Canyon Villas

Allegation investigated: Personal Rights

Licensing Program Analyst (LPA) Jose De La Cruz conducted an unannounced visit regarding the above allegation. LPA was greeted by Resident Care Director Ileen Lund, to whom he identified himself and explained the purpose of the visit. On June 2, 2026, the Reporting Party (RP) alleged that the facility attempted to evict a resident (R1) due to undisclosed behaviors. The complaint also alleged that R1 felt discriminated against and expressed statements indicating they did not want to live anymore. On June 12, 2026, LPA conducted an unannounced visit to the facility to interview staff and review records. Per the Executive Director (ED) and Staff 1 (S1), R1 had not submitted any complaints to the facility regarding staff or feeling discriminated against. [CONTINED ON LIC9099-C] Unsubstantiated [CONTINUED FROM LIC9099] An eviction notice had been delivered to R1, and an eviction date was provided, however, R1 was already looking for a new facility due to having received a previous eviction notice, which required reissuance due to unrelated circumstances. According to the ED, R1 was able to locate and move to a different facility before the effective date of the most recent eviction notice, approximately one week after receiving it. That same day, LPA contacted the RP. RP stated they were aware of the reasons the eviction notice was issued and confirmed that R1 had relocated to a new facility. RP reported that R1 was happy at their new facility and disclosed the reason R1 previously felt discriminated against, which related to the level of care R1 required. RP explained that this need made it difficult for R1 to find a new placement initially. Regarding the statement that R1 “didn’t want to live anymore,” LPA asked RP whether they believed this indicated genuine intent. RP stated that R1 often uses that phrase without intent to act on it and that they did not believe R1 was at risk of self-harm. LPA subsequently visited R1 at their current facility and conducted an interview. R1 stated they wished to move forward and leave the prior situation behind. R1 denied any intention to harm themselves and acknowledged feeling discriminated against during the eviction process. However, R1 expressed optimism about starting over at the new facility and not reliving the previous experience. Based on interviews, record review, and LPA observations, the preponderance of evidence standard was not met. Therefore, the allegation is unsubstantiated. No deficiencies were cited in accordance with Title 22 of the California Code of Regulations. Report and Appeal Rights were discussed with and provided to the Resident Care Director Ileen Lund. Signature below confirms receipt.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 08-AS-20260602102308

Allegation investigated: Staff illegally evicted a resident in care.

Licensing Program Analyst (LPA) Jose De La Cruz made an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Vonda Boller. The facility's license shows a maximum capacity of four (4) developmentally disabled adults, ages 18 through 59, all ambulatory On 5/13/2026, it was alleged that the facility engaged in the illegal eviction of a resident (R1). A review of records found that on 4/23/2026, the facility submitted a copy of R1’s 30-day eviction letter to the Department as required, indicating violations of facility policy as grounds for the eviction, which would be in effect as of 5/28/2026. [CONTINUED ON LIC9099-C] Substantiated [CONTINUED FROM LIC9099] On 5/14/2026, the Department conducted a review of the eviction letter to determine compliance. According to the notice, seven (7) policy violations were listed including, "verbal abuse directed toward other residents or staff," “yelling at and threatening staff", and “using profanity and offensive language.,” and others. Listed policy violations did not specify the supporting details as required such as the date, place, witnesses and circumstances of each policy violation that occurred. Other required elements were also missing which included the specific statement required by California Code of Regulations, Title 22, 87224(d)(1)(D), which protects Residents from involuntary transfers by informing them of the facility’s responsibility to file and be granted an unlawful detainer in court should the resident fail to vacate per the terms of the notice. On 5/22/2026, LPA interviewed R1, who confirmed receiving the eviction notice, but refuted the details included on the document. The Facility Administrator was also interviewed, who confirmed that the eviction notice was on hold while the requested changes were being made. Based on the foregoing, the preponderance of evidence standard was met. The complaint was substantiated and deficiencies were cited and listed on the attached LIC 9099(d). Exit interview conducted. Report, LIC 9099(d) and Appeal Rights discussed with, and provided to Executive Director Vonda Boller, whose signature below confirms receipt.the state’s words, verbatim · CDSS document, May 22, 2026 · control 08-AS-20260513172708

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Jun 5, 2026

87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons… for the eviction with… the date, place, witnesses, and circumstances concerning those reasons. This requirement was not met as evidenced by: Based on record review, the Licensee served an eviction notice to one resident (R1) based on seven (7) facility policies, without dates, place and/or witnesses regarding those violations which posed an immediate personal rights risk one of 96 residents (R1) in care.the state’s words, verbatim · CDSS document, May 22, 2026

Plan of correction: Eviction notice is being corrected, once the corrections are done it will be submitted to the department for review.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose De La Cruz made an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Nursing Coordinator Ileen Lund (ENC). The facility's license shows a maximum capacity of 133 non-ambulatory elderly residents ages 60 and above, 16 of whom might be bedridden and a hospice waiver for 16 residents. LPA and ENC toured the interior and exterior of the facility and inspected different rooms in the three floors of the facility, which was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. While reviewing the medication room LPA observed that the medication for a specific client was not dispensed, and it was registered as dispensed, with no refusal notes on the electronic MAR. No pools, bodies of water or fireplaces exist on the premises. Per ENC, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC809] Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. One deficiency was cited per California Code of Regulations, Title 22 (refer to the LIC809-D page). No Civil Penalties were assessed. Plan of Correction was jointly developed with the staff responsible. An exit interview was conducted with Director of Human Resources Mari Perez, to whom a copy of this report, the LIC 809-D pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.the state’s words, verbatim · CDSS document, Dec 15, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not assist residents with incontinence care Staff did not treat resident with dignity

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Vonda Boller. Throughout the investigation, the Department secured records and conducted interviews with external and internal sources, including staff and clients. It was alleged staff did not assist residents with incontinence care. On March 11th, 2024, it was reported to the Department staff were not assisting residents and residents were left in soiled briefs. The LPA interviewed two residents (Resident # 2 (R2) and Resident # 3 (R3)), who were allegedly witnessed to be left in soiled briefs. The LPA was not able to qualify R2, as R2 was not able to answer the LPAs questions. An external source providing services to R2 did not report any concerns regarding lack of incontinence care for R2. (See LIC 9099-C page for continuation of report.) Substantiated R3 was qualified to be oriented during an interview. R3 did not have any concerns with the lack of care and noted staff would assist within a reasonable time. One source revealed management had discussed call button response times with the facility's receptionist. The call button calls went to the receptionist and the receptionist relayed the calls to staff. Management believed the receptionist was not relaying the calls to staff; therefore, response times were high. This source confirmed the receptionist did relay the calls to floor staff, and several residents and family members had reported concerns with how long it took staff to respond. The response time ranged from five minutes up to forty minutes. Additional interviews with internal sources corroborated several residents had disclosed concerns with how long it took staff to respond to calls for assistance. An additional source reported response times for incontinence care could be up to thirty minutes. Based on the evidence obtained, the allegation was substantiated. It was alleged staff did not treat a resident with dignity. It was reported to the Department staff made Resident #1 (R1) feel ashamed when R1 requested assistance. An interview with one source revealed staff had made comments about having to assist R1. These comments were not made in the presence of R1, but the comments gave the impression staff did not want to assist R1. An interview with R1 confirmed staff had not refuse to assist R1, but staff had made comments that made R1 feel ashamed to ask for assistance with incontinence care. R1 did not report this concern to management. An interview with an external source, who regularly visited the facility, reported some residents had reported concerns regarding staff interactions, including staff not treating residents with dignity. An interview with an additional resident also revealed staff had raised their voice and made condescending comments toward the resident. Although R1 did not report this concern to management, there is enough evidence to substantiate the allegation. The deficiencies were cited in an LIC 9099-D page and a plan of correction was jointly formulated with Executive Director Vonda Boller. An exit interview was conducted with Executive Director Boller, to whom a copy of this report, LIC 811, LIC 9099D and Licensee/Appeals Rights (LIC 9058), were provided. It was alleged staff did not assist a resident with bathing. It was reported to the Department the facility did not properly assist Resident # 5 (R5) with showers, and this may have led to wounds. Interviews with several internal sources did not reveal any concerns with lack of assistance with showers, nor residents sustaining any wounds as a result. An interview with an external source providing services to R5 reported there were no concerns regarding the facility not assisting R5 with showers. This source also noted there were no concerns with R5 developing any wounds due to inappropriate assistance with showers. One source did report the facility did not assist a resident with showers. Interviews revealed contradicting statements on whether staff did, or did not assist this resident. It was alleged staff did not ensure a resident had clothing. It was reported to the Department the facility did not ensure Resident # 6 (R6) had enough clothing. Interviews with internal sources revealed R6 had enough clothing, but R6 preferred to wear dresses. Sources had witnessed staff redirecting R6 to R6’s bedroom to assist with clothing changes. On one occasion, R6 was witnessed in a common are only wearing undergarments. Interviews with external sources, including an agency providing services to R6, revealed there were no concerns with R6 not having enough clothing. As R6’s health declined, R6 developed anxiety and a concern of R6 undressing was discussed with an external source. It was also revealed the facility communicated with R6’s responsible party to request additional clothing. Interviews did not reveal any concerns with staff encouraging R6 to stay in R6’s bedroom, nor staff preventing R6 from participating in activities and ambulating through the facility. Based on the evidence obtained, there was not enough evidence to prove the alleged violations occurred, therefore, the allegations were unsubstantiated. An exit interview was conducted with Executive Director Vonda Boller, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Mar 20, 2025 · control 08-AS-20240311111904

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Mar 20, 2025

87625 (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure residents were kept clean and dry, which posed a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2025

Plan of correction: Executive Director agreed to provide care staff in sevice training regarding incontinence care. Proof of training will be submitted to the LPA by 4/3/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Mar 20, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as ewvidenced by: Based on interviews, the Licensee did not ensure residents, Inlcuding R1, was treated with dignity, which posed a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2025

Plan of correction: Executive Director agreed in service training to staff regarding personal rights. Proof of training will be submitted to the LPA by 4/3/25.

Allegation investigated: Staff did not ensure food provided was of good quality Staff did not provide sufficient food Staff did not provide activities Licensee did not follow admissions agreement

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Housekeeping Director Emy Rivera. Executive Director Vonda Boller arrived during the visit and assisted the LPA. Throughout the investigation, the Department secured records and conducted interviews with external and internal sources, including staff and residents. It was alleged staff did not ensure food provided was of good quality. Interviews with internal and external sources revealed contradicting statements regarding the quality of the food provided. Some sources disclosed the food was of good quality, that staff provided options, and that staff were receptive to feedback. Other sources reported the food was mediocre, but still of good quality. These sources had not address this with staff. Unsubstantiated On multiple visits to the facility, the LPA observed the facility’s dining service, and inspected the facility’s food supply. There were no immediate concerns with the quality of food observed by the LPA during these visits. It was alleged Staff did not provide sufficient food. Interviews with staff and residents revealed the amount of food provided was sufficient. Prior to serving the food, staff would confirm with each resident the portion size desired. Residents were able to request additional servings and there was no concern with lack of food. Interviews also revealed there were snacks placed throughout the facility and were accessible to the residents. During multiple visits to the facility, the LPA inspected the facility’s food supply and determined there were no concerns with the amount of food at the facility. The LPA also toured the facility and witnessed mini fridges with yogurts, parfaits, fruit, snack bars, and bottled water readily available to the residents in care. It was alleged the licensee did not provide activities. Interviews with staff and residents confirmed the facility had scheduled in-house and off-site activities for all residents to attend. Interviews with staff, residents, and the executive director, confirmed the facility had replaced transportation vehicles and the new transportation vehicle was not able to accommodate for residents in electric scooters, or wheelchairs. These interviews also revealed the facility would assist residents who wanted to participate in off-site activities in arranging Metropolitan Transit System (MTS) services. During multiple visits, the LPA witnessed activities schedules posted throughout the facility. It was alleged the licensee did not follow an admissions agreement. It was reported to the Department the facility declined to provide transportation to medical appointments as agreed in Resident # 1’s (R1) admission agreement. Interviews with several sources, including R1, staff, and residents, denied the facility ever refusing to assist residents in arranging transportation to medical appointments. The facility scheduled transports to medical appointments on Tuesdays. Residents who used Ambulatory Assistive Devices (ADDs) were assisted with arranging transportation with MTS, or other providers able to accommodate ADDs. Review of R1’s admission agreement noted the facility would assist in arranging transport and providing transport on one designated day per week. Based on the evidence obtained, there was not enough evidence to prove the alleged violations occurred, therefore, the allegations were Unsubstantiated. An exit interview was conducted with Executive Director Vonda Boller, to whom a copy of this report and Licensee/Appeals Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Feb 26, 2025 · control 08-AS-20240520114334

Allegation investigated: Lack of supervision resulted in sexual abuse

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced follow up complaint investigation visit to deliver complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Chief of Operations Aurora Madueno. Throughout the investigation, the Department secured records and conducted interviews with external and internal sources, including staff and residents. It was alleged lack of supervision resulted in sexual abuse. On July 21st, 2023, it was reported to the Department Resident # 1 (R1) was sexually assaulted at the facility, by an unknown male. R1 was noted to be alert and oriented to person, place, and situation. It was also noted R1 required assistance with Incontinent care, and full assistance with transferring in and out of bed. R1 was not diagnosed with Dementia, but Mild Cognitive Impairment (MCI) was noted. (See LIC 9099C for Continuation). Unsubstantiated Additionally, R1 had an auditory and visual impairment, incontinent of both bowel and bladder, and a motor impairment. On July 4th, 2023, R1 attended the facility’s BBQ during the day and was witnessed watching the fireworks display in the Baldwin room with other residents. An interview with R1 revealed the following information. On or about the early morning of July 4th, 2023, R1 was awakened by an unknown male touching R1’s genitals. R1 asked this male what he was doing, without commenting, the unknown male walked out of the room. R1 reported the unknown male was confronted by another male outside R1’s doorway who asked the unknown male what he was doing in that room. R1 heard the other male comment, “what are you doing? this is not your room.” R1 did not call for help, nor push R1’s pendant that was on the night stand at the time. R1 lived independently and did not report the incident until the following morning when R1’s daughter visited. R1 reported feeling safe residing at the facility and felt secured now that R1 doors locked R1's door in the evenings. Interviews with staff consistently reported there was no male staff working on the shift in question. Staff who reported checking on R1 throughout the evening did not notice anyone walking around the facility late at night. R1 had a night light in the room that was on during the evening, and it illuminated the room, in case R1 got up to use the bathroom. Staff noticed R1 was in R1’s room and did not hear anything unusual. R1’s room was near the medication room and staff would have heard any verbal altercations or disruptions in the hallway. Interviews with residents, and R1’s neighbors, revealed they did not hear, nor saw anything unusual that evening. Residents reported if there was any type of verbal disturbance in the hallways, they would have heard it, as it was usually quiet at that time. Interviews with R1, R1’s neighbors, and staff confirmed R1 would leave the apartment door open and unlocked. This was also upon R1’s family request. (See additional LIC 9099C for continuation of report.) Review of the San Diego Police Department’s (SDPD) Crime/ Incident report corroborated R1 had disclosed the same information about the incident, that was reported to the Department. An officer with SDPD reviewed facility surveillance footage and determined an unknown male entered the facility on the date in question, at approximately 9:42 pm, through the main entrance door. This male was seen exiting the facility at approximately 9:44 pm. Interviewed staff were not able to identify who this male was, and it was noted it could be a family member, or someone dropping off a package, but this was not clear. SDPD submitted a Be on Look Out (BOLO) bulletin of a photo of the unknown male entering the facility, but no one had responded to it. It appeared there was not enough information to continue the police investigation and it would be suspended until additional information was obtained. Since the incident, the facility placed cameras in the hallways and throughout the building. R1’s bedroom door was now locked. There was no information to support that the unidentified individual in the surveillance footage entered R1's bedroom. There was no information to support that the alleged sexual abuse occurred, and it is unclear who entered R1’s apartment on the evening of July 4th, 2023. Based on the information obtained, the allegation was Unsubstantiated. An exit interview was conducted with Chief of Operations Aurora Madueno, to whom a copy of this report, LIC 811 Confidential names list, and Licensee/Appeals Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Jan 10, 2025 · control 08-AS-20230721120022

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Continuation Annual Inspection visit. The LPA introduced himself and disclosed the purpose of the visit to Human Resources Director Mari Perez. Illeen Lund and Aurora Madueno assisted the LPA during the visit. The facility was licensed for a capacity of one hundred thirty-three (133) non-ambulatory residents, of which sixteen (16) may be bedridden. The facility also had an approved hospice waiver for sixteen (16) residents. The LPA conducted interviews and reviewed staff and resident records. The facility was clean, in good repair, and walkways were free of obstructions. There no pools, nor bodies of water observed on the premise. Per staff, no firearms, nor ammunition were stored at the facility. No deficiencies were cited on today's date. An exit interview was conducted with Chief of Operations Aurora Madueno, to whom a copy of this report, and Licensee Rights (LIC 9058), were provided via email. An email mail read receipt confirms the documents were received by Madueno.the state’s words, verbatim · CDSS document, Jan 10, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection visti. The LPA introduced himself and disclosed the purpose of the visit to Administrator Vonda Boller. The facility was licensed for a capacity of one hundred thirty-three (133) non-ambulatory residents, of which sixteen (16) may be bedridden. The facility also had an approved hospice waiver for sixteen (16) residents. During today visit, the LPA toured the interior and exterior of the facility, and inspected resident bedrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. The facility had sufficient space to facilitate dining, laundry, visitation, meetings, and resident activities. There were no pools, nor bodies of water observed on the premises. Per staff, the facility did not store any firearms, nor ammunition at the facility. Carbon monoxide detectors and the facility's signal system/ pull cords were tested at random. Fire extinguishers and required licensing posting were observed in visible areas of the facility. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, and stored in locked areas. A review of facility records was initiated, including the facility's liability insurance, Infection Control Plan, and Emergency Disaster Plan. Due to time constraints, an additional visit is necessary to complete the annual inspection. An exit interview was conducted with Administrator Vonda Boller, to whom a copy of this report, and the Licensee (LIC9058), were provided via email. An email read receipt confirms the documents were received.the state’s words, verbatim · CDSS document, Jan 2, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced Case Management visit. The LPA identified himself, and discussed the purpose of the visit with Executive Director Vonda Boller. Ileend Lund assisted the LPA during the visit. Today's visit was in response to an LIC 624 Incident Report, which the licensee self-submitted to the CCLD San Diego Regional Office (received on 06/25/2024), involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, the LPA collected and reviewed records, including a physician's report, identification emergency profile, pre-appraisal, and care plan. Guidance was provided by the LPA and no deficiencies were cited on today's date. An exit interview was conducted with Boller, to whom a copy of this report, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058), were provided via electronic mail. An electronic mail read receipt confirms the documents were received by Boller.the state’s words, verbatim · CDSS document, Jul 10, 2024

Allegation investigated: Facility staff did not conduct emergency drills

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced a follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Vonda Boller. Throughout the investigation, the Department secured pertinent records and conducted interviews with sources, including staff and residents. It was alleged the facility staff did not conduct emergency drills. Interviews along with review of records revealed the facility conducted multiple emergency drills in 2023. These emergency drills were not conducted quarterly for each shift, as indicated in the Health and Safety Code. This deficiency was cited in an LIC 9099D. A plan of correction was jointly formulated with Executive Director Boller. The facility has generated a emergency drill schedule for 2024, therefore, the Plan of Correction was cleared on today's date. Substantiated An exit interview was conducted with Executive Director Boller, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Mar 29, 2024 · control 08-AS-20240318152126

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: Mar 29, 2024

1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement was not met as evidenced by: Based on interviews and review of records, the Licensee did not ensure emergency drills were conducted quarterly for each shift, which posed a potential health, safety, and personal rights risk to 103 of 103 residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: Executive Director agreed to provide the LPA a schedule of planned emergency drills for 2024. POC was cleared on today's date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required 22 month Inspection. LPA Rodgers was granted entry into the facility by Administrator, Vonda Boller, after identifying herself and stating the purpose of the inspection. The facility serves 133 non-ambulatory elderly residents, age 60 and above, of which 16 may be bedridden in rooms #134-#147 only. There is an approved Hospice Waiver for 16 residents. This is a three-story complex, and the facility does not feature a secured perimeter. LPA was accompanied by Administrator Boller, during a tour of the facility, which was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, and food storage areas. There is a fire signal system in place and the carbon monoxide detectors were operational. The last disaster drill was conducted on November 2023. Exterior and interior passageways were free from obstructions. According to Administrator Boller, there are no weapons and/or ammunition stored on the premises. Pull cords were available in each resident units and LPA Rodgers observed functionality of signal system. Resident's room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars, and nonskid mats were present in residents’ showers. Hot water temperature in residents’ bathrooms were compliant. [Continued on 809-C] Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closet. The medication room is secured and has a locked medication cart, medications were labeled and kept in compliance with label instructions. LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA Rodgers also conducted a review of In-service training procedures. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted and a copy of this report and Licensee/Appeal Rights - LIC 9058 (rev. 01/16) were provided to the Administrator Boller, whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Dec 20, 2023