California Mission Inn

Allegation investigated: Staff are not addressing pests at facility

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate the above allegation. LPA met with Heather Cummings Chief Operating Officer and discussed the purpose of the visit. The investigation consisted of LPA taking tour of facility, including rooms 262, 261,263 256 253, 255 which are all adjacent to room 262, reviewing and obtaining copy of staff and client rosters, a copy of email from family member of resident with pest issue dated 06/29/2026, pest sighting log from 12/27/2026 to 06/29/2026, pest control invoice for service call from Bellas Exterminator Dated 06/29/2026, Interviewing five (5) clients, three (3) staff and one (1) family member W#1 The investigation revealed regarding the allegation: Staff are not addressing pests at facility. It is alleged that facility room #262 has rat/mice infestation and facility is not adresssing it. (continued on 9099) Unsubstantiated (continued from 9099) Based on the information gathered during visit, the allegation is deemed UNFOUNDED. A finding of UNFOUNDED means that the allegation is either false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to staff. (Continued from 9099C) LPA interviewed three (3) staff and all three (3) staff acknowledged they have an issue in room 262 and have addressed it. LPA interviewed five (5) residents and four (4) of five residents could not corroborate the allegation. R1 stated that R1 saw a rat as late as last night and crawled on R1 TV tray. R1 stated that staff have addressed the issue by sealing a hole in the wall and setting mechanical and glue traps on the floor. W1 stated the issue was first reported to staff on May 19, 2026, and facility acted on May 21, 2026. W1 stated facility continued to address issue but the issue is still lingering. LPA inspected R1 room and noticed a gapping hole in the closet ceiling as well as rodent dropping on the closet floor. LPA asked staff to close and sealed the hole in the closet and to clean the droppings on floor. Since facility has been addressing the pest issue in R1 room, there is not enough evidence to substantiate that facility has done nothing to address the issue. Based upon records review, interviews conducted, and observations, 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. An exit interview was conducted, and copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 29, 2026 · control 28-AS-20260623083126

Allegation investigated: Staff are making inappropriate comments in the presence of resident(s) in care. Staff interrupted the sleep of a resident in care.

Licensing Program Analyst (LPA) Alberto Lopez made initial visit to investigate the above allegations. LPA met with Maria Reledo, Wellness Director and discussed the purpose of the visit. The investigation consisted of LPA obtaining and reviewing resident and client rosters. Upon further review, LPA noticed that R1 was not on resident roster. LPA confirmed this with staff Maria Reledo, Wellness Director, and by reviewing the resident roster. Based on the information gathered during visit, the allegation(s) are deemed UNFOUNDED. A finding of UNFOUNDED means that the allegations are either false, could not have happened, and/or are without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to Maria Roleda, Wellness Director. Unfoundedthe state’s words, verbatim · CDSS document, May 19, 2026 · control 28-AS-20260514095250

Allegation investigated: Staff are making inappropriate comments in the presence of resident(s) in care. Staff interrupted the sleep of a resident in care.

Licensing Program Analyst (LPA) Alberto Lopez made initial visit to investigate the above allegations. LPA met with Maria Reledo, Wellness Director and discussed the purpose of the visit. The investigation consisted of LPA obtaining and reviewing resident and client rosters. Upon further review, LPA noticed that R1 was not on resident roster. LPA confirmed this with staff Maria Reledo, Wellness Director, and by reviewing the resident roster. Based on the information gathered during visit, the allegation(s) are deemed UNFOUNDED. A finding of UNFOUNDED means that the allegations are either false, could not have happened, and/or are without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to Maria Roleda, Wellness Director. Unfoundedthe state’s words, verbatim · CDSS document, May 19, 2026 · control 28-AS-20260514095250

Allegation investigated: Staff do not assist resident with showering Resident sustained dermatitis due to staff neglect Facility is operating out of ratio Staff do not provide residents with adequate clothing

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate the above allegations. LPA met with Chief Operating Officer Heather Cummings and discussed the purpose of the visit. The investigation consisted of taking tour of facility, reviewing and obtaining staff and resident rosters, interviewing four (4) staff S#1 – S#4, five (5) residents R#1 – R#5 and obtaining bathing schedule for facility. The investigation revealed regarding allegation: Staff do not assist resident with showering. It is alleged that facility is not providing bathing services to a resident (name not provided) LPA interviewed four (4) staff and all four (4) staff denied the allegation. LPA interviewed five (5) residents and four (4) of five residents could not corroborate the allegation. LPA reviewed the shower schedule, and residents are provided with bathing services twice a week or more if required. There is insufficient evidence to support this allegation. (continued on 9099C) Unsubstantiated (continued on 9099C) Resident sustained dermatitis due to staff neglect. It is alleged that a resident (name not provided) obtained dermatitis due to not having hair washed. LPA interviewed four (4) staff, and all four (4) staff denied any resident having dermatitis. LPA interviewed five (5) residents and all five (5) could not corroborate the allegations. Several staff stated that no resident currently has dermatitis at the facility. There is insufficient evidence to support this allegation. Facility is operating out of ratio. It is alleged that facility is operating out of ratio because resident (name not provided) is not being assisted out of bed. LPA interviewed four (4) staff, and all four (4) staff denied the allegation. The caregivers interviewed all stated they can meet the resident’s needs. LPA interviewed five (5) residents and all five (5) could not corroborate the allegations. Several residents stated there is enough staff to meet resident's needs. There is insufficient evidence to support this allegation. Staff do not provide residents with adequate clothing. It is alleged that facility is not providing residents with clothing due to resident (name not provided) being in the same clothes for five (5) straight days. LPA interviewed four (4) staff, and all four (4) staff denied the allegation. All four (4) staff stated they have not seen any resident in the same clothes for 5 days. The caregivers interviewed all stated that facility has a donation closet that provides clients clothing for free if they are in need, LPA interviewed five (5) residents and all five (5) could not corroborate the allegation. There is insufficient evidence to support this allegation. Based upon records review, interviews conducted, and observations, although the allegation(s) 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 copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 20, 2026 · control 28-AS-20260414112657

Allegation investigated: Staff are not meeting resident's showering needs Staff did not ensure resident's room was free of odors

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate the above allegations. LPA met with Chief Operating Officer Heather Cummings and discussed the purpose of the visit. The investigation consisted of LPA reviewing and obtaining copy staff and resident rosters of R1 admission agreement, needs and appraisal, physician’s report, bathing log, taking tour of R1 room,and other random rooms, interviewing Six (6) staff and seven (7) residents. The investigation revealed regarding allegation: Staff are not meeting resident's showering needs. It is alleged that facility staff is not providing bathing services to resident as required. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. LPA interviewed seven (7) residents and all seven (7) could not corroborate the allegation. (continued on 9099C) Unsubstantiated (continued from 9099C) Facility records show that resident was admitted to facility on 02/06/2026 and was provided with bathing services on the following dates 02/10/2026 02/12/206, 02/17/2026, 02/19/2026, 02/24/2026, 02/26/2026, 03/03/2026, 03/05/2026, 03/10/2026, 03/12/2026, and 03/17/2026 Resident stated resident refused to bathe one time. Date is unknown. LPA observed resident to be clean, groomed and in clean clothes. There is not enough evidence to substantiate this allegation. Allegation: Staff did not ensure resident's room was free of odors. It is alleged that room has urine odor. LPA interviewed six (6) staff, and all six staff denied the allegation. One staff member stated that there was a urine smell in resident’s room a while back, but it had been addressed immediately. LPA interviewed seven (7) residents, and all seven (7) residents could not corroborate the allegation. LPA inspected resident’s room and another six random rooms and did not notice any kind of foul smell in any of the rooms. Based upon records review, interviews conducted, and observations, although the allegation(s) 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 copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 17, 2026 · control 28-AS-20260313164816

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alberto Lopez conducted a case management visit in conjunction with a complaint that has the control 28-AS-20260313164816 During record review of the facility staff associations. it was revealed that contractor #1 (C1) was not associated to the facility while working as a caregiver for one resident. It was revealed that S1 had worked at the facility from February of 2026 - 03/17/2026 while not being fully associated, and therefore was not allowed to work with residents or be present in an agency licensed by the department. Facility sent contractor home this same day. The related deficiency is cited on the LIC809D page. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2)(3) · Plan of correction due date: Mar 18, 2026

87355(e)(2)(3) (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:(2)Obtain a California clearance or a criminal record exemption as required by the Department or (3)Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by: Contractor #1 was present in facility without a criminal record clearance and was not associated to facility.the state’s words, verbatim · CDSS document, Mar 17, 2026

Plan of correction: Administrator will obtain criminal record clearance and associate contractor #1 before being allowed in facility to assist residents .Administrator will send proof to LPA. $500 immediate civil penalty assessed. Contractor was sent home by faclity.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto Lopez conducted the unannounced annual inspection on 01/06/25. LPA met with Administrator, Jared Green, and the reason for the visit was explained. The facility is licensed for 85 non-ambulatory residents, ages 60 and over, of which 9 may be bedridden. There is a hospice waiver approved for 20 residents. LPA toured the facility with Maria Roleda, Wellness Coordinator reviewed files and medications using the Compliance and Regulatory Enforcement (CARE) tool. The following were observed: The facility is a 2-story building that consists of residents’ bedrooms on both floors. Each floor also has common areas, activity rooms, and communal restrooms. The dining hall and kitchen are located on the first floor. There is a memory care unit on the 2nd floor. The memory care unit has an indoor and enclosed outdoor area for resident recreation activities. LPA selected random rooms to inspect in both memory care and assisted living side. There were no sharps or cleaning products in their rooms. Facility is free of odors from incontinence. LPA observed adequate food supplies of 2-day perishable and 7 days of non-perishable. The facility receives food supplies twice a week. The kitchen is free of rodents and insects. LPA reviewed six (6) resident files. Resident files have an admission agreement, physician's report, consent forms, resident appraisal, personal rights, and property and valuable form. LPA reviewed five (5) staff files. The administrator's certificate expires on 4/14/26. Staff files have the health assessment with TB test result, criminal background clearance letter, and personnel record. Staff are receiving ongoing training. Medications are centrally stored in the locked cart. The facility utilizes the electronic medication log to document when given. LPA checked the medications for 4 residents and did not observe any discrepancies. Some PRN did not have labels. Facility has an updated Emergency Disaster Plan and conducts quarterly disaster drills for each shift. Last drill was 08/29/25 No deficiencies were issued today. Technical advisories provided exit interview was held, and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Oct 6, 2025

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff verbally abused a resident in care. Staff are spraying chemicals in a resident's room. Staff are serving food that is not of quality to a resident in care.

Licensing Program Analyst (LPA) Alberto Lopez made a subsequent visit to the facility to deliver findings. LPA met with Hayden Petrovick, Marketing Director and discussed the purpose of the visit. During the visit, LPA took tour of common areas and R1 room. LPA interviewed S#6 via phone prior to visit. On 08/14/2025 Licensing Program Analyst (LPA) Alberto Lopez made an initial 10-day visit to investigate the above allegations. LPA met with Maria Roleda, Clinical Supervisor and discussed the purpose of the visit. The investigation consisted of: LPA took tour of common areas and resident’s room, interviewed five (5) staff (S#1-S#5), Six (6) residents (R#1-R#6), reviewed and obtained staff and residents rosters, food menus, food order form and alternative menu choices for residents on special diets. R1 physicians report, and incident report. (continued on 9099C) Unsubstantiated (continued from 9099) The investigation revealed regarding allegation that Staff verbally abused a resident in care. It is alleged that a staff member harassed and verbally abused a resident in care. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. All six (6) staff stated they have never witnessed any staff being verbally abusive or harassing any residents. S6 denied being verbally abusive to resident and stated S6 goes out of way to accommodate resident. LPA interviewed six (6) residents and five (5) of five (6) residents were not able to corroborate the allegation. R1 stated there are no witnesses regarding verbal abuse. There is insufficient evidence to support this allegation. Allegation: Staff are spraying chemicals in a resident's room. It is alleged that staff are spraying chemicals in the resident’s room, and it can be smelled on resident's clothing. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. LPA interviewed six (6) residents and five (5) of six (6) residents were not able to corroborate the allegation. LPA toured resident’s room and room was not malodorous or smell like chemicals. Some staff stated that resident had requested that no chemicals be used in resident’s room, only water to clean and disinfect. R1 stated that R1 did mention to staff to only use water to clean and disinfect. LPA toured common areas and there was no chemical odor anywhere in the facility or in resident's room. R1 stated that it is R1 decision to not have any caregiver come into R1 room and not the staff at facility. There is insufficient evidence to support this allegation. Allegation: Staff are serving food that is not of quality to a resident in care. It is alleged that the food is not of good quality and may have poison. LPA interviewed six (6) residents and four (4) of six (6) residents were not able to corroborate the allegation. One (1) resident stated she loved the food and especially the deserts. One resident stated that the food has too much salt, sugar and oil. One staff member stated that residents are provided with a menu checklist to choose alternate food items that fit their taste and/or diets. LPA toured the dining room during lunch hour, and the food was observed to be in good presentation and nutritious. LPA observed other residents with alternate meal items that they pre-selected in the early morning hours. All the residents observed in the dining room had finished their food during the visit. There is no evidence to support the allegation. Based upon records review, interviews conducted, and observations, although the allegation(s) 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 with Hayden Petrovick, Marketing Director. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 16, 2025 · control 28-AS-20250806154735

Allegation investigated: Staff did not provide resident with a 60-day notice of rent increase. Facility has plumbing issues.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegations listed above. LPA arrived unannounced and met with Staff, Heather Cummings. The purpose of the visit was explained. The administrator was not available during the visit. LPA obtained a copy of the staff and resident rosters, toured the premises, and obtained documents pertaining to Resident #1. Allegation – Staff did not provide resident with a 60-day notice of rent increase. Per the Business Office Manager, the facility had a rent increase that applied to all residents. The letter went out on 10/31/24 to inform residents and/or responsible party that an increase will take into effect on 1/1/25. LPA obtained a copy of a rent increase letter to Resident #1. The notice of increase letter was dated 11/1/24 with effective date of January 1, 2025, which was at least 60-days of notice. Unsubstantiated Staff explained that Resident #1 resides in the cottages that is considered independent living and has a separate address. Staff do not provide care or supervision to the individuals in the cottages. However, since the housing is on the premises, the rent increase had applied to the cottages as well. Allegation – Facility has plumbing issues. Staff indicated that if they find anything in disrepair, they will put in a work order. Maintenance staff indicated they try to fix the issues right away when they receive a work order. Per staff, R1 resides in the cottages which is considered independent living and has a separate address. However, maintenance will assist with any items in disrepair if they are notified. LPA spoke to R1 who stated the plumbing issue has been resolved. Based on information gathered, R1 has a separate address from the facility and is not receiving any care or supervision from staff. The facility roster does not contain R1’s name as part of their resident roster. Interviews with staff indicated that R1 is independent and resides in the cottages which care is not provided. 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. An exit interview was conducted with Staff H. Cummings. A copy of this report along with the appeal rights was provided.the state’s words, verbatim · CDSS document, Mar 4, 2025 · control 28-AS-20250225110007

Allegation investigated: Staff do not respond to resident's call for assistance in a timely manner Staff do not ensure that resident's toileting needs are met

Licensing Program Analyst (LPA) Alberto Lopez made initial 10-day visit to investigate the above allegations. LPA met with Maria Roleda, Clinical Supervisor and discussed the purpose of the visit. The investigation consisted of: LPA took tour of common areas, interviewed five (5) staff (S#1-S#5), five (5) residents (R#1-R#5), reviewed and obtained staff and residents rosters, R1 skilled nursing facility (SNF) discharge orders, R1 admission agreement, R1 move in record, R1 SNF follow up note dated 11/18/2024, Calstro Hospice progress notes dated 01/06/2025, Pointclickcare notes from 11/29/2024 – 01/26/2025, MedChoice LA Home Health Care Inc. dated 11/29/2024, R1 Physician's Report for Residential Care Facilities for the Elderly (RCFE) dated 11/26/2024, Calstro Hospice admission documentation dated 12/27/2024, R1 medication list, R1 Special Diet Clarification form dated 11/26/2024. DHCS Individual Service Plan – Assisted Living Waiver. Facility food menu. Call light record for month of December 2024. (Continued on 9099C) Substantiated The investigation revealed: Allegation: Staff do not respond to resident's call for assistance in a timely manner. It is alleged that facility staff take too long after pendant is push for assistance. LPA Interviewed five (5) staff and four (4) of five (5) staff denied the allegations. One staff stated that when staff arrived for their shift one day, R1 was soiled and not assisted in timely manner. LPA interviewed five (5) residents and two (2) of five (5) residents stated that facility staff sometimes take a long time to assist them. LPA reviewed call light log, and, on at least 4 different occasions, it did take over 60 minutes for staff to assist residents during the month of December 2024. There is enough evidence to substantiate this allegation. Allegation: Staff do not ensure that resident's toileting needs are met. It is alleged that resident was left in his bodily fluids after bowel and bladder movement and developed a rash due to staff neglect. LPA interviewed five (5) staff and four (4) of five (5) staff denied the allegations. LPA interviewed five (5) residents and four (4) of five (5) residents were not able to corroborate the allegation. One staff stated that when staff arrived for their shift one day, R1 was soiled and not assisted in timely manner. Some staff stated R1 had rash when R1 arrived to facility. There is enough evidence to substantiate this allegation. Based on interviews and information obtained the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Health and Safety Code, Chapter 3.2, Article 02. See LIC 9099D. The Investigation revealed: Allegation: Resident sustained a pressure ulcer due to staff neglect. It is alleged that resident developed a pressure ulcer due to neglect of facility. LPA interviewed five (5) staff and five (5) of five staff denied the allegation. LPA interviewed five (5) residents and four (4) of five (5) residents cold not corroborate the allegation. R1 was admitted to facility on 11/27/2024 with ulcer on right foot and admitted to Home Health agency on 11/29/2024 to provide wound care. Documentation shows R1 had pressure ulcer(s) as far back as 11/18/2024 while residing at SNF. R1 was admitted to Hospice on 12/23/2024 and documents from Hospice show R1 had stage 2 and stage 3 ulcers. R1 has history of skin breakdown when admitted. Facility addressed the issue right away by ordering wound care for resident through home health agency. There is not enough evidence to support this allegation. Allegation: Staff do not follow resident's special diet. It is alleged that resident was on special diet and facility did not honor it by feeding R1 pasta, pastries, pizza and food that R1 is not supposed to eat. LPA interviewed five (5) staff and five (5) of five staff denied the allegation. LPA interviewed five (5) residents and four (4) of (5) residents were not able to corroborate the allegation. LPA reviewed doctor’s orders for R1 and it showed that R1 was regular diet with no dietary restrictions. Other special needs were documented as no salt added (NAS) thin liquid. Two (2) residents stated that the food does not have salt and that they must add salt to their taste. Staff stated that food is cooked with NAS as many residents cannot have salt in their diets. Based upon records review, and interviews conducted, the findings indicate that, although the allegation(s) 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 with Maria Roleda, Clinical Supervisor. A copy of the report was provided. .the state’s words, verbatim · CDSS document, Jan 30, 2025 · control 28-AS-20250124155256

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 6, 2025

Personnel Requirements -General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance... This requirement is not met as evidenced by: Statements from staff and residents in care, revealed that staff are not responding to the call light assistance within a reasonable time frame which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 30, 2025

Plan of correction: The Administrator will provide an in-service training to all staff on Personnel Requirements and ensure that all staff are adhering to the residents call light request. Provide the in service sign in sheet with staff signatures and topics discussed by POC due date 02/06/2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(a)(1)(c) · Plan of correction due date: Feb 6, 2025

Managed Incontinence. The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following circumstances: (1) The condition can be managed with any of the following: A program of scheduled toileting at regular intervals. This requirement was not met evidenced by: Statement obtained from staff and resident stated R1 was left in soiled diaper for unreasonable time.the state’s words, verbatim · CDSS document, Jan 30, 2025

Plan of correction: The Administrator will review Title 22 Regulations, Section 87625 on Managed Incontinence and conduct an in-service training with all staff and provide a copy of the sign in sheet of all attendees along with the topics covered during the in-service training. POC is due to CCL by 02/06/2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection on 9/24/24. LPA met with Administrator, Jared Green, and the reason for the visit was explained. The facility is licensed for 85 non-ambulatory residents, ages 60 and over, of which 9 may be bedridden. There is a hospice waiver approved for 20 residents. LPA toured the facility, reviewed files and medications using the Compliance and Regulatory Enforcement (CARE) tool. The following were observed: The facility is a 2-story building that consists of resident bedrooms on both floors. Each floor also has common areas, activity rooms, and communal restrooms. The dining hall and kitchen is located on the first floor. There is a memory care unit on the 2nd floor. The memory care unit has an indoor and enclosed outdoor area for resident recreation activities. LPA selected random rooms to inspect in both memory care and assisted living side. There were no sharps or cleaning products in their rooms. Facility is free of odors from incontinence. LPA observed adequate food supplies of 2 day perishable and a week of non-perishable. The facility receives food supplies twice a week. The kitchen is free of rodents and insects. LPA reviewed 5 resident files. Resident files have the admission agreement, physician's report, consent forms, resident appraisal, personal rights, and property and valuable form. LPA reviewed 5 staff files. The administrator's certificate expires on 4/14/26. Staff files have the health assessment with TB test result, criminal background clearance letter, and personnel record. Staff are receiving ongoing training. However, LPA provided a technical assistance to ensure staff are receiving the required number of hours on dementia care. Medications are centrally stored in the locked cart. The facility utilizes the electronic medication log to document when given. LPA checked the medications for 5 residents and did not observe any discrepancies. Facility has the updated Emergency Disaster Plan and conducting quarterly disaster drills for each shift. No deficiencies were issued today. An exit interview was held and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Sep 24, 2024

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff do not provide resident with activities. Staff isolates resident while in care. Resident is left in soiled diapers for an extended period of time. Staff are not meeting resident's toileting needs. Staff do not ensure that resident has clean linens.

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to facility to investigate the above allegations. LPA met with staff Heather Cummings and Maria Cruz. Rhon Hipolito, Executive Director arrived a short time later and assisted with the visit. The investigation consisted of LPA interviewing six (6) staff, two (2) residents and attempted to interview 4 other residents, taking a tour of facility including all the rooms and common areas in memory care section of facility. LPA reviewed and obtained copies of staff and residents rosters, R1 Medication Review Report, R1 Service Plan Review updated 05/21/2024, R1 Emergency Contact Information, R1 appraisal dated 04/18/2024, R1 Admission Agreement. R1 Task List Schedule for May 2024. R1 Physicians Report For Residential Care facilities for the Elderly (RCFE) dated 05/21/2024, R1 Hospice - Vitas Health Care Physician Recertification dated 02/28/2024, R1 Vitas Addendum Plan of care dated 2/24/2024, AR change form dated 4/18/24, Vitas case sheet dated 04/04/2024 (continued on 9099C) Unsubstantiated The investigation revealed: Allegation: Staff do not provide resident with activities. It is alleged that resident is not included or encouraged to participate in activities. LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegations. LPA interviewed two (2) residents and one (1) of two (2) could not collaborate the allegation. LPA attempted to interview four (4) other residents but was unsuccessful. R1 reported that staff never ask R1 to join in activities. S4 reported that S4 always encourages R1 at least 3 times for each daily activity to join in the activities but refuses. LPA observed S4 encouraging R1 to join in activities and R1 refused which is R1 right. LPA observed many residents participating in different activities during different times of visit. There is insufficient evidence to prove the alleged allegation. Allegation: Staff isolates resident while in care. It is alleged that resident is isolated by staff. LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegations LPA interviewed two (2) residents and two (2) of two (2) residents could not collaborate the allegation. LPA attempted to interview four (4) other residents but was unsuccessful. R1 stated R1 likes to be alone and enjoys staying in R1 room listening to music. Staff reported that they encourage resident to leave room several times daily but refuses. There is insufficient evidence to prove the alleged allegation. Allegation: Resident is left in soiled diapers for an extended period of time. It is alleged that resident is left in soil diapers. LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegations. Staff provided a task log to LPA that documents when diapers are changed and it is consistent with care plan. Staff stated that they will deviate from scheduled diaper change and provide service earlier than scheduled if needed. LPA interviewed two (2) residents and two (2) of two (2) residents could not collaborate the allegation. LPA attempted to interview four (4) other residents but was unsuccessful. LPA toured all the rooms in memory care and no room or common area had foul odors or evidence that residents are left in soil diapers. There is insufficient evidence to prove the alleged allegation. Allegation: Staff are not meeting resident's toileting needs. It is alleged that resident is not being assisted in toileting needs. LPA interviewed six (6) staff and six (6) of six (6) staff denied the allegations. Staff provided a task log to LPA that documents when personal care is provided and it is consistent with care plan. (continued) LPA interviewed two (2) residents and two (2) of two (2) residents could not collaborate the allegation. LPA attempted to interview four (4) other residents but was unsuccessful. There is insufficient evidence to prove the alleged allegation. Allegation: Staff do not ensure that resident has clean linens. LPA interviewed six (6) staff and 6 of 6 staff denied the allegations. LPA interviewed two (2) residents and two (2) of two (2) residents could not collaborate the allegation. LPA attempted to interview four (4) other residents but was unsuccessful. S3 reported that S3 is responsible to change the linens in all the resident's rooms once per week. S3 stated S3 will change the linens more frequently if they get soiled before the scheduled day. S3 stated that someone changed R1 linens today and S3 does not know who. LPA asked S3 to show LPA R1 linen that had just been changed and LPA observed it to be clean and dry. There is insufficient evidence to prove the alleged allegation. Based upon records review, interviews conducted, and observations made the findings indicate that, although the allegation(s) 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 with Executive Director Rhon Hipolito. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 21, 2024 · control 28-AS-20240514104301

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent Annual Required 1-year Visit on 10/30/2023 at 10:23 am. Initial Annual Required 1- year visit was conducted on 10/19/23. LPA was met by Wellness Director, Ruby Racca-Magao and explained the purpose of the visit. The facility is licensed for 85 non-ambulatory adults, ages 60 and over, of which 9 may be bedridden. There is a hospice waiver approved for 20 residents. There are currently 14 residents in memory care and 34 in assisted living. LPA Ramirez reviewed ten (10) personnel records and ten (10) resident records and received a copy of facility liability insurance. Three (3) out of the ten (10) personnel records reviewed are care givers in the facility memory care unit. LPA Ramirez observed an Administrator's Certificate for Dwight Dunagan which expires 07/11/2024. LPA Ramirez did not observe and deficiencies during today's visit. Exit interview was conducted with Administrator Dunagan. A copy of this report and appeals rights was provided.the state’s words, verbatim · CDSS document, Oct 30, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 10/19/2023 at 11:03 am. LPA was met by Wellness Director, Ruby Racca-Magao and explained the purpose of the visit. The facility is licensed for 85 non-ambulatory adults, ages 60 and over, of which 9 may be bedridden. There is a hospice waiver approved for 20 residents. There are currently 14 residents in memory care and 34 in assisted living. The facility consists of 2 floors and a memory care unit on the 2nd floor. There are resident rooms on both floors, along with common areas, and communal bathrooms. There is a chapel room in which it is utilized by both California Mission Inn and California Mission Inn Rose Manor facilities. * Signage are posted throughout the facility. They consist of proper wearing of the masks, sneezing etiquettes, and COVID-19 symptoms checks. * Sufficient amount of PPE supplies of at least 30 days were observed in the storage area located in the first floor. Disinfectants and cleaning supplies are stored and locked in the housekeeping area. * Sufficient food supplies of 2 day perishable and a week of non-perishable items are observed. Food items are restocked every Tuesday and Friday. Water temperature in kitchen sink was measured at 136 degrees F. LPA Ramirez will issue Technical Violation. * LPA Ramirez selected the following rooms at random to inspect: 128, 130, 154, 155, 254, 257, and 276. All resident rooms contained required linens, lighting and furniture. * Dining room area was observed to be clean and contained multiple tables with plenty of seating. * LPA observed medication room to be locked and inaccessible to residents in care. Due to time constraints, LPA will return to complete annual inspection. No deficiencies were issued today. An exit interview was held. A copy of this report, LIC 9102 and appeal rights were given to the Wellness Director.the state’s words, verbatim · CDSS document, Oct 19, 2023

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.