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Allegation investigated: Staff did not report incident to licensing. Facility call light system is inoperable. Staff did not provide residents with adequate meal service. Facility did not employ adequate staff to meet the needs of residents in care.

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the allegations listed above. LPA met with facility Cognitive Care Director, Ashley Mendoza , and explained the purpose of today's visit. Regarding the allegation that staff did not report incident to Licensing, Licensing Program Analyst (LPA) conducted interviews and reviewed facility records related to the reported resident fall incident involving resident 1.LPA reviewed a completed Unusual Incident/Injury Report documenting the resident experienced an unwitnessed fall on 01/31/2026 resulting in hospitalization. Facility records reflected the facility completed a written incident report and provided a fax cover sheet and confirmation report indicating a nine-page report was transmitted to the Licensing office on 02/05/2026 with a successful transmission result. Although the incident report was not located in the facility’s electronic Licensing file at the time of LPA review, records reviewed did not reveal sufficient evidence to support that the facility failed to report the incident to Licensing..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. Unsubstantiated Regarding the allegation that the facility call light system is inoperable, Licensing Program Analyst (LPA) conducted interviews and reviewed facility records, including paging system activity reports. Interviews conducted with staff revealed the facility uses a functioning call light system which alerts staff when residents activate pull cords. Staff stated residents are monitored throughout the day and staff respond to resident needs. Staff stated that during WiFi interruptions, staff conduct routine rounds and safety checks on residents. LPA reviewed facility records related to the call light system and observed the system was operational. Although some records reflected longer reset times, the facility staff stated this may occur when staff do not fully reset the pull cord system after responding to residents. Interviews and records reviewed did not reveal sufficient evidence to support that the call light system was consistently nonfunctional or inoperable. 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. Regarding the allegation that staff did not provide residents with adequate meal service, Licensing Program Analyst (LPA) conducted interviews and reviewed facility records including facility menus and alternative menu options. Interviews conducted with staff revealed the facility provides residents with three daily meals as well as alternative meal options when requested. Staff stated residents are offered substitutions if they do not prefer the meal being served and residents are encouraged to eat throughout the day. LPA reviewed facility menus which documented a variety of meal options and alternative menu selections available to residents. Interviews and records reviewed did not reveal sufficient evidence to support that residents were not being provided adequate meal service. 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. Regarding the allegation that the facility did not employ adequate staff to meet the needs of residents in care, Licensing Program Analyst (LPA) conducted interviews and reviewed facility staffing schedules and records. Interviews conducted with staff revealed the facility maintains staffing coverage throughout each shift and staff stated they are generally able to respond to resident needs in a timely manner. Staff acknowledged there are occasions when resident calls increase during busy periods; however, staff stated assistance is available from other staff members when needed. LPA reviewed staffing schedules and did not observe sufficient evidence to support that the facility failed to employ adequate staff to meet resident needs. 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 with facility, Cognitive Care Director, Ashley Mendoza, and copy of report providedthe state’s words, verbatim · CDSS document, May 6, 2026 · control 24-AS-20260210143137

Type of visit: Required - 1 Year

On 3/19/2025, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required inspection. LPA arrived, stated purpose of visit and met with Executive Director/Administrator, Paul Rocha to conduct today's inspection. . Current, facility has 117 residents who reside in Independent living, 54 residents who reside in Assisted Living, and 52 residents who reside in Cognitive Care. The main building, is a three story building which has Independent Living on first and third floor, Assisted Living is on second floor. Facility buildings toured. Each floor has a choice of dining rooms and menu options. Menus are posted throughout the facility. Kitchen toured, refrigerator was at 37 degrees F and freezers were at 0 degrees F. Facility observed to have 2-day supply of perishable and a 7-day supply of non-perishable food available. Facility receives food deliveries 3-4 times per week. Independent villas and resident apartments toured during facility tour. LPA observed apartments to have skid resistant surfaces in showers, grab bars available. Apartments toured observed to well lit, and a comfortable temperature for residents. Residents receive housekeeping in Assisted Living daily and Independent Living receive housekeeping twice weekly. The Cognitive Care building, has a separate kitchen and dining area. Residents have a open courtyard with shading and seating that is utilized for gardening and activities. Residents observed to be engaged with music and social activity during facility tour. Facility is equipped with smoke detectors, fire sprinklers, and pull stations throughout buildings. Fire extinguishers are present throughout buildings, in each hallway with a service date of 5/07/2025. LPA reviewed resident records during inspection. Due to time constraints, LPA will return to review medication, staff files and complete inspection tool. Exit interview conducted and a copy of report will be provided via e-mail for facility records.the state’s words, verbatim · CDSS document, Mar 19, 2026

Allegation investigated: Unqualified staff injecting residents with medication.

On 03/04/2026, Licensing Program Analyst (LPA) J. Duarte arrived unannounced to deliver findings. LPA met with Administrator Paul Rocha. Interviews and documentation revealed that Med Techs assist resident with injectable medication using a hand over hand technique and LVNs also assist residents in administering injectable medication. Based on interviews conducted and documentation, the allegation: “Unqualified staff injecting residents with medication,” 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. No deficiencies issued. Exit interview conducted. A copy of this report was discussed and provided to facility Administrator Paul Rocha, whose signature on this form confirms receipt of this document. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 4, 2026 · control 24-AS-20251222095613

Allegation investigated: Residents develop multiple pressure injuries due to staff neglect. Residents develop multiple UTI's due to staff neglect. Staff handle residents in a rough manner. Staff do not ensure residents' hygiene needs are being met. Staff do not provide adequate supervision to residents resulting in falls. Staff do not ensure to provide residents' with fluids.

On 03/04/2026, Licensing Program Analyst (LPA) J. Duarte, arrived unannounced to conduct interviews and deliver findings. LPA introduced self, stated the purpose of the visit and met with Executive Director and Administrator Paul Rocha. The Department conducted interviews and reviewed records. Based on the interviews conducted and records reviewed, the allegations; residents develop multiple pressure injuries due to staff neglect, residents develop multiple UTI's due to staff neglect, staff handle residents in a rough manner, staff do not ensure residents' hygiene needs are being met, staff do not provide adequate supervision to residents resulting in falls, and staff do not ensure to provide residents' with fluids are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur or did not occur; therefore, the allegations are Unsubstantiated. No deficiencies were issued. An exit interview was conducted. A copy of this report was discussed and provided to Administrator Paul Rocha, whose signature on this form confirms receipt of this document. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 4, 2026 · control 24-AS-20260105161419

Type of visit: Case Management - Annual Continuation

On 3/04/25, Licensing Program Analysts (LPAs) M. Medina and D. Boyd. conducted an unannounced annual required inspection. LPAs stated the purpose of the visit and were allowed entry into the facility. LPAs met with Administrator, Paul Rocha, who conducted the tour of the facility with LPAs. LPA Medina reviewed a sample of staff and resident files and observed the files to have the required documentation and staff training. LPA Boyd will document the physical plant tour and inspection tool results on a separate report. Exit interview conducted. No deficiencies cited.the state’s words, verbatim · CDSS document, Mar 4, 2025

Type of visit: Case Management - Other

On 3/4/2025 Licensing Program Analysts (LPAs) Daiquiri Boyd and Melinda Medina made an unannounced visit to the facility. LPAs toured the new addition to the Cognitive Care building. LPA received the fire clearance on 2/21/25 which was granted by Fresno Fire Department. Fire clearance was granted for an additional 20 residents to occupy the addition to the dwelling. LPAs toured the additional living space on property. The additional space is properly furnished for the increase of 20 residents. LPA observed smoke detector and carbon monoxide detectors to be operational. Fire extinguishers were serviced on 12/18/2024. The individual rooms toured in this building are new additions and have furnishings available if needed by new residents. The new wing in cognitive care has fifteen (15) single bedrooms with a shared "Jack and Jill" style shared bathroom. The remaining five (5) bedrooms are private. Each bedroom has a sink in the entrance area. All bedrooms are equipped with call buttons. All bathrooms have built in shower chairs, grab bars, and non-skid floor surface in the shower. Bedrooms do not have built-in closets, but include an armoire with space to hang belongings. Newly built medication room with locked doors was toured. Pending review and approval by Fresno Regional Office (FRO) and Continuing Care Contracts Bureau (CCCB).the state’s words, verbatim · CDSS document, Mar 4, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Daiquiri Boyd and Melinda Medina, conducted an unannounced annual visit to the facility and met with Administrator, Paul Rocha (AD). LPA stated the purpose of the visit and was accompanied by AD while conducting the inspection of the facility grounds. This facility includes several buildings. The main building is a three story building that houses residents that are Independent Living on floors one and three and Assisted Living on the second floor. Each floor has a choice of dining facilities and menu options. Menus are provided on site and by the interactive video/TV monitors in each wing of the facility. Kitchen toured and observed to be clean and well taken care of. Refrigerator was at 37 degrees F and freezers were at 0 degrees F. There was observed to be a perishable and non-perishable food supply to feed all residents for seven days. Independent Living consists of 70 residents and Assisted Living has 55 residents. LPA observed thermostat to be at 73 degrees F. On each level of the facility main building, there is a locked Maintenance room with cleaning supplies. There is a Medication Room on the second floor that is a locked room containing movable, locked medication carts. This facility uses PointClickCare system to track the medications the residents are taking. LPAs checked water temperatures in five resident bathrooms and found it to range from 115 degrees F to 120 degrees F. LPA observed laundry rooms with keyed entry to have working washers, dryers, and cleaning supplies. Each hallway in the facility contains a video monitor that displays the menu for the day, weather, activity times for all events taking place in the facility. LPAs inspected resident bedrooms for water temperature, non-slip surfaces, lighting, grab bars, seating. Residents receive housekeeping in Assisted Living daily and Independent Living receive housekeeping twice weekly. All rooms were found to be in like new condition, properly functioning, and well maintained. The Cognitive Care building (previously Memory Care) currently houses 34 residents. This building has it's own kitchen and three dining areas. Meals prepared here are specific to this building and are prepared to enhance well being of those with cognitive issues. There are currently eight residents on hospice care. There are Independent Living Villas on the property of the facility and there are forty residents residing independently therein. LPAs toured one of the private, resident villas and found it to be newly built with new amenities and furnishings. PPE for the whole community is centrally stored in all buildings for all residents. Last fire drill with staff was conducted on 12/25/24. Fire Department inspected interior sprinkler system on 12/18/24. The semi-annual alarm inspection was done by Fresno Fire Department. on 06/18/2024. LPAs observed and reviewed Infection Control Plan and Disaster Binders, both found to be updated. LPA Medina reviewed staff and resident records and will document on a Annual Continuation report. Exit interview conducted. A copy of this report provided for facility records. No deficiencies cited during inspection.the state’s words, verbatim · CDSS document, Mar 4, 2025

Type of visit: Case Management - Other

On 02/18/2025, Licensing Program Analyst (LPA) Daiquiri Boyd made an unannounced visit to the facility for the purpose of conducting a check of the facility and records to verify that an employee is not employed or on the premises. Individual named Angelina Padilla has not been employed at this facility since August 30, 2023. This individual was employed at this facillity for approximately two months. CDSS No. 7924292003the state’s words, verbatim · CDSS document, Feb 18, 2025

Allegation investigated: Questionable death Staff left residents soiled for extended periods of time

On 12/04/24, Licensing Program Analyst (LPA) M. Medina conducted an unannounced subsequent complaint visit to conduct additional interviews and deliver findings. LPA introduced self and stated purpose of visit and allowed entrance. LPA met with Executive Director/Administrator, Paul Rocha during visit. This Department investigated the allegation of questionable death and staff. During the investigation, this department obtained a copy of Resident 1 (R1) death certificate. Based on record review of R1's death certificate, it was determined R1's cause of death was respiratory arrest. Facility has Point Click Care (PCC) system that monitors and tracks all residents toileting, brief changes, and any assistance with activities of daily living (ADLs) provided by staff on shift. This Department has found that the above allegations are UNFOUNDED, meaning they were false, could not have happened, and/or were without reasonable basis. We have therefore dismissed the complaint. No deficiencies issued during this complaint visit . Exit interview conducted. A copy of this report was provided to Administrator for facility records Unfoundedthe state’s words, verbatim · CDSS document, Dec 4, 2024 · control 24-AS-20240507171907

Type of visit: Required - 1 Year

Licensing Program Analysts L. Padgett and Katie Brown (LPA), conducted an unannounced annual visit to the facility and met with Administrator, Paul Rocha (AD). LPA stated the purpose of the visit and was accompanied by AD while conducting the inspection of the facility. This facility has independent villas, a main building with independent residents on the first and third floor and Assisted Living on the second floor. Memory Care is in its own building. LPA toured the main building with AD. LPA observed ambient thermostat to be at 73 degrees F. On the first floor, LPA toured the Harvest Café. Menu is displayed on TV screen. This café serves grab and go items. Area observed to be in good condition. LPA observed Fire Side lounge area to have seating area, faux fireplace with does not emit heat and board games. This floor also has fitness room with exercise machines and free weights. Kitchen storage observed to have supply of paper goods, cleaning supplies/disinfectants and hand soap. LPA checked water in Guest/Resident bathroom, temperature was found to be 106.9. LPA observed laundry rooms with keyed entry to have working washers and dryers and cleaning supplies. In The Grape Vine kitchen LPA observed that the kitchen was well maintained, with working lights and well maintained appliances. The kitchen counters and sink are free from debris, well maintained and clean. LPA observed that refrigerator was kept at a 40 degree F, and the freezer at 2 degrees F. LPA observed a 2 day perishable food supply. The kitchen pantry was clean, organized, and had 7 days of non-perishable food. No expired food was observed. A 2nd floor kitchen was toured. Two refrigerators observed, one is kept at 38 degrees F and the other 43 degrees F. LPA observed the dining rooms on each floor. All are well lit with adequate seating. There are TV screens in the hallways which display the weather, activity calendar and events. LPA observed multiple seating and activity areas that contains games and puzzles, TV’s, coffee and ice water, bowls of fresh fruits (apples, bananas and oranges). LPA observed Activity room with piano, keyboard, tables, chairs and board games. LPA observed the hallways leading to the resident rooms, smoke detectors, and carbon monoxide are installed. A fire extinguishers are mounted on the walls and were inspected on 5/1/2023 with the correct pressure gauge as indicated on the meter. The smoke alarm and carbon monoxide detectors are tested monthly by MS Fire Protection, last inspection was on 3/12/2024. LPA observed room #206 is not shared, has a private bathroom with covered trash bin, shelves for toiletries, grab bars, non-skid flooring. The water temperature measured at 111.6 degrees F. The room is well lit, a dresser, reading lamp, the furniture is in good condition, the linens are in good condition. Room has kitchenette The bedroom has a closet, dresser and night stand. LPA observed that Room #257 is not shared, has a private bathroom with covered trash bin, shelves for toiletries, grab bars, non-skid flooring. The water temperature measured at 110.1 degrees F. The bedroom is well lit, a dresser, reading lamp, the furniture is in good condition, the linens are in good condition. The bedroom has a closet, dresser and night stand. LPA observed that bedroom #260 is not shared, has a private bathroom with covered trash bin, shelves for toiletries, grab bars, non-skid flooring. The water temperature measured at 110.8 degrees F. The rooms are well lit with required furniture in good condition. LPA with AD inspected exterior areas. LPA, observed the landscaping is well maintained, trees, bushes and grass in good condition. Patio furniture is clean and ready for use. The exterior walkways are free from obstructions and debris. LPA toured the memory care building with AD. Ambient temperature was 75 degrees F. LPA toured 4 resident rooms. Room 25 had required furniture in good condition. Fall prevention measures are in place. LPA observed resident in bed watching TV. Room 2 has a hospital bed with ½ rails, chair, dresser, TV. Resident was not in the room. Room 8 is a single room with required furnishing in good condition. LPA observed resident to be in good spirits. Water temperature was checked and observed to be 108.3 degrees F. Room #24 had required furnishing in good condition, resident was sleeping. Medication room toured. Medications are centrally stored. No insulin or refrigerated medications. Laundry room observed to have 3 washers, 2 dryers, cleaning chemicals stored in cabinets. Laundry room is kept locked with key entry. LPA observed prep kitchen in open area, nothing is stored in cabinets. Refrigerator observed to be 33 degrees F. LPA observed 6 residents in the activity area engaged in conversation. LPA observed the kitchen to be in good condition with well maintained appliances. LPA observed Dry goods and canned items, knives on magnet block. Refrigerator was 36 degrees F, Freezer 0 degrees F. LPA reviewed residents and staff records, infection control plan was not provided for review. LPA is requesting the following documents be submitted to the Fresno CCL office by 4/5/2024: Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A)the state’s words, verbatim · CDSS document, Mar 25, 2024

The state marks this report as 8 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff do not prevent inappropriate interactions between residents

Licensing Program Analyst L. Padgett arrived unannounced to deliver amended investigative findings on the above allegation. LPA met with Paul Rocha and explained the purpose of the visit. The Department investigated the complaint alleging: Staff do not prevent inappropriate interactions between residents. During the course of the investigation the Department conducted interviews with staff and witnesses and reviewed resident and facility records, including incident reports, resident care notes, physician’s report pertaining to Residents R1 and R2. The Department determined that staff on duty did not prevent sexually inappropriate non-consensual interactions between the two residents in the Memory Care Unit. Per Department’s investigation: On 10/24/2023, in the Memory Care Unit of the facility resident R1 was found in resident R2’s bedroom; resident R2 had his arm around resident R1’s waist and resident R1 was pushing resident R2 away. Resident R2’s genitalia was exposed out of his brief. On 10/27/2023 in the Memory Care Unit of the facility staff S1 went to check on resident R2 in his bedroom and saw resident R2 sitting on his bed with resident R1 laying across Resident R2’s body. Resident R1’s pants were down to her ankles, briefs pushed to the side and R2’s fingers were inserted in R1’s genitalia. Staff S1 pulled resident R1 away and assisted resident R1 to her bedroom. Staff S1 also advised Memory Care Director (S2), but Staff S2 stated the residents had personal rights to be involved in romantic/physical relationships. Based on resident R1’s Admission Agreement, resident R1 has a power of attorney assigned and is unable to make decisions or give consent. During the Department’s interviews with Executive Director (S3) and Memory Care Director (S2); they reported these two incidents were isolated and there were no prior or subsequent incidents. However, per resident R2’s Progress Notes, there were two incidents where resident R2 was seen touching/caressing other residents in the facility. Additionally, there were two other incidents that were not documented: resident R2 had resident R1 in resident R2’s bedroom, and resident R1 was crying, and resident R2 attempted to touch another resident’s breast area. Based on the investigation conducted by the Department, the preponderance of evidence standard has been met, therefore the allegation, Staff do not prevent inappropriate interactions between residents is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099-D. Exit interview was conducted with Paul Rocha and appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Mar 18, 2024 · control 24-AS-20231027143209

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Mar 22, 2024

87468.2(a)(8) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, ... for the elderly shall have all of the following personal rights: (8) To be free from neglect… intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: Based on the investigation by the Department, staff in the Memory Care Unit did not prevent resident (R1) from being inappropriately touched by R2. This posed an immediate risk to the health, safety and/or personal rights of the residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2024

Plan of correction: Plan of Correction (POC); in service training conducted with staff on Mandating Reporting/Residents Rights was submitted by Licensee by as requested.No further action is required.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Mar 25, 2024

This deficiency was dismissed due to granted appealthe state’s words, verbatim · CDSS document, Mar 18, 2024