalty assessed*the state’s words, verbatim · CDSS document, Nov 15, 2024

Plan of correction: Interim Administrator to submit LIC9098 by plan of correction due date, indicating they will not be present or working at the facility, and will not return to the facility until after they have obtained fingerprint clearance, is associated to facility, and submited proof of required clearance and association to CCL.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(a) · Plan of correction due date: Nov 18, 2024

Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator. Licensee did not meet this requirement as evidenced by: interim Administrator does not have an actively current Administrator certificate. This poses an immediate Health, safety or personal rights risk to residentsthe state’s words, verbatim · CDSS document, Nov 15, 2024

Plan of correction: Facility to submit written plan indicating plan for implementation and start date of qualified and certified administrator. Facility to submit all required documents for change of Adminstrator as well. Plan to be submitted to CCL by plan of correction due date of 11/18/2024

Type of visit: Case Management - Incident

At approximately 1:00pm LPA Christi Coppo and arrived unannounced to conduct a case management regarding Incident Report received on 8/9/2024. On 8/9/2024 facility submitted to CCL Incident Report indicating resident (R1) had eloped. R1 has a diagnosis of dementia and resides in Memory Care. R1 had been recently moved from AL to Memory Care and was experiencing some confusion. On 8/8/2024 resident had been experiencing some restlessness and stopped to rest in a chair outside another resident's room. R1 had fallen asleep in the chair; rather than wake R1, staff let them rest and checked on them as staff performed their shift duties. At approximately 3:15am, NOC caregiver (S1) noticed that the resident was no longer in the chair. S1 went to check R1's bedroom to make sure they weren't in their room. S1 then alerted Resident Care Coordinator (RCC) (S2) that R1 was unaccounted for. RCC then notified Health and Wellness Director (HWD). While performing checks and searching, police notified the facility that R1 had been located and that an officer was with R1 at a nearby gas station. NOC Med Tech (S3) retrieved R1 from police and escorted them back to the facility. At approximately 3:30am, R1 returned to the facility. HWD performed a thorough head to toe examination of R1 and found resident to be sleepy, but without injury. R1's care plan was updated and increased safety checks were performed every 30 minutes. All required parties were notified. Upon R1's return, facility immediately conducted investigation of elopement. Investigation found that the north egress door had not latched completely after staff had exited, so the alarm was not engaged. This is the reason for the alarm not sounding when R1 opened it. Maintenance director and Admin conducted staff training and performed an elopement drill which included a demonstration of facility egress doors and alarms. Procedures for locating and searching for residents were also part of the drill. Training log and drill attendance form provided to LPA at time of case management. Additionally, facility implemented census check and egress door check as part of shift change procedures; checks are completed every shift change. Continued on 809C... Continued from 809... Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Aug 13, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4) · Plan of correction due date: Aug 20, 2024

87705 Care of Persons with Dementia (c)(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidenced by: incident of resident elopment, which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2024

Plan of correction: Facility immediately conducted elopement training with staff. Training record provided to LPA. Additionally, Adminstrator has implemented census check and egress door check as part of shift change procedure. Deficiency cleared.

Allegation investigated: Facility did not notify responsible party of resident's change of condition Facility did not seek timely medical for resident in care

At approximately 1:45pm, Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegations and met with Heidi Gallagher, Director of Health and Wellness (DHW). Temporary Administrator Alex Baiasu contacted by phone and gave permission for DHW to sign. During investigation, the Department conducted interviews and reviewed documents including, but not limited to, medical records and facility records. Facility did not notify responsible party of resident's change of condition, Facility did not seek timely medical for resident in care - Complaint alleges that prior to their passing, resident, R1 had stopped eating for 5 days and had been refusing medications as well but the responsible party was not notified, and facility did not seek timely medical care. Continued on 9099C... Unsubstantiated Continued from 9099... Progress notes reviewed as part of the investigation show that resident was eating less food and refusing medications due to the pills being too large to swallow. Resident’s doctor was faxed to request an order for pill crushing. Per staff interviews, resident had been on a decline for approximately one year and showed signs of a low appetite in addition to refusing medication. Due to resident already declining, there was no identified change of condition which warranted further medical intervention. Per evidence obtained during investigation, on the day that resident passed away they requested Tylenol due to complaints of a headache. Staff attempted to transfer resident to their wheelchair when they became unresponsive. Resident was placed back in bed and 911 was called. Resident passed away at the facility due to Major Neurocognitive Disorder (Dementia), Type unspecified without Behavioral Disturbances. Other significant factors in the case of death were listed as, Atrial Fibrillation, moderate protein calorie malnutrition, diastolic heart failure, chronic community acquired pneumonia. Based on record review and inconsistent statements provided during interviews, CCL is unable to determine if violations occurred. Therefore, the allegations are Unsubstantiated. A finding that the complaint is Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.the state’s words, verbatim · CDSS document, Jul 11, 2024 · control 21-AS-20230921102025

Allegation investigated: Staff are not following a resident's needs and services plan

At approximately 8:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with Health and Wellness Director, Heidi Gallagher, and Interim Executive Director, Alex Baiasu. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff are not following a resident’s needs and services plan.” Complainant alleged that facility did not follow Resident 1 (R1’s) care plan by not changing or rotating them enough and stated that facility staff were to change and rotate R1 every two hours. Review of R1’s file indicated that they were admitted to Hospice on 12/26/2023. Review of R1’s Personal Service Plan, dated 01/04/2024, stated R1 was to be checked and changed approximately every 3 to 4 hours. Continued on LIC9099C Unsubstantiated Continued from LIC9099 LPA conducted interviews with involved parties and received inconsistent statements. Interviews with facility staff stated that they would come in to change and rotate R1 but that R1’s family would refuse to have care done. Interviews conducted with R1’s Hospice Provider stated that they saw facility staff come into R1’s room to see if R1 needed care services. Per Hospice Provider, they did not witness facility staff provide care services during their visits and believed that facility staff would wait until Hospice left to change and rotate R1. Per R1’s Hospice Provider, they did not have concerns regarding the care being provided by the facility as R1’s pressure injuries showed improvement. Review of R1’s records dated 01/18/2024, showed that R1’s stage 3 pressure injuries had improved. Review of Hospice Collaboration notes dated 01/05/2024 and 01/09/2024 corroborated that R1’s pressure injuries were improving. Review of Facility Shift Reports dated 12/14/2023, 12/17/2023, 12/21/2023, 01/01/2024, 01/02/2024, 01/03/2024, 01/10/2024, 01/11/2024, 01/14/2024, 01/17/2024, 01/18/2024, and 01/19/2024 showed when R1 was checked, changed and rotated, and when family would refuse care. Interview conducted with R1’s Responsible Party stated that there were a few days when they observed that R1 was not checked by facility staff for 8 to 16 hours, and that they changed and rotated R1 because facility staff did not do it. Per interview, care services were never refused. R1’s Responsible Party also stated that they observed facility staff come in more frequently to check on R1. Based on record review and inconsistent statements provided during interviews, the LPA is unable to determine if violations occurred. Therefore, the allegation is Unsubstantiated. A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Health and Wellness Director, and Interim Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 11, 2024 · control 21-AS-20240118085437

Type of visit: Case Management - Incident

At approximately 1:30pm Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a case management pertaining to Incident Reports received by CCL on 2/15/2024 and 2/20/2024, respectively. Upon LPA arrival LPA learned that there is not a current Administrator or Executive Director. LPA was advised that a corporate representative is here in the interim of hiring a replacement for Katelyn Ledesma. The corporate representative is Operations Specialist Dimple Kamdar and their Administrator Certificate is # 6027505740, expired 7/2021; however, they are currently in renewal status as of 8/22/2023. LPA discussed with Operations Specialist the need for corporate to have an Administrator at all times. Per Title 22 regulation 87405(a) All facilities shall have a qualified and currently certified administrator. LPA advised Kamdar, should an Administrator quit or be released from duty, CCL must be notified within 30 days. Also, once the replacement candidate is chosen, the required documentation must be sent to CCL for review and approval. LPA will follow up and discuss the requirements with the Brookdale corporate representative. As pertains to Incident Report received by CCL on 2/15/2024, on 2/7/2024 resident (R1) was sent to Kaiser and returned to facility on 2/13/2024 at 1:00pm. R1 was placed on hospice while in the hospital. R1 is their own responsible party. R1 returned to facility with their family member who was using combative language with staff and using profane language. Family member was refusing to let any staff in R1's room, claiming they will take care of administering R1's pain management medications per R1's hospice care plan. Facility Health and Wellness Director (HWD) was immediately informed by attending med tech as to the aforementioned. Per LPA review of charting notes, a check was performed by staff every hour on the hour in order to gain access to R1 and attend to their care needs. At each instance staff were met with combative and profane language by R1's family member. HWD worked with hospice nurse to administer R1's pain management medications, despite the effort of R1's family member to deny staff access to R1. Hospice nurse was successful in administering pain management medication. Between the hours of 1:00pm on 2/13/2024 and 9:30pm on 2/14/2024 staff attempted to provide care to R1 ten times, per LPA review of charting notes. R1 passed on 2/14/2024 at approximately 10:15pm. Continued on 809C... Continued from 809... LPA discussed with Operations Manager and HWD implementing a plan going forward on how they will address situations in which staff providing care to residents is denied or blocked. Facility to implement a plan to maintain compliance with Title 22 regulation 87411(a) Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Facility to submit written plan implemented in either the Plan Of Operation, the residents' Admission Agreements, or residents' Care Plans and submitted to CCL no later than 4/5/2024. As pertains to Incident Report received 2/20/2024, on 2/8/2024 resident (R2) was taken to a routine podiatrist appointment at which the podiatrist suspected that R2 had osteomyelitis and needed to have EMS transport to ER for surgery. Per incident report, resident was transported back to the facility and then EMS services were called to transport R2 for surgery. R2 was returned to facility at the refusal of the podiatrist to call EMS services, per HWD this is not the policy of the facility. Per LPA review of charting notes, care plan, LIC602, and pre-placement appraisal R2's need for care related to feet not present. R2's preplacement appraisal indicated one amputated toe; per LPA interview with HWD R2 was admitted with contracted toes. LPA discussed with Kamdar adding additional observation of R2's feet to care plan in order to ensure that proper attention and care is given and ensure resident's feet are being properly assessed. Any potential issues need to be addressed in a timely manner. All residents' care needs are to be addressed in their appraisal and/or care plan. No deficiencies cited. Exit interview conducted with Operations Specialist and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 19, 2024

Type of visit: Case Management - Annual Continuation

At approximately 11:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Resident Services Coordinator, Marissa Vargas, and Business Office Manager, Danielle Oseguera. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for 40 ambulatory, 100 non-ambulatory, which includes 20 bedridden for a total capacity of 140 residents. Facility has an approved hospice waiver for 15 individuals. Upon arrival, LPA was informed that there were currently 82 residents in care. LPA was also informed that there were 7 direct care staff members on-site. LPA reviewed 5 staff files and 4 resident medications. Staff files were found to be well organized and thorough. During file review, LPA observed that two staff members did not have current first aid certificates. (See Technical Violation, LIC9102, H&S Code 1569.618(c)(3)). During medication review, LPA observed that one resident had three routine medications that were not documented or centrally stored as required (this deficiency has been cited, see LIC809D, 87465(h)(6)). Facility's last fire/disaster drill was conducted January 2024. Facility's smoke detectors and sprinkler system were last inspected February 2024. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, LIC9102 (Technical Violation), Plan of Corrections, and Appeal Rights discussed and provided to Business Office Director and Resident Care Coordinator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 15, 2024

Type of visit: Required - 1 Year

At approximately 11:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Resident Services Coordinator, Marissa Vargas, and Health and Wellness Director, Heidi Gallagher. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for 40 ambulatory, 100 non-ambulatory, which includes 20 bedridden for a total capacity of 140 residents. Facility has an approved hospice waiver for 15 individuals. Upon arrival, LPA was informed that there were currently 80 residents in care. LPA was also informed that there were 6 direct care staff members on-site. At approximately 12:00PM, LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 12:15PM, LPA conducted a walk-though of the facility and observed the following: Facility is a 6 story building for Assisted Living and Memory Care. Facility's Memory Care is allocated to one floor. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 10 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected February 2023. At approximately 1:15PM, LPA reviewed a sample size of 8 resident files. All files were found to be well organized, thorough, and contained the required documentation. No Deficiencies Cited during visit. LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. Exit interview conducted. Copy of report discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 26, 2024

Allegation investigated: Staff did not repair a resident's pull cord device Staff did not respond timely to a resident's alerts

At approximately 10:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Business Office Manager, Danielle Oseguera. During the course of the investigation, LPA requested and reviewed documents, and conducted interviews. There are allegations that staff did not repair a resident's pull cord device and that staff do not respond timely to a resident's alerts. Based on record review and staff interviews, LPA confirmed that some resident pull cords are in need of repair/replacing and were not operable when tested by facility staff. Staff interviews conducted stated that the facility's call system occasionally does not work. Staff interviews stated that sometimes residents will call for assistance, but the call does not always show up on the care staff's pagers. Care staff have started to check the facility's computer to see if any calls are appearing since it does not always appear on their pagers. Continued on LIC9099C Substantiated Continued from LIC9099 Review of facility call log records indicated that multiple residents have called for assistance and did not receive a response. Records also indicated that multiple residents have waited 30 minutes or longer for assistance. Based on record review and staff interviews, these allegations are Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An Immediate Civil Penalty in the total amount of $500 is being assessed for repeat violations of Regulation 87411(a) and 87303(i) more than once in a 12 month period. (See LIC421IM)** Exit interview conducted. Plan of Corrections reviewed and developed with Business Office Director. Copy of report, LIC9099D, LIC421IM, Plan of Corrections, and Appeal Rights discussed and provided to Business Office Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 8, 2024 · control 21-AS-20231212163014

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jan 9, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: based on record review, the Licensee did not comply with the section cited above. Multiple call records showed that residents waited for at least 30 minutes or longer to receive assistance from care staff or did not receive assistance at all. This poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2024

Plan of correction: Licensee to submit a written plan outlining how resident care needs will be met when all or part of the facility's signal system is inoperable. Plan to be submitted by POC due date, 01/09/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i) · Plan of correction due date: Jan 9, 2024

87303 Maintenance&Operation (i) Facilities shall have signal systems...:(1)All facilities licensed for 16 or more...(A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce... signal...loud enough to summon staff. This requirement was not met as evidenced by: based record review and interviews conducted, Licensee did not comply with section cited above. Facility call cords need replacement and pagers don't always indicate resident calls. This poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2024

Plan of correction: Licensee to submit a written plan/protocol on how facility will ensure that their signal system equipment remains operable. Facility to also outline how resident care will be maintained and responded to timely by care staff. Plan/protocol to be submitted by POC due date of 01/09/2024. Licensee to conduct In-service training on facility plan/policy with all care staff. In-service Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures by POC due date of 01/18/2024.

Allegation investigated: Facility failed to respond to resident's pendant/call button/phone calls

Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegation and met with Robert Alvarado. Facility failed to respond to resident's pendant/call button/phone calls - Complaint alleges that a resident pushed their pendant but staff did not respond. LPA confirmed through document review that there have been multiple occasions where residents' pendants were not responded to. A Civil Penalty in the amount of $250 is being assessed for repeaiting regulation 87411(a) more than once in a 12 month period. Based on record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Substantiatedthe state’s words, verbatim · CDSS document, Nov 30, 2023 · control 21-AS-20231030165241

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 1, 2023

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Licensee did not meet this requirement based on document review confirming that the call bells for multiple residents was not responded to by staff. This is an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Nov 30, 2023

Plan of correction: Based on conversation with facility management, facility has provided and plans to provide additional training to staff regarding responding to the needs of residents. Deficiency is cleared.

Allegation investigated: Facility staff did not ensure that resident's call button is accessible Facility is not meeting the needs of resident in care

Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegation and met with Robert Alvarado. Facility staff did not ensure that resident's call button is accessible - Complaint alleges that pull cord in the resident's room is tucked behind their bed so resident does not see it. While conducting a walk through of the facility, LPA observed that the pull cord at the head of the bed for noted resident was pulled forward and laying on resident's bed. Continued on LIC9099C Unsubstantiated Continued from LIC9099 Facility is not meeting the needs of resident in care - Complaint alleges that resident requires constant supervision and that staff are not meeting the need. LPA confirmed through document review that resident's doctor did not identify the resident as needing one to one supervision. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 21-AS-20231023101800

Allegation investigated: Insufficient Staffing Facility is not ensuring that residents have incontinence supplies

Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegations and met with Robert Alvarado. Administrator, Katelyn Ledesma was unavailable during this visit. Insufficient Staffing - Complaint alleges that facility does not always have two caregivers to assist residents who need two people to transfer them. This allegation was supported by interviews and review of staff schedule indicating that staff do have shifts where they work by themselves. Facility is not ensuring that residents have incontinence supplies - Complaint alleges that there are not always sufficient incontinence supplies for residents. This allegation is supported by interviews indicating that while there may be backup supplies sometimes, there are not always backup supplies resulting in caregivers using other residents' supplies which are not always replaced. It is facility policy that incontinence supplies Continued on LIC9099C Substantiated Continued from LIC9099 are not provided by the facility unless the resident has signed up to have facility obtain supplies. While some individuals were aware of facility protocol, which includes "express" delivery of supplies, not all staff were familiar with it. Based on interviews which were conducted and document review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.the state’s words, verbatim · CDSS document, Nov 20, 2023 · control 21-AS-20230927100309

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 21, 2023

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports...This requirement was not been met as evidenced by interviews and record review showing that caregivers have worked by themselves despite residents requireing two-person assists. This is an immediate risk.the state’s words, verbatim · CDSS document, Nov 20, 2023

Plan of correction: Facility agrees to submit a written plan indicating how they will ensure sufficient staffing at all times to meet the needs of residents who require a two-person assist no later than 11/21/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Nov 30, 2023

87464 Basic Services A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by interviews revelaing that there is not always incontinence supplies resulting in staff using supplies from other residents.the state’s words, verbatim · CDSS document, Nov 20, 2023

Plan of correction: Facility agrees to provide training to staff regarding facility protocol to obtain incontinence supplies and submit proof of training to CCL no later than 11/30/2023.

Type of visit: Case Management - Incident

Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Robert Alvarado. Administrator, Katelyn Ledesma was unavailable during this visit. LPA is following up regarding two medication errors. Per self-reported incident report, resident, R1 had a change in their medication and was inadvertently given the medication that was discontinued. Once mistake was realized, facility staff called 911 and continued to monitor resident. R1 did not have adverse affects and did not require a hospital visit. Per self-reported incident report, it was discovered that resident, R2 had not received their medication since move-in, approximately one week, due to the medication information not being input into facility's internal medication database. No adverse affects were reported. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.the state’s words, verbatim · CDSS document, Nov 20, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Nov 21, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. Plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with with self-administered medications as needed. This requirement was not met as evidenced by report review showing that two residents were not provided medications as prescribed. This is an immediate risk to health and safety of residents.the state’s words, verbatim · CDSS document, Nov 20, 2023

Plan of correction: Facility agrees to provide an in-service to all staff who assist with self-administrator of medication regarding facility protocol regarding inputting new and/or updated medications into the internal database and submit planned training schedule date to CCL no later than, 11/21/2023

Allegation investigated: Facility did not provide written incident report to responsible party

Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegation and met with Administrator, Katelyn Ledesma. Facility did not provide written incident report to responsible party - Complaint alleges that facility did not provide the resident's death report to their responsible party. Interviews revealed that facility did not provide report because the facility was unable to determine whether the responsible party had authority to receive the report. LPA's review of R1's Admission Agreement and interviews revealed that the death report was not provided to the individual who signed the Admission Agreement. Continued on LIC9099C Substantiated Continued from LIC9099 Health and Safety Code 1569.880 requires that Admission Agreements are signed by the resident or their representative indicating that the individual who signed the resident's Admission Agreement is their representative/responsible party so should have been provided the death report per Regulation 87211 Reporting Requirements Based on interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.the state’s words, verbatim · CDSS document, Nov 6, 2023 · control 21-AS-20230921102025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Nov 10, 2023

87211 Reporting Requirement (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following: (1) A written report shall be submitted to the licensing agency & to person responsible for the resident within 7 days of the occurrence of any of the events specified in (A) through (D) below...(A) Death of any resident from any cause regardless of where the death occurred... Licensee didn't meet requirement as evidenced by: Based on interviews & document review death report was not provided to responsible person.the state’s words, verbatim · CDSS document, Nov 6, 2023

Plan of correction: Facility to submit self-certification that they have provided the death report to R1's responsible party/representative no later than 11/10/2023

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

Allegation investigated: Residents' pendants are not working Staff do not help residents in a timely manner

Licensing Program Analyst Victoria Bertozzi arrived unannounced to deliver findings regarding the above complaint allegations and met with Health and Wellness Director, Heidi Gallagher. During investigation LPA conducted interviews with staff, residents and other interested parties, reviewed documents and made observations. Residents' pendants are not working - Complaint alleges that the call bell system that includes the pendants was not working for multiple weeks. LPA confirmed through multiple staff and resident interviews that the call button system was down for multiple weeks. Facility has since had system repaired. Continued on LIC9099C Substantiated Continued from LIC9099 Staff do not help residents in a timely manner - Complaint alleges that because the call button system was not functioning, residents did not receive help in a timely manner. Per interviews, residents were to be checked every two hours when the call button system was not working though interviews revealed that staff were not always able to meet that timeline resulting in at least one resident not having their needs met timely. Based on interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.the state’s words, verbatim · CDSS document, Oct 23, 2023 · control 21-AS-20230914133321

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411 · Plan of correction due date: Oct 24, 2023

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Licensee did not meet this requirement based on interviews that confirm not all resident's needs were met timely due to the signal system being down and staff not being able to supervise per stated protocol. This is an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 23, 2023

Plan of correction: Administrator to provide CCL the written facility policy and/or protocol regarding how resident's needs are met when all or part of the signal system is inoperable and how resident's needs are met during those times by POC due date, 10/24/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i) · Plan of correction due date: Oct 24, 2023

87303 Maintenance&Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. Requirement not met based on interviews indicating signal system was inoperable for multiple weeks.the state’s words, verbatim · CDSS document, Oct 23, 2023

Plan of correction: Signal system has been repaired. Deficiency is cleared.

Allegation investigated: Facility did not meet resident's needs Facility did not follow resident's care plan Facility did not respond to call buttons Facility staff did not ensure that resident received warm food Facility did not properly respond to resident's injuries

Licensing Program Analysts Bertozzi and Coppo arrived unannounced to complete complaint investigation regarding the above allegations and met with Administrator, Katelyn Ledesma. Facility did not meet resident's needs, Facility did not follow resident's care plan – Complaint alleges that resident requires assistance with meals and catheter care in the form of the catheter bag being emptied and meals being delivered. Per complainant, the catheter bag was to be emptied three times per day and there were multiple occasions where the catheter bag was not emptied timely noting two occasions where the resident’s catheter came out requiring a nurse to come to the facility and re-insert the catheter. Complainant reported that the catheter may have come out as a result of the bag being overfull. Per interview with individual involved with resident’s care, the catheter line could have come out from the catheter bag being overfull but it is not clear if that was the reason in this case. Continued on LIC9099C Unsubstantiated Continued from LIC9099 Review of resident’s care plan states that the bag should be emptied twice daily or as needed. Interviewed staff denied not emptying catheter bag timely with some stating that resident had increased urinary output. Pictures provided show a full catheter bag but it is not clear if it was because of increased urinary output or if facility staff were not emptying bag timely. Per complaint, there was an incident where resident did not wake up until the afternoon resulting in resident not having breakfast and lunch and not having their catheter bag emptied. Additionally, facility staff are not clearing away disposable containers after meals. Interviews provided conflicting information about whose responsibility it is to clear containers. Complaint also alleges that resident missed meals due to them not being delivered. LPA was unable to confirm. Per staff interview, residents are woken up for meals. Facility did not respond to call buttons – Complaint alleges that resident used the call button on several occasions and there was no response. LPA attempted to obtain call button records but was unsuccessful. Per interviews, resident frequently contacted their responsible party instead of using the call button system. Facility staff did not ensure that resident received warm food - Complaint alleges that staff did not take into account resident’s vision restraints and notify resident that meals were being left for them, resulting in resident having cold food. Per staff interview, dining staff were not initially notifying resident, R1 when they dropped off a meal but once the issue was brought to their attention, dining staff started to notify R1. Per interview, there is a microwave in the resident’s room and caregivers would heat up meal for resident, as needed. Facility did not properly respond to resident's injuries – Complaint alleges that resident was observed with a wound on their arm by a family member and when the resident was brought to the reception area the receptionist stated they did not have a First Aid Kit. Per chart notes a Medication Technician came and provided first aid to the resident. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. No deficiencies cited.the state’s words, verbatim · CDSS document, Oct 3, 2023 · control 21-AS-20230714123714