Buena Vista Assisted Living

Allegation investigated: Staff do not serve residents with food of good quality Staff did not meet resident’s showering needs. Staff do not safeguard resident's personal belongings

LPA contacted Reporting Party (RP) and they stated the Alleged Victim (AV) no longer wishes to follow through with the complaint. On July 21, 2026, Licensing Program Analyst (LPA), Ahliah Sharp, conducted an unannounced visit to the facility to deliver the findings regarding the allegations above. During the investigation, LPA conducted an inspection of the facility, interviewed Staff and Residents, reviewed facility records and meal logs from the weeks of January 19th-25th; January 26th-February 1st; February 23rd -29th and March 2nd -8th. On March 12, 2026, Community Care Licensing (CCL) received a complaint alleging that Staff do not safeguard Resident's personal belongings, Staff do not serve Residents with food of good quality, and Staff did not meet Resident’s showering needs. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Regarding the allegation pertaining to the quality of food, information obtained from interviews with Residents indicated there are no concerns regarding the quality of the food. LPA observed menus which identified a typical breakfast consisting of Oatmeal, cereal, and milk that are offered daily in addition to itemized scheduled breakfast items (e.g., omelets, toast, pancakes, fruit, yogurt etc.). Lunch menu provides flexible options (sandwiches nachos, soup, etc.) and an afternoon snack at 2:30pm. Dinner also has a flexible schedule with pork chops, meat loaf, ravioli and salads etc., and an evening snack at 7:00pm. Regarding the allegation pertaining to Staff not meeting Resident’s showering needs, information obtained from an interview with Executive Director (ED) Robyn Icamen, the facility abides by and maintains a shower schedule for Residents. It was explained there is an application on their work phone that provides them with the schedule of who is supposed to shower that day and if a Resident opts out, it is logged in this system. Information obtained from interviews with Staff confirmed the information. Information obtained from interviews with Residents had no complaints about their showering needs being met. It was further reported that some Residents refuse showers, but the facility works with Residents to prevent this from being problematic or habitual. Residents were able to articulate which day(s) of the week they were scheduled and reported never missing their designated day. LPA observed the shower schedule log; it indicated that Residents receive their regularly scheduled showers. Regarding the Resident’s belongings being safeguarded, information from ED indicated that this has not been an issue or area of concern. Apart from occasional laundry mishaps; which is typically rectified quite quickly, due to Staff’s familiarity with Resident’s belongings, this has not been an issue that she has been made aware of. Information obtained from interviews with Staff stated the same thing as what was shared above; an occasional mishap with laundry. Information obtained from interviews with Residents, two Residents mentioned issues with their belongings. It was stated that laundry is often misplaced but typically provided later. The remaining Residents interviewed reported no issues with their belongings. Continued on LIC9099C... Continue from LIC9099C... Based on information obtained from interviews with Staff and Residents, record review, and observation, the allegation that Staff do not safeguard Resident's personal belongings, Staff do not serve Residents with food of good quality, and Staff did not meet Resident’s showering needs, have all been deemed UNSUBSTANTIATED. Unsubstantiated means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was provided to ED Robyn Icamenthe state’s words, verbatim · CDSS document, Jul 21, 2026 · control 18-AS-20260312145021

Allegation investigated: Staff do not ensure Resident’s room is cleaned appropriately Staff do not ensure Resident’s room is free of pests Staff do not ensure Resident’s hygiene needs are met

On July 21, 2026, Licensing Program Analyst (LPA), Ahliah Sharp, conducted an unannounced visit to the facility to deliver the findings regarding the allegations above. During the investigation, LPA interviewed staff and residents, reviewed facility records, and conducted observations. Regarding the cleanliness of Resident’s rooms, it was reported that while visiting Resident at the facility, reporting party (RP) became outraged due to the appearance of Resident and their room. RP reported seeing dirty clothes in the corner of the room, and that it ‘smelled like urine’ alleging Resident was not being cared for properly. RP reported seeing ants all over, including some on Resident while in bed and on ceiling. RP stated they had video/pictures to corroborate their allegations. Information obtained from interview with Executive Director (ED), stated that the responsibility for cleaning not only falls on the housekeeping staff, but also on the caregivers in the absence of housekeeping. Continued on LIC9099C... Unsubstantiated Continued from LIC9099 LPA also interviewed additional staff, including housekeeping and it was reported that they all work together to ensure the cleanliness of the facility. One staff did not think it was ‘clean’ but admitted that everyone views cleanliness differently. Information obtained from interviews with Residents stated they do not have any issues with the cleanliness of their rooms. Some Residents do not want it done by Staff and are ‘particular’ about how they want certain things, but otherwise, when Housekeeping is off, all other Staff are responsible. On April 6th, April 9, and May 12, 2026, LPA conducted visits to the facility. During each visit, LPA observed the facility to be free of debris and clutter. LPA did not observe any issues regarding cleanliness of the facility that would pose any immediate health or safety concerns or personal rights issues. Regarding the allegation that staff do not ensure Resident’s rooms are free of pests, ED reported that pest control comes two (2) times each month to service the outside, and in the event a Resident mentions a need inside, that is provided on a case-by-case basis as well. Information obtained from staff stated that they see an occasional pincher bug [Earwig] from time to time but stated that being in a ‘desert’ area, it is not uncommon. Information obtained from interviews with residents stated they had no concerns about pests. LPA conducted an interview with Additional Witness and it was stated that photographs and video of their concerns were taken. LPA requested the evidence on two (2) separate occasions, but the Additional Witness failed to provide any evidence supporting the allegation. Regarding the allegations pertaining to staff not ensuring Resident’s hygiene needs are being met, information obtained from interviews with ED stated that showering schedules are implemented and tracked through a new digital system. On occasion, Resident might want to refuse showers, but it is logged and Staff will work hard to encourage Resident to shower at a later time or date. Information obtained from interviews with Staff corroborated the reports from ED. Information obtained from residents and reviewing records, also corroborated the reports from ED. Continued on LIC9099C... Continued from LIC9099C... Based on the information obtained regarding the allegations and the inability to obtain pertinent evidence, this complaint has been deemed UNSUBSTANTIATED. Unsubstantiated means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of the report was provided to ED Robyn Icammen.the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 18-AS-20260402112716

Allegation investigated: Staff did not safeguard resident’s personal belongings Staff stole resident’s personal belongings

On July 21,2026, Licensing Program Analyst (LPA), Ahliah Sharp, conducted an unannounced visit to the facility to deliver the findings regarding the allegations above. During the investigation, LPA conducted an inspection of the facility, interviewed five staff and 11 residents, and conducted a review of records. On April 2, 2026, Community Care Licensing (CCL) received a complaint alleging that staff did not safeguard resident’s personal belongings and that staff stole resident’s personal belongings. Information obtained from interview with Administrator indicated that the facility does not have an issue with belongings other than the occasional laundry mishap. Information obtained from interviews with staff stated the same as listed above. Continued on LIC9099C... Unfounded Continued from LIC9099... S1 mentioned a Resident falsely accusing S1 and another Staff of taking an item in the past but that Resident was memory care and tends to get confused. S1 mentioned they have a security system and said that it would be easy to check the cameras to prove S1 had not taken Resident’s item. Interview with Residents stated that from time to time, as mentioned above, laundry ends up in the wrong room, but it is quickly rectified. Interview with Additional Witness stated that the missing items noted in the allegations were not missing from the facility, but from a previous facility that Resident was placed at. It was stated that there were no concerns or issues regarding Resident’s personal property at this facility. LPA conducted a review of Resident belongings form and that revealed that the forms were left blank. They are provided for family members to fill out during intake, but according to ED, most simply opt out of filling it out since many residents come with very little. It is noted that they did not fill out the form,the responsible party signs as verification and ED also signs and forms are placed in the respective files. Based on the information obtained from interviews and record reviews, the allegation that staff did not safeguard Resident’s personal belongings and staff stole Resident’s belongings are deemed to be UNFOUNDED. Unfounded means the allegation is false, could not have happened, or is without a reasonable basis. The Department has dismissed the complaint. An exit interview was conducted and a copy of the report was provided to ED Robyn Icamenthe state’s words, verbatim · CDSS document, Jul 21, 2026 · control 18-AS-20260402112716

Type of visit: Required - 1 Year

On 5/12/2026, Licensing Program Analyst (LPA) Ahliah Sharp conducted an unannounced required annual visit. LPA met with Executive Director Robyn Icamen who was informed of the purpose of the visit. The facility’s current census is 49, with approval for fifty-eight (58) ambulatory, fifteen (15) non-ambulatory, one (1) bedridden resident; and a hospice waiver approved for eight (8) residents. LPA conducted a tour of the interior and exterior of the facility, reviewed facility documents and conducted five interviews; two (2) staff and three (3)residents. LPA observed the following: LPA observed the physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good working conditions. The outdoor area was observed to be free of any hazards. LPA observed a courtyard with outdoor furniture and shaded area for residents. Facility kitchen had the ability to prepare food in a clean environment and possessed equipment in good working conditions. The sharp and dangerous objects were observed to be inaccessible to residents in the kitchen. Facility kitchen receives one shipment of food every week, ordered on Monday and arrives on Tuesday. LPA observed the facility sketch, exit routes, personal rights, complaint information and emergency phone numbers posted around the facility. The smoke detectors and carbon monoxide detectors were operational. LPA observed the facility exceeded the required two (2) day supply of perishable and seven (7) day supply of non-perishable foods. LPA conducted medication review with staff, and observed the medical sharps stored in locked boxes inaccessible to residents in care. Continued on LIC809C Continued from LIC809... Staff files review included, but are not limited to, personnel records, criminal record clearance, required training, and valid first aid/CPR certification. The employee health screenings had been removed when the new company took over. They were advised that they would need to be made available in the employee files. Resident files included but are not limited to signed admission agreements, pre-placement, personal rights, needs and service plans, and updated physician reports. LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. Facility contained multiple charged fire extinguishers last serviced in March 2026, and Fire and Earthquake drills were last conducted on April 15, 2026. LPA observed all six (6) of the thermostat temperatures ranging from 75-78 degrees F. LPA advised ED about the water temperature needing to be a little warmer even though the resident was comfortable with the current temperature of 99.9F and the access to the health screenings of the staff need to be placed back in the staff files. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to ED Robyn.the state’s words, verbatim · CDSS document, May 12, 2026

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

Type of visit: Case Management - Other

On 9/17/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced case management visit to the facility due to the capacity increase request submitted by the Licensee. LPA Flores met with Administrator, Robyn Icamen, and explained the purpose of the visit. At the time of the visit there was (40) forty residents. The facility is currently licensed for (15) fifteen non-ambulatory, (33) thirty-three ambulatory residents, of to which (1) one may be bedridden. The facility is wishing to add additional bedding to selected units to create a shared bedroom. LPA observed units to a large enough space to allow for easy passage between and comfortable usage of beds and other required items of furniture specified below, and any resident assistant devices such as wheelchairs or walkers. Units observed did not have more than two residents shall sleep in a bedroom. LPA reviewed a Fire Safety Inspection Request (STD. 850) dated 7/21/2025, granted a fire clearance for (58) fifty-eight ambulatory, (15) fifteen non-ambulatory residents, to which (1) one may be bedridden. LPA toured the facility with Administrator Robyn. The physical plant is ready for the capacity increase as the facility sketches show sufficient livable space to accommodate the requested capacity. No health or safety issues were observed during the visit. A new license will be mailed to the facility to reflect the approved capacity increase. An exit interview was conducted where this report was reviewed and provided to Administrator, Robyn Icamen.the state’s words, verbatim · CDSS document, Sep 17, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Debbie Palacios conducted an unannounced annual required visit . LPA met with Clinical Care Director Vanessa Navarro who was informed of the purpose of the visit. Facility was approved for thirty three (33) Ambulatory, fifteen (15) Non-ambulatory, and one (1) bedridden resident; Hospice waiver approved for eight (8) residents. LPA conducted a tour of the interior and exterior of the faciity, reviewed facility documents and conducted interviews. LPA observed the following: LPA observed the physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed a courtyard with outdoor furniture and shaded area for residents. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies and detergents were stored and inaccessible to residents in care. The sharp and dangerous objects were observed to be locked and inaccessible to residents in the kitchen. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector and carbon monoxide was operational. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Facility receives one shipment of food every week scheduled for Wednesday. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Staff files reviewed include but not limited to have personnel records, health screenings, criminal record clearance, required training, and valid first aid/CPR certification. Resident files included but are not limited to signed admission agreements, pre-placement, personal rights, needs and service plans, and updated physician reports. LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. Facility contained multiple charged fire extinguishers last serviced on 03/31/2025.Fire and Earthquake drills were conducted on 04/03/2025. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Clinical Care Director Vanessa Navarro.the state’s words, verbatim · CDSS document, May 23, 2025

Type of visit: Case Management - Deficiencies

This Case management– Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Abdoulaye Zerbo on 1-9-25 for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 18-AS-20250109153636. LPA met with Robyn Rebollar and explained purpose of the visit. During the visit, LPA interviewed management and observed that the facility did not report the power outage to the department. Based on observations, record review and interviews , deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809-D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative, Robyn Rebollar.the state’s words, verbatim · CDSS document, Jan 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80061(b)(1)(E) · Plan of correction due date: Jan 23, 2025

80061 Reporting Requirements (b) ...during the operation of the facility... a report shall be made to the licensing agency...(1) Events reported shall include the following(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. Requirement was not being met as evidenced by: Licensee did not report SIRs to the Department for the power outage that occured on 1-8-25 at 12:30 PMthe state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Licensee will conduct staff training on the reporting requirements and provide proof of training and training material to LPA by the plan of correction date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with MedTech Gabriella Delharo, who was informed of the purpose of the visit. Clinical Care Director Vanessa Navarro arrived shortly after LPA's arrival to assist LPA with tour of the facility. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed a courtyard with outdoor furniture and shaded area for residents. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies and detergents were stored and inaccessible to residents in care. The sharp and dangerous objects were observed to be locked and inaccessible to residents in the kitchen. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector and carbon monoxide was operational, and the hot water temperature in multiple resident bathrooms met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Facility receives one shipment of food every week scheduled for Wednesday. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA reviewed eight (8) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid Certification. Five (5) resident files were reviewed, and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and Physician's Report. The listed administrator possesses a current administrator's certificate. Resident medication was centrally stored and locked in the medtech room. LPA reviewed medications prescribed to the residents and found all medication listed on electronic Medication Administer Record (eMAR) and all required labeling was found to be in place. LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. Facility contained multiple charged fire extinguishers. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Clinical Care Director Vanessa Navarro.the state’s words, verbatim · CDSS document, May 9, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff does not ensure residents records are properly maintained Resident is left in soiled adult brief for an extended period of time Staff does not ensure discontinued medications are properly discarded

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation(s) listed above. LPA met with Robin Rebollar-Icamen and explained the purpose of the visit and the elements of the allegation(s). The allegation(s) were investigated and the investigation consisted of observations, interviews and a review of both staff and resident records. Regarding the allegation staff does not ensure residents records are properly maintained. It was alleged that Staff #1 (S1) had not been charting the resident’s medication logs correctly. As Resident #1 (R1) has a medication that was prescribed that requires to have their vitals taken and documented before the medicine is dispensed. Upon a review of the Medical Administration Record (MAR) revealed that S1 not been had not been taking the R1's vital signs daily or charting the residents’ records for medication dispensed. Additionally, the vitals log, was observed to have been completed or documented R1's vital readings as of July 27, 2023, when it should haved began on July 26, 2023. However upon review of the order, the doctor's order was noted to have been faxed after hours, to the facility at 7:37pm. Substantiated Upon a further review of R1's facility file, there were not any documents for LPA to review such as Emergency ID Sheet, Admission Agreement, Physician’s Report, Needs/Services, Plan Functional Capabilities, or any Assessment Forms. During today's visit LPA observed for three (3) reviewed files out of (38) resident files to have the required documentation. Based on record review the allegation of staff does not ensure residents records are properly maintained is SUBSTANTIATED. Resident is left in soiled adult brief for an extended period of time Per the Business Office Manager/Med Tech Vanessa the incontinent residents are checked every two hours. Interviews conducted with residents revealed that sometimes it is impossible to be checked every two hours but, that when assistance is needed whether calling on the telephone or using their pendant/call button staff responds right away. The Nurse visit notes from an outside agency revealed that R1 had skin irritation believed to have been caused from being left in a soiled brief. Further interviews conducted with facility staff revealed that yes, there are residents that are left in a soiled adult brief and it is usually occurs during shift change, and that staff are reported to ignore the resident call lights. Based on interviews and records review the allegation of resident is left soiled in an adult brief for an extended period of time is SUBSTANTIATED. Staff does not ensure discontinued medications are properly discarded During a complaint visit conducted on 08/01/23, LPA conducted a review of R1's medication as well as the Medication Administration Record (MAR) and observed for a medication to have been finished on 7/28/23, however the medication was was still in R1's basket. During today's visit LPA observed for R2 to have medication in their basket that was not on the physician's order. LPA was informed that R2 was admitted to the facility with that medication. R2 was admitted to the facility on 08/04/23. Per Business of Manager/Med Tech Vanessa the medications are disposed of by the facility Nurse, and is done as needed. Per Vanessa the facility Nurse comes to the facility two(2)- three (3) times per week. Based on observations and records review the allegation of staff does not ensure discontinued medications are properly discarded is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted and a copy of this report, and appeal rights were provided to Robin Rebollar-Icamen. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted and a copy of this report and appeal rights were provided to Robin Rebollar-Icamen.the state’s words, verbatim · CDSS document, Oct 23, 2023 · control 18-AS-20230728141755

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Nov 6, 2023

87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: the licensee failed to ensure that 1 out of 1 resident records were maintained with the necessary information for LPA to review. This poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 23, 2023

Plan of correction: The licensee agrees to conduct an audit of resident records, and will submit a copy of facility audit checklist. Proof of POC is to be submitted to the department by 5pm on the due date indicated.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 6, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ... Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: the licensee failed to ensure that residents were checked and chanaged as required.the state’s words, verbatim · CDSS document, Oct 23, 2023

Plan of correction: The licensee agrees to increase staffing on the NOC shift, by adding an additional staff. Proof of POC is to be submitted to the department by 5pm on the due date indicated.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(i)(3) · Plan of correction due date: Oct 23, 2023

87465 Incidental Medical and Dental Care Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s established record procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following:the state’s words, verbatim · CDSS document, Oct 23, 2023

Plan of correction: The requirement is not met as evidenced by: the licensee failed to destroy a discontinued medication 1 out of 1 times. This poses a potential heath, and safety risk to persons in care. The licensee agrees to conduct an audit of medications and physician orders, and destroy and needed medication. Proof of POC is to be submitted to the department by 5pm on the due date indicated.