California Lifestyles II

Allegation investigated: Staff are mismanaging resident's medication

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA interviewed staff and reviewed and obtained pertinent documentation such as medication orders. Regarding the allegation that staff are mismanaging resident's medication, the investigation revealed the following: Per physician report dated March 28, 2026, Resident 1 (R1) is not allowed to administer own routine and PRN medications nor store own medications. Facility staff indicated storing and administering routine medications for the resident. However, the resident stored and self administered PRN medications and an inhaler as well as had duplicate routine medications in the room. Resident was hospitalized on September 2, 2026 and has not returned to the facility. LPA observed facility stored insulin but was unable to observe any other medications as a friend picked up all the resident's medications once the resident was hospitalized. CONTINUED ON LIC 9099 C DATED 09/25/2026 Substantiated Based on interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. Deficiency is being cited on the attached LIC-9099D. An exit interview was conducted and a copy of this report as well as the appeal rights were provided at exit.the state’s words, verbatim · CDSS document, Sep 25, 2026 · control 22-AS-20260904165443

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Sep 26, 2026

Basic services shall at a minimum include: Personal assistance and care as needed by the resident.., with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications. This req is not met as evidenced by: Based on interviews conducted, Licensee failed to ensure R1 was assisted with medication administration. R1 was storing/ administering PRN medications when physician report prohibits such action which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2026

Plan of correction: Licensee to conduct an in-service on medication administration and forward proof to LPA by POC due date.

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced plan of correction visit to follow up on citations issued on 09/11/2026. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87506(d) pertaining to Resident Records has been cleared. Facility provided requested records. Licensee has complied with the terms of the POC. Licensee has been advised to maintain all previously cited items in compliance. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 25, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20260904165443. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA requested resident file for Resident 1 (R1). Administrator indicated the file is currently located in Riverside at the Administrator's home with a turn around drive time of 2-3 hours. Licensee to forward a copy of R1's physician report, medication list, admission agreement and pre-appraisal to LPA by close of business Friday September 18, 2026. Based on the observations made during today’s visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy of this report along with appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Sep 11, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(d) · Plan of correction due date: Sep 18, 2026

All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying...This req is not met as evidenced by: Based on interview conducted, Licensee failed to ensure R1's file was on-site at the facility which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: Licensee to forward requested file to LPA by POC due date.

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 6 residents and the home currently has 6 residents, with 3 residents on hospice. Administrator Roy Moeller has a valid certificate that expires on 10/21/2027. Administrator provided updated liability insurance and LIC 500 during the visit. LPA along with Administrator Moeller toured the facility at 11:10 AM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 6 resident bedrooms, living room, dining room, staff room and kitchen as well as 8 restrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 105.0 degrees F and 112.4 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the emergency disaster plan and plan is complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 10/15/2025. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise. CONTINUED ON LIC 809C DATED 11/06/2025 There is shaded outdoor seating for residents. Exit gates are unlocked and operational. LPA observed the emergency food and water supply. LPA reviewed select resident and staff files. All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPA reviewed medication storage and administration. Medications are stored in a locked closet. Medications appear to be administered per physician order. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Nov 6, 2025

Type of visit: Required - 1 Year

On this day Licensing Program Analysts (LPAs) Kimberly Lyman and Fred Arias made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 2 residents and the home currently has 6 residents, with 1 resident on hospice. Administrator (AD) Roy Moeller conducted facility tour. AD Moeller has a valid certificate that expires on 10/17/2025. AD provided updated liability insurance that expires on 8/17/2025. LPAs along with Administrator Moeller toured the facility at 12:00 PM. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 6 resident bedrooms, living room, dining room, and kitchen as well as 6 restrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 106 degrees F and 116.2 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPAs toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPAs reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 10/17/2024. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise and walks. There is shaded outdoor seating for residents. Exit gates are unlocked and operational. LPAs observed the emergency food and water supply. LPAs reviewed six resident files and two staff files. CONTINUED ON LIC 809C DATED 12/20/2024. All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPAs reviewed medication storage and administration. Medications are stored in a locked closet. Medications are being administered per physician order. Medications are audited daily by Administrator and monthly by facility physician. Resident 1(R1)'s room had a strong foul odor radiating from bedroom 5. AD addressed the concern and washed the carpet and replaced the linens during visit. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Dec 20, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident reported to the department. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report/ death report dated 03/14/2024 indicated that on 03/08/2024, Resident 1 (R1) came into the facility from the patio with a cut on the left eye. The cut had a small amount of blood. Caregiver immediately called Administrator and began to clean the wound. Administrator contacted R1's wife who arrived at the facility within minutes with Administrator on the way to facility. R1's wife decided to drive the resident to Kaiser for assessment. Upon leaving the facility with the resident, R1's wife decided to call 911 instead and returned to the facility. Resident was examined by paramedics and was transferred to Mission Hospital where the resident passed away the next day. Per resident's wife, resident passed from a brain bleed. Administrator has provided a copy of the incident report to the Coroner. Per physician report dated 12/07/2023, resident is diagnosed with Dementia. Appraisal Needs and Services dated 12/27/2023 indicates resident walks without any assistive devices. Interview with staff indicates resident would frequently walk throughout the day and the resident had no prior falls. Licensee to obtain a copy of the death certificate and forward to LPA. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 15, 2024