Brookdale Irvine

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Executive Director (Administrator) Shannon Howell and explained the reason for the visit. The Executive Director's Administrator's certificate expires on August 15, 2027. The facility is a three level building with a central courtyard and is licensed for 155 non-ambulatory residents, of which zero (0) may be bedridden and a hospice waiver for fifteen (15). LPA and the Executive Director toured the facility. LPA observed the See Something poster (PUB 475) posted by the resident mail boxes. LPA conducted random room checks, 4 rooms on each floor, for a total of 12 rooms inspected. LPA observed each room had the required furnishings and clean bed linens and adequate storage space. LPA observed each resident room was clean and was free of trip hazards. The hot water temperature in the restrooms inspected measured to between 115.0 to 119.2 degrees Fahrenheit. LPA tested the emergency pull cord in one room on each level. All three of the emergency pull cords are operational. LPA observed the facility has an activity room, fitness room with gym equipment, theater room and a library. LPA observed there is a computer in the theater room that has internet access and is for resident use only. LPA observed the dining room and kitchen are clean. LPA observed a two day perishable and a seven day non-perishable food supply on hand in the kitchen. LPA observed the refrigerator and freezer were at the required temperatures, the freezer was at 0.0 degrees Fahrenheit and refrigerator was at 38.0 degrees Fahrenheit. LPA observed temperature logs for the refrigerator and freezer are posted. LPA observed a 3 day emergency supply of water is stored outside in a storage shed. LPA observed a 3 day emergency supply of food stored in storage room on the first floor. LPA observed all fire extinguishers are fully charged. The last emergency drill was conducted August 13, 2026. The fire alarm system was tested on July 10, 2026. LPA observed each stairway in the facility has an emergency evacuation chair. LPA observed the medication room is kept locked and medication is stored in locked medication carts. LPA inspected the first aid kit. The first aid kit has all the required elements. LPA toured the central courtyard. No bodies of water observed. LPA observed a shaded seating area to sit outside. No obstacles or hazards observed inside or outside of the facility. LPA reviewed 14 resident files and medications. No discrepancies observed. LPA reviewed 6 staff files. LPA observed all staff members are background cleared and associated to the facility. LPA observed Staff 1, Staff 2 and Staff 3, have over 20 hours of training, but did not have 4 hours of training specific to postural supports, restricted health conditions and hospice care. Staff 1, Staff 2 and Staff 3 all have CPR/First Aid training. No other discrepancies observed. LPA consulted with the Executive Director regarding reporting requirements. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.the state’s words, verbatim · CDSS document, Sep 1, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.625(b)(2) · Plan of correction due date: Sep 18, 2026

...training requirements shall also include an additional 20 hours annually..., and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This requirement is not being met as evidenced by LPA observed Staff 1, Staff 2 and Staff 3 did not have 4 hours of training on postural supports, restricted health conditions and hospice care, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 1, 2026

Plan of correction: Licensee agrees to train all caregivers on, 4 hours of training on postural supports, restricted health conditions and hospice care in compliance with HSC 1569.625(b)(2). Licensee to forward proof to LPA by POC due date.

Type of visit: Case Management - Incident

On July 24, 2026, Licensing Program Analyst (LPA) Garlli Tat made an unannounced visit to the facility to conduct a Case Management visit regarding an incident of alleged sexual abuse involving two residents. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Shannon Howell was present and assisted with today's inspection. LPA is following up on a self-reported SOC 341 received by the Orange County Regional Office on July 23, 2026, for Resident #1 (R1). R1 reported to POA that alleged perpetrator, another resident at the facility, was aggressively sexual with them. An investigation began and law enforcement were notified. Case number: 26-8029. Resident #2 (R2), the alleged perpetrator, has since temporarily moved out of the facility. Residents are not allowed to have any contact with each other upon return. On today's visit, LPA, accompanied by the ED, inspected the facility. LPA spoke with R1 during the visit. LPA collected pertinent records for both residents involved, including their Emergency and Identification sheet, Release of Medical Information, Personal Rights, Admission Agreement, Medical Assessment, Personal Service Plan, list of medications for R1, staff roster, and resident roster. Per ED, the incident is still being investigated at this time. Based on observations made during today’s inspection, no deficiencies are being cited. An exit interview was conducted and a copy of this report was reviewed and provided at the time of exit.the state’s words, verbatim · CDSS document, Jul 24, 2026

Type of visit: Case Management - Incident

On June 18, 2026, Licensing Program Analyst (LPA) Garlli Tat made an unannounced visit to the facility to conduct a Case Management visit regarding a resident's death. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Shannon Howell was present and assisted with today's inspection. LPA is following up on a self-reported Death Report received by the Orange County Regional Office on June 10, 2026, for Resident #1 (R1). R1 passed away on June 7, 2026 at 12:53pm. On today's visit, LPA, accompanied by the ED, inspected the facility. LPA observed the facility to be clear of any hazards. No health or safety concerns were observed. LPA collected pertinent records for R1 including R1's Emergency and Identification sheet, Physician's Report, Appraisal, discharge paperwork, Admission Agreement, progress notes, list of medications, staff roster, and resident roster. Per ED, the Death Certificate had not been issued at this time. Based on observations made during today’s inspection, no deficiencies are being cited. An exit interview was conducted and a copy of this report was reviewed and provided at the time of exit.the state’s words, verbatim · CDSS document, Jun 18, 2026

Allegation investigated: Facility staff lost resident's medication. Facility does not have enough staff to meet resident's needs. Facility Staff did not shower resident

On January 28, 2026, at 10:40 AM, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Executive Director (ED) Shannon Howell and explained the purpose of the visit. ED Howell could not stay for the visit and stated Business Office Manager Sharin Belanger could sign on behalf of the facility. The investigation consisted of the following. LPA Kim toured the facility. LPA requested and obtained copies of the resident roster and staff roster. LPA requested a copy of one (1) resident service records which include Physician’s Report, Appraisal/Needs and Services Plan, admission agreement, facility shift notes, and other document records. LPA conducted interviews with five staff and five residents. The investigation revealed the following: Continued on LIC9099C Unsubstantiated Allegation: Facility staff lost resident's medication. It is alleged that the facility lost Resident #1’s (R1) medication upon R1’s arrival on August 27, 2021. Due to the staff losing R1’s medication, R1 did not receive any medication until August 30, 2021. Based on record review, the facility’s Order Summary Report dated August 30, 2021, stated the admission for R1 was on August 29, 2021. Admission Agreement was dated on August 18, 2021, but a move-in date was not listed on the Admission Agreement. R1’s ID and Emergency information stated the admission date was on August 18, 2021. There are no shift reports for R1 in August to indicate any lost medication. There is nothing in the Shift reports from September that indicate facility lost resident’s medication. Based on interviews conducted, four out of five staff and five out of five residents denied the allegation. One out of five staff could not confirm or deny the allegation. S1 stated that upon arrival to the facility, R1 did not bring R1’s medication with them to the facility. It was not the facility who lost the medication. S2, S3, and S4, stated they have not heard of a situation where facility has lost a resident’s medication. All residents stated that they have never heard a situation where the facility lost a resident's medication. Based on the information gathered, there is no sufficient evidence gathered to confirm the above allegation. It is determined that four out of five staff and five out of five residents denied the allegation. There are no records to indicate such an event occurred. Allegation: Facility does not have enough staff to meet resident's needs. It is alleged that R1 has serious medical conditions and there is not enough staff to meet the medical’s needs. Based on interviews conducted, four out of five staff and five out of five residents denied the allegation. One out of five staff could not confirm or deny the allegation. S2 and S3 stated the facility has met the needs of all residents. S2 and S3 stated the staffing ratio for the morning shift from 6:00 AM to 2:00PM is for five caregivers and two medication technicians. Staffing ratio for afternoon shift from 2:00 PM to 10:00PM is for five caregivers and two medication technicians. The Nocturnal shift is from 10:00 PM 6:00 AM which has four caregivers and one medication technicians. All residents stated that the staff met all of their resident’s needs. Continued on LIC9099C Based on record review, the assignment sheet dated from January 26, 2026, to January 31, 2026, stated there are four to five caregivers and two medication technicians working from 6:00 AM to 2:00 PM per day, four to five caregivers and two medication technicians working from 2:00PM to 10:00 PM, and two to three caregivers and one to two medication technicians working from 10:00 PM to 6:00AM. Based on the information gathered, there is no sufficient evidence gathered to confirm the above allegation. It is determined that four out of five staff and five out of five residents denied the allegation. There are no records to indicate the facility does not have enough staff to meet the resident’s needs. Allegation: Facility Staff did not shower resident It is alleged that R1 did not receive a shower. The facility charged R1 $1035 for showers services two times per a week. Based on record review, a notice dated September 20, 2021, stated the facility did not provide shower services because R1 refused. R1’s spouse denied this ever occurred. It also stated in the notice that R1 could not shower because the wheelchair was too big to enter into the shower room for R1 to receive a shower. Shift Report dated September 18, 2021, stated that a resident from Room 342 received a sponge bath. There is no shower log or any progress notes from 2021 available at the time of the visit. Based on interviews conducted, four out of five staff and five out of five residents denied the allegation. One out of four staff could not confirm or deny the allegation. S1 stated that facility provided a sponge bath because R1 could not bear weight on their legs. When staff would try to assist with showers for R1, the spouse would interfere and kick the staff out of the room. All residents stated they do not recall a time hearing a resident ever being denied or not provided showers. S2, S3, and S4 stated that if residents needed to receive a shower, they would be provided with a shower. S2, S3, and S4 do not recall a time where a resident’s wheelchair would be too big for the resident to take a shower. Continued on LIC9099C Based on the information gathered, there is no sufficient evidence gathered to confirm the above allegation. It is determined that four out of five staff and five out of five residents denied the allegation. There are no records to indicate that Facility Staff did not shower resident. Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegations that Facility staff lost resident's medication, Facility does not have enough staff to meet resident's needs, and Facility Staff did not shower resident. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview was conducted and a copy of the report was provided to Business Office Manager Sharin Belangerthe state’s words, verbatim · CDSS document, Jan 28, 2026 · control 22-AS-20210923120435

Allegation investigated: Staff did not follow proper protocol regarding rate increase

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Business Office Manager (BOM) Sharin Belanger. LPA explained the reason for the visit. This agency has investigated the complaint alleging that staff did not follow proper protocol regarding rate increase. Regarding the allegation, the following was revealed: During the course of the interviews seven of ten individuals interviewed denied the allegation. During the investigation LPA reviewed the Brookdale Senior Living rent increase dated September 24, 2025, for Resident 1 (R1). Per Brookdale Senior Living rent increase, it states effective January 1, 2026, your current Basic Service Rate will increase. Per Health and Safety Code 1569.655 under (a) it states if a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, CONTINUED ON LIC9099-C. Unsubstantiated the licensee shall provide no less than 90 days’ prior written notice to the residents or the residents’ representatives setting forth the amount of the increase and the reason or reasons for the increase. During the course of the interviews the Executive Director (ED) reported that R1's Power of Attorney (POA) was notified via mail on September 24, 2025. Per ED, the rent increase notification was mailed to the POA's mailing address on file. ED reported that all residents were notified no less than 90 days before the rent increase went into effect. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with BOM Belanger, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 16, 2026 · control 22-AS-20260109102618

Allegation investigated: Facility is not taking measures to prevent resident harrassment

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced 10-day visit to the facility for the complaint and to deliver the findings. LPA Rodriguez explained the purpose of today's visit and was greeted by front desk staff. For this visit. LPA met with business office manager (BOM) Sharin Belanger. During the investigation, LPA Rodriguez toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that facility is not taking measures to prevent resident harassment. 8 out of 8 resident interviews and 2 out of 2 staff interviews did not corroborate with the allegation. Per interviews, resident 2 (R2) has a drinking problem, and per physician report, R2 is prohibited to drink alcohol due to the disruptive behaviors that surface when drinking. **Continued on LIC9099-C... Unsubstantiated Due to the facility not providing R2 with alcohol, R2 will leave the facility and drink when out in the community and will return back intoxicated. Per documentation review, there was an incident where resident 1 (R1) accidentally bumped shoulders with R2, to which R2 then referred to it as "groping". R2's responsible party was notified, and the facility also held a meeting to discuss about R2’s condition, to which R2's responsible party provided confirmation that when R2 drinks, R2 has a history of being disruptive and making false statements. Due to the ongoing behaviors of R2, facility has issued a final warning to R2 and stated that an eviction will be issued next, to which R2’s responsible party agreed to the terms. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with BOM Belanger. A copy of this report was explained and provided.the state’s words, verbatim · CDSS document, Nov 24, 2025 · control 22-AS-20251117160122

Allegation investigated: Facility is not providing appropriate care for resident

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced 10-day visit to the facility for the complaint and to deliver the findings. LPA Rodriguez explained the purpose of today's visit and was greeted by Executive Director (ED) Shannon Howell. During the investigation, LPA Rodriguez toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that facility is not providing appropriate care for resident. 8 out of 8 resident interviews did not corroborate with the allegation by stating that facility provides “great care”. 1 out of 1 staff interview did not corroborate with the allegation. Per resident 1 (R1) admission agreement, R1 was not placed on a 1:1 supervision. Continued on LIC9099-C... Unsubstantiated Per R1 physician report, R1 has “poor safety awareness…high fall risk” “lack of impulse control”, and “lack of hazard awareness”. Per record review of incident reports, between the months of August-October, R1 sustained a fall on 9/29/25 and 10/14/25, of which 911 was contacted both times to ensure R1 obtained medical care. Per record review, it also revealed that a care plan meeting was held on 10/15/25 with R1’s responsible party to address R1’s falls and change of condition. LPA conducted a tour of R1’s room and observed that there were no hazards or obstructions in the room and also observed that R1 has accessibility to a pendant button to alert staff when needed. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with ED Howell. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 22-AS-20251016104903

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced case management visit to the facility to follow up on an incident that was reported to the Department on 7/28/25. LPA Rodriguez was greeted and met with facility by Business Office Manager (BOM) Sharin Belanger and Wellness Director (WD) Mary Clark. On 7/23/25, resident 1 (R1) sustained an unwitnessed fall at the facility, which resulted to a head injury and radial head fracture. Per LPA's interview, observation and review of documents, R1 sustained an accidental unwitnessed fall on the way to use the bathroom, and facility immediately contacted 911 for medical attention. Per R1's physician report, R1 is able to use bathroom on their own and able to care for own tolieting needs. Upon R1's return to the facility after the hospital discharge, facility has designated staff to assist R1 with tolieting. During this visit, LPA Rodriguez observed that R1 was clean and happy. For this visit, there were no health and safety concerns noted. No citations were issued for this visit. An exit interview was conducted with BOM Belanger and WD Clark. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Aug 4, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced visit to the facility for the required annual inspection. LPA Rodriguez was greeted and met with facility by Business Office Manager (BOM) Sharin Belanger and Wellness Director (WD) Mary Clark. LPA Rodriguez observed the PUB475 "See Something, Say Something" poster posted in the hallway. LPA Rodriguez observed the administrator certificate for Shannon Howell which expires on 8/15/2025. LPA Rodriguez toured the interior and exterior portions of the facility with BOM Belanger. The facility is a three level structure and is licensed for 155 non-ambulatory residents, of which 15 may be on hospice and 0 may be bedridden. Currently, there are a total census of 150 residents in care. LPA Rodriguez conducted random bedroom checks, of which bedrooms were observed to have furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Water temperature in restrooms were measured to be between 113.1-116.2 degrees Fahrenheit. Smoke and carbon monoxide detectors were operational and most recent fire inspection took place on 6/25/25, of which inspection was passed. LPA Rodriguez observed that facility had fire extinguishers that were charged, mounted, located in multiple areas of the facility, and dated for July 2025. Auditory alarms and wander guard functions were also tested and observed to be operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. LPA Rodriguez observed that the pull cord in the resident bathrooms, and resident call buttons were operational. LPA Rodriguez observed evacuation chairs in the stairwells. Facility does not have delayed egress doors. LPA Rodriguez observed the emergency disaster evacuation plan is posted and located behind the front desk. Continued on LIC809-C Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Facility had back-up emergency food and water supply. LPA Rodriguez toured the kitchen and observed the weekly food menu. Medications, toxins, sharp items and knives were locked and inaccessible to residents in care. LPA Rodriguez observed that First Aid Kit had all the required components. For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued. LPA Rodriguez conducted an exit interview with BOM Belanger and WD Clark. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 4, 2025

Allegation investigated: Facility staff did not handle resident properly resulting in injury.

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced visit to the facility to deliver the findings. LPA Rodriguez explained the purpose of today's visit and was greeted by business office manager (BOM) Sharin Belanger. It was alleged that facility staff did not handle resident properly resulting in injury. Six interviews were conducted with staff and residents, of which all six interviews did not corroborate with the allegation. Interviews conducted with resident 1 (R1) stated that staff are friendly and helpful, and verified that staff never handled R1 in a way that resulted in injury. Per record review, R1 is not diagnosed with dementia or cognitive impairment and during R1's hospitalization, R1 was placed on blood thinners, and was informed that R1 would be more prone to bruising. Record review also revealed that R1 requires assistance getting to and from the wheelchair, to which R1 confirmed that staff will utilize a gait belt, and denied of staff grabbing R1's wrists and arms to move. R1 was observed to have bruises on the arm, however confirmed that it was due to receiving an IV at the hospital and being on blood thinner medication. Unsubstantiated Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with BOM Belanger. A copy of this report was explained and provided during the visit.the state’s words, verbatim · CDSS document, Jun 11, 2025 · control 22-AS-20230817142044

Allegation investigated: Staff did not respond to resident's call button in a timely manner Staff spoke inappropriately towards resident Staff are not providing adequate food service to resident Staff did not meet resident's hygiene needs Staff are not meeting resident's needs Staff did not safeguard resident's personal belongings

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced visit to the facility to continue the investigation and to deliver the findings. LPA Rodriguez explained the purpose of today's visit and was greeted by business office manager (BOM) Sharin Belanger. It was alleged that staff did not respond to resident's call button in a timely manner. LPA Rodriguez conducted a total of 10 resident interviews of which all 10 resident interviews did not corroborate with the allegation. It was verified by residents that staff do respond to a resident's call button. 1 out of 1 staff interview did not corroborate with the allegation by stating that the target response time when a call button is pressed, is to be no longer than 30 minutes. Per record review of the pendant report, in the month of April and May, staff responded to a resident's call button between 7 to 24 minutes. During the tour of the facility, LPA conducted random call button checks, to which staff responded within 3 to 8 minutes. . Unsubstantiated It was alleged that staff spoke inappropriately towards resident. LPA Rodriguez conducted a total of 10 resident interviews of which all 10 resident interviews did not corroborate with the allegation. All 10 resident interviews disclosed that staff are friendly and nice. 1 out of 1 staff interview did not corroborate with the allegation by stating that there have been no complaints or issues about staff speaking inappropriately to a resident. Per record review, facility staff are required to complete training regarding on how to care for residents and on personal rights and it was verified that if staff are not trained on the topic of properly caring for residents, then staff are not allowed to be on the floor until training has been completed. It was alleged that staff are not providing adequate food service to resident. LPA Rodriguez conducted a total of 10 resident interviews of which all 10 resident interviews did not corroborate with the allegation. Resident interviews stated that the food is good and “more than enough”. 1 out of 1 staff interview did not corroborate with the allegation by stating that although there is a set menu for the month, if a resident is requesting for a different meal, then the facility will accommodate them. Per record review, facility prepares meals with reduced sodium, fat and cholesterol. Per interview and record review, facility will tailor meals to residents in accordance with their physician report if it is stated that the resident has dietary needs and restrictions. Per observation, facility serves breakfast, lunch, dinner, and snacks, with choices of dairy, meat, grains, fruits, and vegetables. It was alleged that staff did not meet resident's hygiene needs. LPA Rodriguez conducted a total of 10 resident interviews of which all 10 resident interviews did not corroborate with the allegation. 3 out of the 10 resident interviews specified that they are able to meet their own hygiene needs, but are aware that staff are available to assist if needed. 7 out of the 10 resident interviews stated that staff assist them with bathing and dressing, however stated that if they decline in wanting a shower that day, then staff will offer another opportunity to assist with bathing the next day. 1 out of 1 staff interview conducted, did not corroborate with the allegation by stating that staff will abide by the resident’s physician report and services plan to determine if a resident requires assistance with meeting their hygiene needs, but if a resident declines, then staff will not force a resident to shower or get dressed. Per record review, facility tracks which residents require assistance with their hygiene needs in a log, and if a resident declines, then the facility will document it. Per documentation review, resident 1 (R1) needed assistance with bathing, however declined all the time the staff attempted to assist. It was alleged that staff are not meeting resident's needs. LPA Rodriguez conducted a total of 10 resident interviews of which all 10 resident interviews did not corroborate with the allegation. All 10 resident interviews verified that their needs are met, and discussed about how helpful the staff are, and confirmed that there were no health and safety concerns regarding the care being provided. 1 out of 1 staff interview did not corroborate with the allegation by stating that there have been no complaints with residents needs not being met. Per observations, LPA observed that residents were fed, clean, content and safe. It was alleged that staff did not safeguard resident's personal belongings. LPA Rodriguez conducted a total of 10 resident interviews, and 1 staff interview of which all 11 interviews did not corroborate with the allegation by stating that residents are responsible for their own belongings. Per record review, residents are informed upon admission that they are responsible for their own belongings, and if a resident would like for staff to safeguard their personal belongings, then they must sign a form. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with BOM Belanger. A copy of this report was explained and provided during the visit.the state’s words, verbatim · CDSS document, Jun 11, 2025 · control 22-AS-20240503163000

Allegation investigated: Facility failed to provide reasonable accommodation to a resident's needs & preferences

Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility to initiate a 10-Day complaint investigation into the above allegation. LPA met with Business Office Manager Sharin Belanger. LPA spoke to Executive Director (ED) Shannon Howell via telephone. LPA conducted a walk-through of the facility, obtained copies of the Staff schedule and Resident roster and other pertinent documents. LPA also conducted interviews with the Executive Director via telephone, Business Office Manager, Health & Wellness Director, 2 staff and 13 residents. Regarding allegation that Facility failed to provide reasonable accommodation to a resident's needs & preferences, the investigation revealed the following: On 07/28/2024, Resident 1 (R1) was intoxicated and had a fall hitting R1's head. On 07/30/2024, facility received a doctor's order for R1 that states "Can Drink NO Alcohol...Patient should be in an Alcohol Rehab Program". On 07/30/2024, R1, R1's Emergency Contact, ED, Health & Wellness Coordinator, and Resident Care Coordinator had a meeting to discuss the new order from R1's Doctor. R1 agreed to abide by the doctor’s order and was enrolled in an Alcohol Rehab Program. Unfounded On 01/09/2025, R1 presented a new doctor’s order stating R1 "May continue two mini-drinks at dinner" to the Health & Wellness Nurse. Interview with Dining Director, confirmed R1 received two glasses of wine during dinner on 01/09/2025. Facility was following doctor's orders to ensure R1’s health Is not endangered. Therefore, allegation that Facility failed to provide reasonable accommodation to a resident's needs & preferences is Unfounded meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was sent to email on file.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 22-AS-20250109160520

Allegation investigated: - Facility staff did not follow admission agreement

Licensing Program Analyst (LPA) Michael Tea made an unannounced complaint visit on this day to deliver findings for the allegation mentioned above. LPA met with Executive Director (ED) Shannon Howell. It was alleged that facility staff did not follow admission agreement. During the investigation LPA interviewed residents and staff; checked resident files; and reviewed resident invoices; personal service plans; assessments; staff progress notes; and daily shift reports. The investigation determined the following: On the signed Admission Agreement on page 2 Section I Clause B “Personal Service Plan,” states “Prior to moving in and periodically throughout your residency, we will use a personal service assessment to determine the personal services you require. The personal service assessment will be used to develop your Personal Service Plan. The results of the assessment, our method for evaluating your personal care needs, and the cost of providing the additional services (the “Personal Service Rate”) will be shared with you.” Responsible Party said they were not given notice about the updated services for R1. Substantiated Interview with Executive Director (ED) reported that R1’s responsible party were aware of the services being provided and billed every month. However, personal service plan and assessment notices on April 14, 2023, did not have signatures from R1’s responsible party. R1’s responsible party signed a new personal service plan dated October 20, 2023, thus agreeing to services to be provided. Since services plan dated April 14, 2023, was not signed, there is no proof or acknowledgement that R1’s responsible party agreed to updated services being provided from the time period of April 14, 2023, through October 20, 2023. Therefore, based on the preponderance of evidence through records reviewed and interviews the allegation facility staff did not follow admission agreement is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with Executive Director Shannon Howell and a copy of this report and appeal rights was provided.the state’s words, verbatim · CDSS document, Dec 13, 2024 · control 22-AS-20240515084741

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Dec 27, 2024

Rate increase due to change in level of resident care; notice ... (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. This requirement is not met as evidenced by: Responsible party of R1 stated they did not receive notice or signed or agreed with Personal Service Plan updates. No sign copy of Personal Service Plan for disputed charges on April 14, 2023 service plan updates.the state’s words, verbatim · CDSS document, Dec 13, 2024

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

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today's visit was to conduct a case management. LPA Tea was greeted and granted entry into the facility by Executive Director Shannon Howell. On this day LPA Tea amended LIC9099, LIC9099C dated 09/13/2024. LPA reviewed amended report with Executive Director. An exit interview was conducted with the executive director Shannon Howell . A copy of this report and amended LIC9099, LIC9099C was provided to the facility.the state’s words, verbatim · CDSS document, Dec 13, 2024

Allegation investigated: Facility lacks staff

This unannounced investigation inspection by Licensing Program Analysts (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPAs arrived at the facility and were greeted by facility staff. LPA met with Iris Nunez, Resident Care Coordinator, and explained the nature of the inspection. The department received a complaint on 6/19/2024 stating the facility lacks staff. During the investigation, the Department interviewed Executive Director, staff and residents in care. (continued on LIC9099-C) Substantiated (continued from LIC9099) On 6/24/2024 LPA Mason conducted a visit to the facility. LPA obtained copies of the staff roster, resident roster and staff schedule. LPA conducted interviews with ED, 4 staff and 9 residents. ED did not explicitly state whether or not the facility is understaffed. Of the staff interviewed, 4 out of 4 stated the facility is understaffed. Of the residents interviewed, 1 out of 9 stated the facility is understaffed. During the interview, ED stated the facility is hiring. Of the staff interviewed, 3 out of 4 stated the facility was hiring at the time of the visit. Based on staff interviews conducted, LPA determined that the facility is understaffed. The preponderance of evidence standard has been met. The allegation is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Nov 8, 2024 · control 22-AS-20240619132458

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 15, 2024

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The Licensee did not comply with the section cited above due to 4 out of 4 staff stating the facility is understaffed. This poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 8, 2024

Plan of correction: Based on the staff roster reviewed on 11/8/2024, LPA determined that, since June 2024, the facility has hired: 2 Cooks, 8 Servers and 2 Dishwashers. LPA determined facility fulfilled the POC. POC cleared during visit

Allegation investigated: - Facility staff charged for services not rendered

Licensing Program Analyst (LPA) Michael Tea made an unannounced complaint visit on this day to deliver findings for the allegation mentioned above. LPA met with Executive Director (ED) Shannon Howell. It was alleged that facility staff charged for services not rendered. During the investigation LPA interviewed residents and staff; checked resident files; and reviewed resident invoices; personal service plans; assessments; staff progress notes; and daily shift reports. The investigation determined the following: The facility was supposed to provide medication; dressing and grooming; and showering or bathing services which were discussed in the personal service plan and assessment summary and admission agreement of Resident 1 (R1). (Continued on LIC9099C) **THIS IS AN AMENDED REPORT** Unsubstantiated Per interview with R1, R1 reported they receive assistance with the following activities of daily living: medication and daily shower services. R1 states the facility has been good with keeping up with their services and that they feel the facility is run very well aside from a water pipe leakage incident in their room. R1 said that the staff are very good and have never bullied or pressured them into anything. R1 confirmed that Resident 2 (R2) speaks for them and helps a lot. R1 has no complaints about R2’s help and asserted that R2 is not controlling and has no complaints about R2. Interviews with facility staff reported that R2 interferes with R1’s activities of daily living (ADL) services. The Facility Executive Director Shannon Howell and management team addressed the problem with the responsible party of R1 and R2 however staff reported the interference continued as R1 and R2 are always together. Interviews with four of four staff confirm that R2 interferes with personal services provided to R1. One staff confirmed that despite R2’s interference, they try to go through and provide the services and do their job. The staff reported letting R2 know they are providing the services to R1. Per interview with R2, R2 stated staff asks them for help when R1 needs to take a shower. Then they just leave R1 in a towel all wet and does not help dress R1. Per R2 this is a service that is to be provided to R1. R2 said that they help R1 because R1 asks for their help. R2 said that they are fighting for R1 and they don’t like to see R1 being treated badly and is happy to help. Progress Notes and Shift reports notates R1 would at times refuse to take a showers; switch shower times for later in the afternoon; or have R2 assist them with their shower before staff could assist R1. Therefore based on LPA Tea's observation and interviews conducted and records review the allegations the staff charged for services not rendered has been determined to be unsubstantiated meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies cited at this time and an exit interview was conducted with Executive Director Shannon Howell and a copy of the report and confidential names list was provided to the facility. **THIS IS AN AMENDED REPORT**the state’s words, verbatim · CDSS document, Sep 13, 2024 · control 22-AS-20240515084741

Type of visit: Required - 1 Year

On this day, Licensing Program Analysts (LPA) Alvaro Ramirez, Jr. made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry to facility by Business Office Manager (BOM) Sharin Belanger. LPA Ramirez toured the interior and exterior portions of the facility with BOM Belanger. During this visit, there are a total of 21 staff members on duty. The facility is a three level structure and is licensed for 155 non-ambulatory residents, of which 15 may be on hospice and 0 may be bedridden. Currently, there are a total census of 119 residents in care. LPA Ramirez initiated random bedroom checks, of which bedrooms were observed to have furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Water temperature in restrooms were measured to be between 111.0-115.8 degrees Fahrenheit. Smoke and carbon monoxide detectors were operational and most recent fire inspection took place on August 06, 2024, of which inspection was passed. Auditory alarms and wander guard functions were also tested and observed to be operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. LPA Ramirez also tested pull cords in resident bathrooms, and observed to be operational. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Facility had back-up emergency food and water supply. LPA toured the kitchen and observed the weekly food menu. LPA also observed handouts for Resident Programs Daily Events which included express manicure, Jeopardy Wii and Spanish 101. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged, mounted and located in multiple areas of the facility. LPA observed exit stairwells and each floor had an evacuation chair. Facility does not have delayed egress doors. CONTINUED ON LIC809-C... For the exterior portion, LPA Ramirez observed patio furniture under shading, and the grounds were free of any hazards. LPA observed the emergency disaster and evacuation plan, which is posted at the main entrance behind the front desk. LPA Ramirez observed that First Aid Kit had all the required components. Medications were locked and inaccessible to residents in care. Toxins were also observed to be locked and inaccessible to residents. During the tour LPA did not observed the Elderly (RCFE) Complaint Poster (PUB 475), a Deficiency was issued today. LPA reviewed ten resident files and five staff files. LPA observed that five of five staff records reviewed did not include a Health Screening Report, a Deficiency was issues today. For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued. LPA Ramirez advised BOM Belanger to use the general email address: CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA. LPA Ramirez conducted an exit interview with BOM Belanger and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 13, 2024

Type of visit: Office

An informal conference was held on this date at the Orange County Adult and Senior Care Regional Office, in Orange, California. The information meeting purpose and process was explained to Executive Director Specialist (ED) Shannon Howell. Present during the meeting were Licensing Program Manager (LPM), Sheila Santos, Licensing Program Analyst (LPA) Celine De Perio, and the new Executive Director Specialist, Shannon Howell. LPM Santos reviewed the following items with Executive Director Specialist: Complaint: 22-AS-20221003131319 with allegation of facility staff sexually assaulted resident in care. Substantiated on June 2, 2023. Importance of taking immediate action regarding any incidents of reported inappropriate behaviors towards staff and residents. Quality assurance procedure for licensee and administrator verifying that established procedures and policies are followed. The following plan was put in place: 1. The licensee will provide the internal investigation reports regarding previous Administrator and previous staff (S1). 2. The licensee will provide the facility procedure to safely store personnel records to prevent them to be compromised or lost. During the office meeting additional citations were issued by LPA De Perio. An exit interview was conducted. A copy of this report was read and provided to ED Shannon Howell. Appeal rights explained and provided.the state’s words, verbatim · CDSS document, May 16, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87205(a) · Plan of correction due date: May 30, 2024

87205 Accountability of Licensee Governing Body (a) The licensee, whether an individual or other entity, shall exercise general supervision...and the welfare of the individuals it serves. This requirement is not met as evidence by: Based on the Department’s interviews conducted, during the duration of S1’s employment, despite the complaints of inappropriate behaviors and intoxication, knowing about the sexual harassment allegations, the former management failed to exercise general supervision over the affairs of the licensed facility, initiate any forms of disciplinary action, and allowed for S1 to continue working at the facility. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: As a plan of correction (POC) ED will provide understanding of the regulation cited, and will formulate a training to all staff on the importance of not coming to work intoxicated. ED will provide proof to assigned LPA on or by May 30, 2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: May 30, 2024

87411 Personnel Requirements (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. This requirement is not met as evidence by: Based on the Department’s interviews conducted, during the duration of S1’s employment, S1 was reported of coming into work intoxicated, and facility failed to ensure S1 was physically and mentally capable of providing care to residents. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: As a plan of correction (POC), S1 was terminated on September 17, 2023. Deficiency cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: May 30, 2024

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator… This requirement is not met as evidence by: Based on the Department’s interviews conducted, during the duration of S1’s employment, despite the complaints of inappropriate behaviors and intoxication, management failed to initiate any forms of disciplinary action. Facility failed to perform the duties of a qualified administrator. This poses a potential health and safety risk to residents in carethe state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: As a plan of correction (POC) facility has hired a new administrator Deficiency cleared

Allegation investigated: Resident sustained an injury from a fall while in care

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA met with Sharrin Belenger, Bussiness Office Manager and explained the nature of the visit. Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegation. Findings are based upon this investigation which included interviews conducted and copies of pertinent documents obtained (hospital records, SOC341 and residents facility file). It is alleged that resident sustained an injury from a fall while in care. Hospital records revealed that the attending physician indicated per patient's DPOA with whom he had a lengthy discussion over the telephone who informed doctor that the patient has had multiple hospitalizations since December 2019 initially multiple times at Mission Regional Medical Center followed by multiple recent hospitalizations at Hoag Hospital Continued on LIC9099-C Unsubstantiated Newport Beach. DPOA is concerned that the patient has progressively declined and has had a recent change in residents (R1) physicians due to transition of care from Mission Hospital to Hoag Newport. R1 is aware that they fell and R1 did not use the walker as R1 was recommended to, denies any true loss of consciousness and on my current evaluation denies any acute complaints either. Hospital records revealed that on July 30, 2020, hospital social worker spoke with R1's DPOA and DPOA reported that R1 is at an assisted living facility for three months and the facility has been up front and transparent with the DPOA that R1 would benefit from a facility that would be able to provide a higher level of care. DPOA stated that they have been seeking out an appropriate facility for a couple of weeks now. Interview with staff 1 of 1 (S1) revealed that they spoke to R1’s daughter and informed her that R1 needed a higher level of care. Resident records revealed that R1 was admitted to the facility on May 09, 2020. R1 records for personal service plan was completed upon admission to facility. Personal service Plan indicate that R1 had changes to their care for a high care assistance on the following dates: June 01, 2020, June 2, 2020, July 23, 2020 and August 19, 2020. Personal service plan had updates on those dates for more care. Facility records revealed that R1 received an update personal service plan for the following services: dressing and grooming, showering, or bathing, bathroom assistance, escort & mobility and added service coordination. Incident report received indicates that on July 28, 2020 R1 pulled pendent, LVN assessed R1 for a fall and R1 indicated they had hit their head. Staff immediately called 911 and R1 was transported to the hospital for further evaluation. Based on the information gathered during the investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. This report was reviewed with facility reprensetative and a copy was furnished to the facility.the state’s words, verbatim · CDSS document, Apr 30, 2024 · control 22-AS-20200730163608

Allegation investigated: Staff did not give proper notice to resident's designated representative of rate increases. Staff did not give resident's designated representative explanations for rate increases. Staff incorrectly billed resident for medications. Staff are not following resident's medication doctor's orders.

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted by Executive Director (ED) Shannon Howell. It was alleged that staff did not give proper notice to resident's designated representative of rate increases. LPA conducted an interview with the reporting party (RP) who stated that the current ED explained everything to RP regarding rate increases, of which RP also verified that the notice was received and provided timely. It was alleged that staff did not give resident's designated representative explanations for rate increases. LPA conducted an interview with RP and staff 1 (S1), of which both interviews verified that explanations were provided regarding the increases. Both interviews stated that resident 1 (R1) would order "tray service" to their room and was getting charged every time R1 utilized tray service. Unsubstantiated 1 of the interviews specified that prior management failed to charge R1 for tray services, and now that there is new management at the facility, the management is adhering to the protocol regarding the rate increases. RP also stated that R1 was notified about these increases due to the tray services, to which R1 was provided explanations and encouragement to not utilize tray services if R1 did not want to continue paying. LPA reviewed records and it was observed that prior management did not charge R1 for tray services and obtained verification from R1 that R1 had been utilizing tray services "all the time". It was alleged that staff incorrectly billed resident for medications. LPA conducted an interview with RP and S1 and it was revealed that R1 is being charged for a prescribed medication, however RP believes that R1 does not need it, therefore it should not be billed. The interview with S1 stated that the facility contacted R1's doctor to inquire about if R1's medication should be discontinued, to which the doctor declined and stated that the medication for R1 would be continued as needed. LPA reviewed records and it was observed that the medication chart for R1 is up to date and reflect the medications that are prescribed by the doctor. It was alleged that staff are not following resident's medication doctor's orders. An interview with S1 stated that RP believes what medications R1 should not have, however, S1 verified that the facility manages R1's medications. The medication RP believes should be discontinued is a pro re nata "PRN" of which S1 stated that the PRN medication is only given to R1 as needed per physician report. An interview was conducted with RP, who was unable to provide further information regarding this allegation. RP then requested LPA to "disregard" the allegations/complaint due to obtaining information and explanations from the facility. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with ED Howell. A copy of this report was explained and provided.the state’s words, verbatim · CDSS document, Oct 13, 2023 · control 22-AS-20230726101433

Allegation investigated: Facility allows resident's medication supply to run out Lack of staffing

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation(s). LPA met with Business Office Manager Sharin Belanger and Administrator (AD) Shannon Howell and explained the reason for today’s inspection. The investigation into the allegations of facility allows resident's medication supply to run out and lack of staffing revealed the following: During the course of the investigation, LPAs inspected the facility, interviewed AD, 3 staff, and 10 residents, and obtained and reviewed copies of the Resident Roster, Staff Schedule, Physician’s Report for Residential Care Facilities for the Elderly (Physician’s Report) for 13 residents, Medication Administration Records (MAR) for 10 residents, Weights and Vitals Summaries for 10 residents, the facility’s Diagnosis Report, an email dated 07/10/23 from AD to a prospective resident, and Hoag Hospital Irvine Medical Records dated 09/20/23. Substantiated Regarding the allegation that the facility allows resident's medication supply to run out: Per staff statements, facility medication technicians and nurses are trained to reorder once-a-day medications 7 days in advance and twice-a-day medications 14 days in advance to ensure medications do not run out. Medication audits are also regularly conducted. LPA interviewed AD and the Wellness Director who denied the allegation and stated there are no issues with medications at the facility. LPA interviewed 10 residents and 3 residents stated they received assistance with medications. LPA reviewed MARs for these 3 residents for the past 3 months and observed that 2 of these residents, Resident #1 (R1) and Resident #2 (R2), had missed doses of medications due to the facility running out of supply, including 6 missed doses of Sertraline HCl Tablet 100 MG, 2 missed doses of Klor-Con 10 Oral Tablet Extended Release 10 MEQ (Potassium Chloride), and 1 missed dose of Furosemide Oral Tablet 20 MG (Furosemide). Per the Mayo Clinic, Sertraline is used to treat depression and other psychiatric disorders and missing several doses of an antidepressant may cause discontinuation syndrome the symptoms of which include agitation, sleep disturbances, dizziness, and flu-like symptoms; Potassium Chloride is used to treat blood pressure issues and a lack of potassium may cause muscle weakness, irregular heartbeat, mood changes, or nausea and vomiting; and Furosemide is used to treat fluid retention and swelling caused by congestive heart failure and other conditions and should only be taken as directed by the patient’s doctor. Regarding the allegation of lack of staffing: It was alleged residents were left in their chairs in the same positions for extended periods, wellness checks are not being conducted, and residents’ food intake is not being monitored properly resulting in weight loss. LPA interviewed AD who denied the allegation and stated that the facility has been using staffing agencies to fill in any staffing gaps since 2020. When interviewed, the Wellness Director denied the allegation and stated that staffing at the facility is based on a system which calculates how many service hours are required daily by the care plans of the residents and determines the number of staff needed. For example, on 08/23/23, the staffing schedule was 3 caregivers and 1 medication technician for the morning shift, 2 caregivers and 1 medication technician for the afternoon shift, and 3 caregivers and 1 medication technician for the overnight shift, with the Wellness Director, Wellness Coordinator, and Residential Care Coordinator also scheduled. Staff interviewed stated that based on their care plans, not all residents receive wellness checks. Residents are able to use their pendant to call for assistance. Residents who have difficulty using the pendant are scheduled for regular wellness checks. LPA reviewed weight records for 10 residents which show that residents’ weight is closely and regularly monitored by the facility and that 2 residents lost enough weight to trigger warnings in the facility system and 1 of these residents has already regained weight. AD stated that AD, the Resident Care Coordinator, and the facility’s nurses conduct twice monthly meetings to discuss resident status and changes and to adjust the residents’ care plan if needed to address issues like weight loss. LPA interviewed 10 residents and none of the residents reported any issues with wellness checks, nutrition, or weight loss. However, 3 residents corroborated that the facility does not have enough staff and that the wait times for assistance after pressing the pendant can be as long as 1 hour and 15 minutes during busy periods. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations of facility allows resident's medication supply to run out and lack of staffing. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. Regarding the allegation that residents are not receiving services paid for: It was alleged residents were not taken out of their rooms for 3 months in 2020 but were paying additional fees to be escorted around the facility. LPA interviewed AD and facility staff who stated that care plans are created based on residents’ needs and, from these care plans, assignment sheets are created which specify what services the residents are to receive and at what frequency. All services are presumed provided unless the care staff reports that the resident refused the service. Refusals are documented in the resident’s progress notes and the facility will address the issue with the resident and their family. LPA interviewed 10 residents and none of these residents corroborated this allegation. Regarding the allegation that lack of care and supervision resulted in a resident's death: Per witness statements, on 05/26/20 Resident #3 (R3) had a pulse oxygen reading of about 95%. R3’s pulse oxygen was not read again until 05/28/20 when R3 called for assistance with complaints of nausea and vomiting at which point their pulse oxygen was checked again and read at 82%. R3 was taken to the hospital where they passed away on 06/01/20. Per staff statements, R3’s primary diagnosis was hypertension with congestive heart failure, R3 was not on hospice, R3’s passing came as a surprise, and R3’s cause of death was respiratory failure related to their congestive heart failure. LPA reviewed R3’s Physician’s Report dated 03/22/18 which states R3’s diagnoses included congestive heart failure, coronary artery disease, and mild cognitive impairment. R3’s Physician’s Report also states that R3 was ambulatory, able to follow instructions, able to communicate needs, able to leave the facility unassisted, able to store and administer their own medications, and had a do-not-resuscitate order but was not on hospice. LPA reviewed Hoag Hospital Irvine Medical Records dated 09/20/23 which state on page 11 that R3 had a history of congestive heart failure, a pacemaker, recurrent pneumonias and bronchitis and that R3 was taken to the hospital on 05/28/20 due to hypoxia after facility staff tested R3’s pulse oxygen at 70%. On pages 17 and 18, the Medical Records indicate that, while having a pulse oxygen of 70%, R3 did not express any shortness of breath and was speaking clear and complete sentences. Per page 35 of the Medical Records, at the hospital R3 stated that, overall, they have been in very good health. However, assessment at the hospital revealed R3 was “profoundly hypoxic” and had “severe sepsis.” On page 47, the Medical Records describe that despite aggressive measures in the Critical Care Unit, R3’s condition deteriorated and R3 and their family decided to start comfort care in lieu of additional aggressive treatment. Per page 65 of the Medical Records, R3 passed away on 06/01/20 at the hospital. The Medical Records do not indicate that hospital staff suspected neglect or lack of care at the facility. The hospital social worker’s assessment on page 61 of the Medical Records states only that R3 lived with their spouse at the facility, had an “independent” level of function, and that the social worker found no “discharge barriers” if R3 were to be returned to the facility. On page 381, the Medical Records indicate that R3 denied having concerns about the facility. No information was obtained indicating that R3 required regular wellness checks or pulse oxygen readings and no reports were received from the hospital, R3’s family, or R3 themselves regarding any concerns about R3’s care at the facility. Regarding the allegation that the facility failed to report an incident as required: It is alleged the facility accepted a resident back from a skilled nursing facility with a diagnosis of Clostridioides Difficile and failed to report it. LPA interviewed AD who denied this allegation. LPA interviewed the Wellness Director who denied this allegation and stated that the facility requires a negative test result or documentation that the infection has colonized before accepting a resident who was diagnosed with Clostridioides Difficile. The Wellness Director compiled a Diagnosis Report from the facility’s electronic medical record system showing all diagnoses of all residents at the facility. LPA reviewed the Diagnosis Report which does not include Clostridioides Difficile. No information was obtained corroborating this allegation. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegations that residents are not receiving services paid for, lack of care and supervision resulting in resident's death, and failure to report incident as required occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. Regarding the allegation that the facility falsifies records: It was alleged the facility cannot accept residents with dementia and the facility ensures none of the residents have a dementia diagnosis by paying the 2 pre-contracted doctors $250 to falsely state that residents do not have dementia on their Physician’s Reports. LPA interviewed AD and the Wellness Director who denied the allegation and stated physician’s reports are completed by residents’ primary care physicians because they have history with these residents. LPA reviewed Physician’s Reports for 13 residents which showed that they were completed by 12 different doctors (2 residents who are related used the same doctor). LPA interviewed 10 residents none of whom provided information corroborating this allegation. AD stated the facility does not accept new residents with dementia and provided an email dated 07/10/23 in which she rejected a prospective resident for having a dementia diagnosis and referred them to facilities with memory care units. AD also stated that current residents who develop dementia are allowed to age in place and continue to live at the facility as long as their assessments indicate their needs can be met at the facility. LPA reviewed the facility’s file and confirmed that the facility is able to accept and retain residents with dementia, meaning the alleged falsification of Physician’s Reports would not even be necessary. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Oct 9, 2023 · control 22-AS-20200610155521

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 10, 2023

87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure 2 out of 3 residents received assistance with medications when the facility ran out of supply, which poses an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: The licensee stated they will create a plan to ensure that medication supply does not run out and submit the plan to LPA by POC due date and will train all medication technicians on the plan and submit proof to LPA within 7 days.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 23, 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. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure sufficient staffing when residents had to wait up to 1 hour and 15 minutes for assistance after calling, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: The licensee stated they will review call wait time records, create a plan to ensure wait times are not excessive during busy periods, and submit the plan to LPA by POC due date.