Brookdale San Ramon

Type of visit: Case Management - Health Checks

On 9/04/2026 at 1:00 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Health and Wellness Director, Baljinder Pamma and explained the purpose of the visit. LPAs toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured between 105-120 degrees F in random residents apartments. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Refrigerator temperature was observed at 38 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 3/5/2026. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 4, 2026

Allegation investigated: Staff did not ensure residents room was clean

On 6/4/2026 at 9:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Lola Bullock, Executive Director. On the allegation; Staff did not ensure residents room was clean Staff interviews stated that the facility did not have a consistent or implemented procedure for logging housekeeping tasks when concerns arose. Staff reported noticing a smell in the resident’s room and checked the refrigerator, bathroom, and bedroom but were initially unable to locate the source. Record review showed one documented concern regarding R1’s room environment. On 11/9/2025, staff reported a “foul smell coming from her apartment” after checking the refrigerator and trash with no identifiable source found. Continued on LIC 9099-C... Substantiated Continued from LIC 9099 The odor was later traced to food in the microwave, which had been obstructed from view. Maggots were removed, and the microwave was replaced. Staff stated a meeting was held afterward, and a daily housekeeping activity sheet was created and implemented to document completed and uncompleted cleaning tasks. Staff further reported that November was a difficult month due to the loss of multiple housekeepers, resulting in management filling in until additional hiring restored full housekeeping staffing levels. Housekeeping reportedly serviced rooms once a week unless notified of a spill or mess requiring additional cleaning. Based on LPAs interviews, 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 being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided. Continued from LIC 9099-A On the allegation; Due to staff neglect, resident sustained pressure injuries Record review showed that R1 developed a pressure related wound requiring ongoing dressing changes and hospice involvement. Notes beginning 12/1/2025 indicated discomfort to the bottom, and by 12/4/2025 hospice staff were changing the wound dressing. On 12/7/2025, staff documented wound drainage and continued pain. R1 frequently refused repositioning, increasing her risk of skin breakdown. A low air loss mattress was ordered and delivered on 12/10/2025. On 12/17/2025, the wound dressing was found contaminated with BM and was changed; hospice continued providing wound care. R1 remained on hospice services until her passing on 12/19/2025. On the allegation; Staff did not follow Physicians’ orders Record review showed several updates to R1’s physician ordered medications. On 10/20/2025, Hydrocodone/Acetaminophen was ordered twice daily for pain, generating drug‑interaction alerts. On 11/12/2025, Furosemide 40 mg was ordered for ascites, and on 11/21/2025, hospice directed that it be discontinued. On 12/08/2025, Morphine Sulfate oral solution was ordered as a PRN for pain and shortness of breath. On 12/10/2025, a Fentanyl patch order was entered, which also triggered interaction alerts. Certain medication orders, including Hydrocodone/Acetaminophen on 10/27/2025 and 11/09/2025, were later removed or adjusted in response to R1’s refusals and changes in her hospice care plan. Record review including the facility MAR, hospice collaboration notes, hospice EMR, and the Kaiser Physician’s Report—showed that R1’s physician and hospice orders were followed. Medications such as Norco, morphine, bowel regimen agents, oxygen, and wound‑care treatments were administered as ordered, with refusals documented, and discontinuation made only per hospice direction. Hospice notes consistently show orders communicated to facility staff and carried out during visits. No evidence was found of missed or ignored physician or hospice orders Continued on LIC 9099-C... Continued from LIC 9099-C On the allegation; Staff left resident in soiled lines/clothing for an extended period of time Staff interviews stated that residents receive laundry services once a week and are responsible for providing their own bed sheets. S1 reported that staff would change soiled sheets when found; however, this was sometimes difficult when a resident only had one set of sheets. S1 further explained that when a resident consistently soiled their bedding, the facility would request additional sheets from the family, though families did not always provide them. S1 added that the previous Wellness Manager often purchased spare sheets for residents who needed an extra set. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 15-AS-20260209082337

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 18, 2026

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visit This requirement is not met as evidenced by: Based on LPAs interview licensee did not comply with the section above by not cleaning a residents microwave which allowed maggots to form which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: The facility agrees to review the regulation and submit a letter of self certification along with the updated housekeeping check list to CCLD by POC date.

Type of visit: Required - 1 Year

On 1/26/2026 at 9:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director (ED), Lola Bullock and explained the purpose of the visit. The facility’s fire clearance was approved for 82 non-ambulatory and 28 ambulatory on the third floor. LPA toured the facility with ED including but not limited to 7 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 68 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 104.8, 107.6, and 108 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. Refrigerator temperature: 39 Freezer temperature:0 There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications are locked and inaccessible to residents in care. Emergency disaster plan last reviewed 3/10/2025. Emergency disaster drill conducted 1/16/2026 .First aid kit observed to be complete. Fire Extinguishers last serviced 3/6/2025. At 12:40pm, LPA reviewed 5 residents records. At 1:00pm, LPA reviewed 5 staff records and 1 of 5 have current first aid training and 5 of 5 are associated to the facility. LPA reviewed a sample of resident’s medications. Report Continues on LIC809-C THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: LPA observed unlocked scissors in activity space unattended and unlocked stainless steel cleaner in resident laundry rooms LPA observed food being improperly stored in kitchen LPA observed that 4/5 staff records reviewed did not have the required first aid training. ***Civil Penalty assessed $250 for repeat violation in 12 month period*** Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 2/10/2026: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Updated Facility sketch Current Administrator’s Certificate The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 26, 2026

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff are not meeting residents toileting needs Staff are not providing adequate food service

On 10/7/25 at 10:00 a.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver complaint investigation findings in regard to the allegations above. LPA met with Executive Director, Lola Bullock and explained the purpose of the visit. On 8/7/2025, 9/12/2025, and 10/7/2025 LPA conducted interviews. On 9/12/2025 LPA also conducted observations at the facility. S1-S10 were interviewd. LPA also attempted to interview R1-R3. Report continues on LIC9099-C Substantiated On the allegation "Staff are not properly supervising residents who may be a fall risk" the following was found: During interviews with staff on 8/7/2025 and 9/12/2025 were able to identify residents needs. LPA also observed sufficient coverage of staff on the day of the visits to meet the needs and services of residents. Based on observations of the staff schedule and staff on duty there is adequate supervision. LPA also briefly spoke to R3 who did not have any concerns with the care that they are receiving. On 9/12/2025 during PM shift LPA also tested call buttons in a random selection of rooms and staff were prompt to respond. Therefore the allegation "Staff are not properly supervising residents who may be a fall risk" is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided. PG. 2 On the allegation "Staff are not meeting residents toileting needs" the following was found: During interviews with staff on 8/7/2025 and 9/12/2025 multiple staff reported that they have found residents wet and their beds "soaked" with urine during their shift. Staff made specific mention of R1, R2, and R3 being excessively wet on multiple occasions. During the interviews it was noted that residents are primarily found excessively wet at the start of the morning shift however it was mentioned that there have been occasions of excessive wetness on other shift. Multiple staff reported that they have reported concerns of residents incontinence needs not being met amongst other caregivers as well as leadership. LPA also attempted to interview R3 regarding incontinence but was unable to.Therefore the allegation of "Staff are not meeting residents toileting needs" is Substantiated. On the allegation "Staff are not providing adequate food service" the following was found: During interviews with staff on 8/7/2025 and 9/12/2025 there was a mixed review of the food being served at the facility. There were reports of the food being "ok", "good", and "healthy". There were also reports of the food "appearing under cooked" primarily the chicken. On 9/12/2025 the Health and Wellness Director (HWD) sampled the dinner meal of the day for the LPA and reported the food to have good flavor and quality. LPA observed the food that the HWD was sampling appeared to be of good quality. However upon inspection of the kitchen LPA observed that already prepared food to be served was not being stored properly and was left uncovered also sandwich supplies where also uncovered and not in use (ie. tomatoes, onion, lettuce, mayo, ect) . LPA also observed that there was a fly in the dinning/Kitchen area. LPA also inspected the food in the refrigerator/ freezer and observed some food in the refrigerator was moldy/expiring. LPA observed RAW chicken stored on top of produce in the refrigerator and open fish in the freezer. LPA also asked R3 about how they liked the food and they said it "sucked" but was unable to elaborate. Therefore the allegation of "Staff are not providing adequate food service" is Substantiated report continued on LIC9099-C PG. 3 Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 15-AS-20250805091456

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Oct 14, 2025

(b)In addition .. the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry... from incontinence. This requirement was not met as evidence by: Based on interview with staff (S1-S10), the licensee did not comply with the section cited above in residents not being kept clean and dry from incontinence which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: By POC date Health and Wellness Director agrees to submit a memo reminding staff of incontinent practices and provide a copy to CCLD

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Oct 14, 2025

(a)The total daily diet shall ...be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidence by: Based on observation, the licensee did not comply with the section cited above in having improperly stored and expired food in the kitchen which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: By POC date Executive Director agrees to conduct a training regarding food storage and cleanliness procedures and notify CCLD

Allegation investigated: Licensee does not maintain the facility in good repair

On 6/13/25 at 9:00 a.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver finding complaint investigation in regard to the allegation above. LPA met with Executive Director, Lola Bullock and explained the purpose of the visit. During prior visit LPA interviewed S1, S2, ED and HWD and found that the southside elevator has been sporadically going down over the past few years and has been increasing in how often there are outages. ED states that they have been actively implementing solutions and has a work order out for repairs. Therefore the above allegation is Substantiated. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted and a copy of this report provided. Substantiatedthe state’s words, verbatim · CDSS document, Jun 13, 2025 · control 15-AS-20250502163330

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 11, 2025

(a) The facility shall be ...in good repair at all times...for the safety and well-being of residents... This requirement is not met as evidence by: Based on interviews the facility did not comply with the section cited above by the southside elevator going in and out of service over the last few years which poses a potential safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 13, 2025

Plan of correction: By POC facility agrees to submit documents for the work being done and notify CCLD of the completed repairs. LPA may conduct a case management once repairs are complete.

Allegation investigated: Improper eviction Resident needs are not being meant Staff left resident in soiled diaper Facility is not providing services that are being charged Facility is short staffed Facility is not proving resident proper meal Resident is being isolated Resident room is being used as staff break and or storage room

On 4/18/2025 at 9:00AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver complaint findings for the above allegations. LPA met with current Executive Director, Lola Bullock and explained the purpose of the visit. During the investigation LPA interviewed staff, residents, reviewed care plans, admissions agreements, physicians reports for R1, toured facility, and reviewed documents. Report continues on LIC9099-C Unsubstantiated On the allegations “Improper eviction” “Resident needs are not being meant” “Staff left resident in soiled diaper” “Facility is not providing services that are being charge” “Facility is not proving resident proper meal” “Resident is being isolated” “Resident room is being used as staff break and or storage room” “Facility is short staffed” the following was found: On 01/14/2025, LPA conducted interviews with R1 and the Executive Director at the time Niare Feaster (ED), reviewed documentation including R1’s admission agreement, care plan dated 10/13/2023, physician’s report dated 04/18/2024, facility billing records, eviction notice, and staff schedules. Facility observations were also conducted. R1 stated they feel there are not enough staff and expressed a desire for more one-on-one interaction, including being accompanied to the activities area every Wednesday at 1:00 PM. R1, who identifies as largely independent, shared they self-administer medication and often decline bathroom assistance. They clarified they do not receive diapering services as part of their care plan and care plan reflects that they do not require incontinence care. R1 reported requiring nighttime toileting assistance due to wheelchair access challenges. R1 also shared concerns about having occasionally forgotten to request meals, resulting in limited options such as toast or pie. R1 expressed dissatisfaction with being billed for services such as oxygen management and bathing, which they believe are not provided. Review of records showed R1 was admitted on 10/13/2023, with a base rate of $7,413.00 per month. The total amount billed through February 2024 was $46,630.62 including late fees, with only two successful payments made since admission, as reflected in the payment history. The ED explained that the oxygen service billed is the facility’s base rate for residents with oxygen, which includes documentation but no hands-on management or intervention. ED stated that toileting assistance remains on the service plan, however R1 seldom uses it and has declined its removal. Report continues on LIC9099-C Continued from LIC9099-C Regarding the eviction, a 30-day notice to quit was issued on 02/02/2024 for non-payment of rent. Staff schedules for February and March 2024, were reviewed by LPA and LPA observed that enough staff were scheduled. LPA also observed an adequate amount of staff at the time of both visits. While R1 reported feeling that more staff would improve their experience, interviews and documentation confirmed no lapses in care or supervision. Observations conducted during the facility visit found R1’s room appropriately maintained and free of any signs it was being used for staff breaks or storage. There were no indications of inappropriate use of the resident’s private space. There was no evidence to support the allegation that staff left R1 in a soiled diaper, and this is further unsupported by the fact that R1 does not receive diapering assistance as part of their care plan. Regarding meals, kitchen staff reported that residents must request meals outside of scheduled times and that snacks, including pie, are available when full meals are not requested. R1 stated that they do forget to order meals sometimes and only wants toast or other small items from the options available. Finally, R1 stated that they remain in their room by choice due to pain and mobility limitations and may request assistance to participate in activities. ED did inform LPA that while staff provide escorts to R1 when available if they would like that to be apart of their care plan it would be an additional charge. Based on interviews, record review, and observations the above allegations are UNSUBSTANTIATED Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 18, 2025 · control 15-AS-20250109160645

Type of visit: Case Management - Other

On 4/18/2025 at approximately 11:15AM, while at the facility on an unrelated complaint investigation LPA A Gomez conducted a case management visit. LPA met with Executive Director, Lola Bullock and explained the purpose of the visit. Upon arrival at the facility LPA met with Executive Director (ED) Lola Bullock and the ED disclosed to LPA that on 4/17/2025 at approximately 6:00PM R1 left the facility in their wheelchair and tried to roll themselves into traffic. ED states R1 is unable to leave the facility unassisted according to their physicians report and that when R1 exited the facility the front desk and other staff followed to ensure their safety. ED states that R1 has a history of suicidal ideations and provided LPA with substantiating documentation. ED notified the police and had R1 transferred to the hospital to be put on a 5150 hold. ED states that due to R1's continues attempts at self harm that they are requiring a 1 on 1 supervision in order for R1 to return to the facility to ensure the safety of the resident. At the beginning of the visit ED informed LPA that R1 is currently at the hospital and LPA advised ED to notify R1's responsible party and update R1's care plan for return. LPA observed that R1's 602 dated 10/4/2023 states that R1 has a history of depression, suicide, and elopement. While at the visit ED received an update that R1's family has decided to move R1 to a facility with a higher level of care. LPA requested to be informed of any updates. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 18, 2025

Allegation investigated: Facility staff did not notify responsible party of change in condition Facility staff serve poor quality food

On 3/27/2025 at 9:00AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct an investigation and deliver findings. LPA met with Executive Director, Lola Bullock. During the course of the investigation LPA conducted interviews, toured facility, observed the Kitchen/food, and reviewed available files. LPA interviewed S3, S4, S5, S6, and Health and Wellness Director (HWD) Report continues on LIC9099-C Unsubstantiated In regard to the allegations "Facility staff did not notify responsible party of change in condition " and "Facility staff serve poor quality food "LPA interviewed S3, S4, S5, S6, and Health and Wellnes Director. S3 was not a staff member at the time of R1's admission but stated that the quality of the food is good. S3 described the food as really good. S3 states that the menu choices are good. S3 has eaten the food and says that they are good; sometimes a little bland but nothing that salt and pepper cant fix. S4 stated that the resident never expressed unhappiness to them about anything. States that when resident would complain about the food they would say it sucks and that they would just agree with the resident . States that they have had the food a few times but that it was nothing memorable. S5 states that R1 never expressed any information about their private life. States that the R1 seemed happy. States that R1 would talk about problems with their jobs and going to court with their spouse but that they would be smiling when discussing it. S5 states that they were surprised to find out about R1 incident. States that R1 would complain about the food and quality and that they(S5) would apologize. S5 states that they have tried the food and that they do not like it. States the food is bland, tuff, and greasy. S6 states that they are trained to look for a change in behavior but was unable to specify in regard to mental health. S6 states that they heard about R1's incident and that when looking at the chart they could see that they had a history of depression. However S6 did not ever work with R1. States that it is very common for residents to complain about the food. States that residents complain about the meat being dry and tough. When LPA interviewed HWD they stated that R1 did not exhibit any change in their routine and that when they(R1) were admitted they were already going through stressors and it was not something new that occurred while at the facility. HWD states that R1 was an independent resident and also a private person. R1 would talk about what they were dealing with in life but never expressed being distressed. HWD states that on the day of the incident with R1 there was no change in their routine. HWD states that R1 had a therapist that they would work with and observed R1 utilizing coping mechanisms such as taking walks. Report Continues on LIC9099-C LPA reviewed the 602 for R1 and observed that they did not have a diagnosis of depression and had a secondary diagnosis of anxiety. On 12/16/2024 LPA observed the food being served to the residents and utilized the Business Manager as a taste tester. The food observed was beef stew, rosemary chicken, bbq chicken, lasagna, and carrots. LPA cut each piece and had no difficulty. The business manager sampled each item and stated that they were easy to chew and had a pleasant taste. LPA asked the chef how each item was seasoned and the chef showed the LPA a variety of seasonings and stated that they also used low sodium seasoning. The food looked appetizing and had a pleasant smell. LPA also observed table salt and pepper available at all dining tables for use. On 3/27/2024 LPA briefly spoke with a R3, R4, and R5 during lunch hour who all stated that they like the food at they facility and have no complaints. Based on interviews, observations, and record reviews the allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 15-AS-20241122153441

Type of visit: Required - 1 Year

On 3/20/2025 at 11:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Niare Feaster and explained the purpose of the visit. The facility’s fire clearance was approved for 82 non-ambulatory and 28 ambulatory on the third floor. LPA toured the facility with Niare Feaster including but not limited to 5 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at xxx degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 104.8, 112.6, 109.2, 108.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. Refrigerator temperature: 38 Freezer temperature:0 There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Emergency disaster plan last reviewed 3/10/2025. First aid kit observed to be complete. Fire Extinguishers scheduled for service 3/8/2024. At 12:30pm, LPA reviewed 5 residents records. At 1:00pm, LPA reviewed 5 staff records and 5 of 5 have current first aid training and associated to the facility. At 11:45am, LPA reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 20, 2025

Allegation investigated: Illegal eviction

On 2/7/2025 at 9:30AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct an investigation and deliver findings. LPA met with Niare Feaster, Executive Director (ED). During the course of the investigation LPA conducted interviews and reviewed available files. ED states that R1 was not able to return to the facility because they had a stage 3 wound and that they told R1 the wound needed to heal before retuning. LPA interviewed R1 as well and R1 stated that the wound was staged at a 3 by one physician and a 2 by another. Report continues on LIC9099-C Unsubstantiated LPA also interviewed the health and wellness director (HWD) who stated that R1 was told that they could not return to the facility with a stage 3 wound. ED and HWD both stated that the resident could return once the wound was no longer a stage 3. There was no documentation available for the LPA to review the official diagnosis of the wound. Title 22 states, "(a)Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:(1)Stage 3 and 4 pressure injuries". R1 never received an official eviction letter and relatives removed R1's belongings. Therefore the allegation "Illegal eviction" is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 7, 2025 · control 15-AS-20240807105106

Allegation investigated: Facility not responding to resident's needs in a timely manner

On 2/7/2025 at 9:30AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct an investigation and deliver findings. LPA met with Niare Feaster, Executive Director (ED). During the course of the investigation LPA conducted interviews and reviewed available files. LPA spoke with the ED who acknowledges that the allegation "Facility not responding to resident's needs in a timely manner" is true at the time that the complaint was made. On 12/16/2024 LPA also interviewed S2, S3, and S4 who all felt that the facility is understaffed which leads to longer response times. Therefore the allegation is SUBSTANTIATED. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Substantiated LPA also interviewed the health and wellness director (HWD) who stated that R1 was told that they could not return to the facility with a stage 3 wound. ED and HWD both stated that the resident could return once the wound was no longer a stage 3. There was no documentation available for the LPA to review the official diagnosis of the wound. Title 22 states, "(a)Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:(1)Stage 3 and 4 pressure injuries". R1 never received an official eviction letter and relatives removed R1's belongings. Therefore the allegation "Illegal eviction" is UNSUBSTANTIATED. During the course of the investigation LPA found through interviews with the ED, R1, and HWD that between the facility van with a lift was down. This van was the primary source of transportation for wheelchair residents. However the ED showed LPA receipts of Uber's that were scheduled for R1. Uber did cancel multiple rides due to not having wheelchair accessible vehicles. However the facility made multiple attempts to assist R1 with getting to their appointments. R1 states that they eventually found their own transportation that they paid for. A review of R1's admissions agreement and handbook showed that the facility does not guarantee transportation but that they will assist in making arrangements which the facility did. Therefore the allegation "Facility did not provide or assist in finding transportation for appointments" is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATEDthe state’s words, verbatim · CDSS document, Feb 7, 2025 · control 15-AS-20240814163008

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 7, 2025

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary...of adequate services. This requirement is not met as evidence by: Based on interviews the facility did not comply with the regulation above by not providing adequete services to residents requesting assistance which posed a potential personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Feb 7, 2025

Plan of correction: ED states that the facility now has low response times for clients and understands the importance of timely responses. POC cleared.

Allegation investigated: Staff made resident move rooms Staff is threatening resident with eviction Staff are not meeting resident's needs

On this day at around 12:00 pm, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct an investigation and deliver findings. LPA met with Niare Feaster, Executive Director (ED). During the course of the investigations LPA conducted interviews and reviewed files. On the allegation of staff made resident move rooms LPA interviewed R1, R2, and R3. All residents agreed that ED offers rooms that become available with a better rate but never forces them to move rooms. All residents stated that if they moved rooms it is because they wanted to. On the allegation of Staff threatening resident with Eviction LPA interviewed R1, ED, and S1. R1 states that the ED mentioned eviction during meal time and that the ED spoke with them and their brother about the eviction. ED states that they did speak with the brother about the eviction after R1 requested the conversation and that coversation happened privately in R1's apartment. ED states that the eviction wasn't mentioned during a meal time but that rather all eviction notifications are done via letter directly sent from coorporate to clients mailbox. Report continues on LIC9099-C Unsubstantiated ED states that eviction letters resemble a bill and when LPA interviewed R1 they stated that they got a bill not an eviction letter. LPA also interviewed S1 who stated that they have never heard staff speak to any residents directly about being evicted. S1 states that they do recall a conversation with R1 and the topic of eviction but that R1 was talking to other residents about it during meal time. R2 and R3 do not recall hearing about a resident being evicted. On the allegation of staff not meeting residents needs LPA interviewed R1, R2, and R3. R2 and R3 both felt that their needs are met at the facility. When LPA interviewed R1 it was found that R1 felt that their needs were not being met but that it was their personal caregiver that was supposed to be providing a 1:1 that was not meeting their needs and that they had no complaints with the facility staff. LPA also obtained a copy of what an eviction notice looks like for reference. 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 allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Aug 15, 2024 · control 15-AS-20240313143757

Type of visit: Case Management - Incident

On 08/09/2024 at 1:50 p.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit due to receiving an Unusual Incident Report (UIR) of a resident having attempted suicide. LPA met with Niare Feaster, Executive Director and explained the purpose of the visit. R1 was admitted to the facility on 9/29/23. Physician's Report dated 6/07/24 indicates that R1 was independent and could leave the facility unassisted. Report indicates that R1 was not at risk of accessing personal grooming supplies. The report also documented that R1 did not have any suicidal ideations. ED stated that R1 had 2 cuts about 1 inch each and that the cuts did not require stiches. Resident is still on a 5150 hold and has not returned to the facility. R1 refused to be transported to the hospital and received first aid from the EMT's. RP was notified of incident and came to the facility to speak to ED and at that time R1 admitted that the cuts were self inficted and that they planned on doing it again. ED notified law enforcement and R1 was 5150 when EMT's returned. R1 is to be reassessed before returning to the facility. RP and ED will determine the best course of action and develop a new care plan as needed. Health and Wellness Director filed an UIR and informed LPA via phone of the incident. LPA toured R1's room with S1 and observed it to be within regulation standards. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 9, 2024

Type of visit: Case Management - Incident

On 6/06/24 at 10:45 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit due to receiving an Unusual Incident Report (UIR) of a resident having committed suicide. LPA met with Jennifer Gordon-Alvarez, Health and Wellness Director and explained the purpose of the visit. During the visit LPA interviewed S1, reviewed R1's facility file and toured R1's room. R1 was admitted to the facility on 11/14/23 from a rehab facility due to having suffered a stoke. Physician's Report dated 6/16/23 indicates that R1 was independent and could leave the facility unassisted. R1 also managed his own medications. The report also documented that R1 did not have any suicidal ideations. S1 stated that R1 routinely took walks on the hill behind the facility. S1 stated that on 6/04/24 at around 5 p.m. she received a call from a friend of R1. The friend stated that he had called R1 numerous times throughout the day and haven't heard back from him. S1 searched for R1 and found him slumped over on the trail behind the facility. S1 observed a small handgun next to R1. S1 called 911, police and paramedics arrived and pronounced R1 decreased from an apparent suicide. S1 filed an UIR and called the facility's LPA to inform her of the incident. LPA toured R1's room with S1 and observed it to be neat and orderly with several personal items. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 6, 2024

Allegation investigated: Staff did not follow proper reporting requirements

On this day, LPA Luisa Fontanilla arrived unannounced to deliver finding for the above allegatoin and met with Jennifer-Gordon Alvarez. LPA explained to Alvarez the purpose of the visit. During the course of investigation, LPA interviewed staff and reviewed records. S9 states R1 reported concerns regarding S8 inappropriate behavior to S9 and S5 on July 12, 2023. SOC 341 was created on July 28, 2023. Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D. Exit interview was conducted with Alvarez and Appeal Rights was provided. Substantiated Resident's bedding is not changed frequently R1’s PSP indicates that R1’s laundry and housekeeping schedule is every Monday. Staff interviewed state R1’s beddings get changed as scheduled unless R1 refuses. And during bed baths, staff interviewed state if the sheet gets wet from the bed bath, they change the beddings. Staff engaged in inappropriate interactions with resident in care During the course of investigation, LPA interviewed staff who state that they have not worked with S8 for a long time. S6 states that all S6 knows about S8 is that S8 resigned from the facility due to an emergency that required S8 to go back to S8’s country of origin. And as far as S6 is aware, S6 treats residents good. However, S6 states S6 is not aware what happens once S8 is alone with the residents inside the room. S9 states S8 resigned from the facility in June 2023. LPA was unable to obtain contact information for S8. Facility does not have a proper Emergency Disaster Plan Based on interviews conducted with the Executive Director, the facility does annual emergency disaster training. Fire and elopement drills are conducted monthly. The facility’s last emergency disaster drill was conducted on May 25, 2023. Based on interviews and record reviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. There are no deficiencies noted.the state’s words, verbatim · CDSS document, Apr 25, 2024 · control 15-AS-20230731144026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Apr 30, 2024

87211(a)(1)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence … (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on interviews and record review conducted, facility failed to report R1’s concerns regarding S8 inappropriate behavior to CCL within 7 days of occurrence which poses a potential risk to the health and safety of the clients under care. The incident was reported to S9 on 7/12/23. SOC 341 was created on 7/28/23.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: By POC date, the Administrator will review cited section and submit certificate of understanding to CCL.

Type of visit: Required - 1 Year

On 02/23/2024 at 7:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a 1-Year Annual Required inspection. LPA met with Executive Director, Niare Feaster and explained the purpose of the visit. The facility’s fire clearance was approved for 82 non-ambulatory and 28 ambulatory. LPA toured the facility with Executive Director including but not limited to random residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73.3 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 106.7, 110.4, 106.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Emergency disaster plan last reviewed 1/1/2024. First aid kit observed to be complete. Fire Extinguishers scheduled for service 3/8/2024. At 8:30am, LPA reviewed 5 residents records. At 9:15am, LPA reviewed 5 staff records and 5 of 5 are associated to the facility. At 10:30am, LPA reviewed a sample of resident’s medications. Continued on LIC 809-C The following Deficiencies were observed during Inspection/Visit: At 8:40AM during resident file review files were observed incomplete. R1 was missing emergency id, emergency medical consent, and personal rights. R3 was missing emergency id, emergency medical consent, and personal rights. Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 03/01/2024: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 23, 2024