Capriana

Allegation investigated: Facility did not provide requested care log documentation

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint received in the Regional Office. LPA was greeted and granted entry by the Concierge at 9:45am. LPA met with Executive Director (ED) Tonya Reynolds and explained the purpose of the visit. LPA obtained the following documents for Resident #1 (R1): Medication Administration Record for February 2026; Charting notes from February 3-26, 2026; Physician's orders dated February 11, 14 and 17, 2026; Bowel protocol for February 2026; Staff Assignments by Month for March 2026; and Shift Reports for February 2026. LPA reviewed email communications regarding R1 with Responsible Parties as well as Resident #1 (R1)’s Durable Power of Attorney for Assets and Resident Services Agreement. LPA also reviewed Unusual Incident Reports submitted to the Department for incidents that occurred on February 11th and 25th, 2026. (Cont9inued on LIC 9099) Substantiated (Continued from LIC 9099) It was alleged that Facility did not provide requested care log documentation. R1’s Durable Power of Attorney (DPOA) requested Activities of Daily Living (ADL) care logs regarding Resident #1 (R1) on February 11, 2026 via email. Three of three staff interviewed stated they responded to Power of Attorney (POA) and provided documentation requested. Additional documentation was requested by the POA but the February ADL care log was determined to be an internal document by the facility and was not provided. ED stated the information on the ADL care logs were transcribed into the alert charting notes; which the POA was given. The original care logs were not provided. Department review of the requested documents determined that the ADL care logs are documentation of R1’s ADL’s which could impact the resident's ability to function or for needed services required. The requested documentation was not provided within two business days to the POA. Based on document review and interviews the preponderance of the evidence standard has been met and the allegation that Facility did not provide requested care log documentation is Substantiated. An exit interview was conducted with Executive Director (ED) Tonya Reynolds and a copy of this report was given to the facility along with a copy of the LIC 9099-D and Appeal Rights.the state’s words, verbatim · CDSS document, Apr 28, 2026 · control 22-AS-20260316151041

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: May 29, 2026

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilties, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19) to have prompt access to review all of their records... Photocopied records shall be provided within two (2) business days...This requirement is not met as evidenced by: Based on LPA interviews, the requested records were not received within 2 days which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Apr 28, 2026

Plan of correction: ED will in-service administrative team on resident rights regarding providing appropriate resident documentation to POA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit for a Case Management deficiency. LPA was greeted and granted entry by the Concierge at 9:45am. LPA met with Executive Director (ED) Tonya Reynolds and explained the purpose of the visit. During a complaint investigation, by the Department, it was discovered that Activities of Daily Living (ADL) care documentation is shredded monthly by Memory Care Director (MCD) and Health Services Director (HSD) due to the documents being classified as “internal” and that this was proprietary information. LPA requested copies of the ADL care documentation for review. Per review of documentation provided, documents contained information related to resident’s ADL care which could impact the resident's ability to function or for needed services required. Per facility policy on Retention of Resident Related Records, “Resident records will be retained according to CA state requirements. In the absence of a state requirement, the records will be retained according to the following guidelines: 5. Resident Monthly Staff Assignment Sheets: Completed sheets are considered worksheets and destroyed when completed at the end of the month.” While the ED stated the information on the ADL care logs were transcribed into the alert charting notes, transcribing of the records does not comply with requirement of original records or photographic reproductions. The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Executive Director (ED) Tonya Reynolds and a copy of this report was given to the facility along with a copy of the LIC 809-D and Appeal Rights.the state’s words, verbatim · CDSS document, Apr 28, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: May 29, 2026

( e) Resident Records ( e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidenced by: Based on LPA record review and interviews requested additional ADL documentation was not retained for three years for Resident #1 (R1). This poses a potential risk to residents due to not maintaining records that provide the full scope of care documentation to properly assess residents’ care.the state’s words, verbatim · CDSS document, Apr 28, 2026

Plan of correction: ED will provide training in-service to management staff regarding appropriate document retention per Title 22 Regulations by POC due date. ED will email documentaton to LPA.

Allegation investigated: Staff does not ensure resident is hydrated. Staff does not ensure to assist resident with feeding.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in the Regional Office. LPA was greeted and granted entry by the Concierge at 1pm. LPA met with Executive Director (ED) Tonya Reynolds and explained the purpose of the visit. During the visit, LPA requested the following documents for Resident #1 (R1): Resident Information Sheet, Physician's Report, Individualized Service Plans and Outside Provider Communication sheet from January 26, 2026. LPA also obtained Resident Information Sheets, Physician's Reports for Residents #2, #3 and #4. It was alleged that Staff does not ensure resident is hydrated. LPA reviewed the Physician's Report from R1 dated February 14, 2025. R1's primary diagnosis is Dehydration and Dementia. LPA reviewed Individualized Service Plans from February 14, 2025 and on December 11, 2025. Due to a change of condition, the re-assessment from December 11, 2025 stated R1 required assistance with eating. LPA reviewed Charting (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) Notes January 4 - January 29. 2026. Charting Notes report R1 is being fed and hydrated on January 4th and a change of condition occurred on January 14, 2026. Home Health was contacted regarding R1 having issues with swallowing. On January 16, 2026 the nurse assessed R1's swallowing and noted R1 was able to swallow water, as well as Ensure; a thicker liquid. The Responsible Party was notified by the nurse and continued to be updated of R1's changing condition. R1 was noted to be lethargic on January 20. 2026. Charting continued to document R1's food intake and hydration On January 25, 2026 R1 was lethargic and refused fluids or food. R1 was sent out to the hospital for further evaluation at 3;30pm. On January 26, 2026 home health recommended an R1 assessment for hospice but R1 was in the hospital at this time. It was also alleged that Staff does not ensure to assist resident with feeding. LPA interviewed four of four staff members who all denied this allegation. Staff stated R1 was full assistance and was assisted with each meal in the dining room unless R1 refused. LPA interviewed three of three residents. Three of three residents denied the allegation that they are not assisted with getting food or water. LPA interviewed one witness who stated staff did not ensure resident was being fed or given proper hydration. Based on LPA's record review, observations and interviews the allegations that Staff does not ensure resident is hydrated and Staff does not ensure to assist resident with feeding are Unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Tony Reynolds, Executive Director and a copy of this report and LIC 811 were provided to the facility.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 22-AS-20260126184730

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Case Management visit to follow-up on an Unusual Incident Report received in the Regional Office on January 24, 2026. LPA was greeted and granted entry by the Concierge at 3pm. LPA met with Executive Director (ED) Tonya Reynolds and explained the purpose of the visit. LPA reviewed Resident #1 (R1's) last two medical assessments dated November 18, 2025 and January 31, 2023. R1 is an independent resident who can ambulate but has a call pendant in case of an emergency On January 21, 2026 at approximately 5:30am, the resident had an unwitnessed fall in the bathroom and was not wearing the call pendant at the time of the fall. Staff discovered resident and immediately called 911. R1's diagnoses include: right superior and inferior pubic ramus, tremors and, osteoporosis. R1 does not have a history of falls. Emergency room evaluation reported resident had a right leg fracture. R1 remains at the hospital at this time. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Executive Director (ED) Tonya Reynolds and a copy of the report LIC 811 were given at the time of the visit.the state’s words, verbatim · CDSS document, Jan 26, 2026

Allegation investigated: Staff are not ensuring accurate information is on resident's physician's orders for medication

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in the Regional Office. LPA was greeted and granted entry and met with Executive Director (ED) Tonya Reynolds and Lizette Flores, Health Services Director (HSD) and explained the purpose of the visit. LPA conducted a joint visit with the Long Term Care Ombudsman (LTCO). LPA requested a copy of Resident #1 (R1)'s lease agreement, Physician's Orders for R1's medications, a medical assessment from December 12, 2025 and email communication from the facility to the responsible party regarding medications. LPA and LTCO audited medication bottles to confirm the prescribing physicians. Per review, the correct prescribing physicians were on the medication bottles and complies with Title 22 regulations. LPA reviewed the bi-annual Medical Assessment, which was reviewed on December 12, 2025 and is effective January 1, 2026. (Continued on LIC 9099) Unfounded (Continued by LIC 9099) It was explained that the Physician's Orders medication record is "profile only" since the pharmacy R1 uses an outside pharmacy. For medications to be inputted to the electronic Medication Administration Record, all medication lists go through the in-house pharmacy. The prescribing physician shown does not change on the profile only. The in-house pharmacy does not actively fill R1's routine medications, thus, the physician on record is the last prescribing physician. R1 came in August 22, 2024 and some medications have not changed and thus, there have been no changes in the prescribing physician unless the prescription changed. LPA interviewed three of three staff members and three of three witnesses. Based on staff and witness interviews, it was agreed the medication record discrepancy from the medication bottle is confusing. It was determined the licensee is complying with regulations. The allegation that Staff are not ensuring accurate information on the resident's physician's orders for medication is Unfounded. The allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Tonya Reynolds, Executive Director and Lizette Flores, Health Services Director and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 6, 2026 · control 22-AS-20251229115217

Allegation investigated: Staff engaged in inappropriate interactions with resident in care Staff mismanaged resident's medication Staff accessed resident's cellphone without proper authorization Staff did not report resident incidents to appropriate parties

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint received in the Regional Office. LPA was greeted and granted entry by the Concierge. LPA met with Executive Director (ED) Tonya Reynolds and explained the purpose of the visit. LPA conducted a visit on November 18, 2025 to investigate the allegations that Staff engaged in inappropriate interactions with resident in care, Staff mismanaged resident's medication, Staff accessed resident's cellphone without proper authorization and Staff did not report resident incidents to appropriate parties. LPA reviewed Resident #1 (R1)'s records which include the Identification and Emergency Information form, Physician's Report, Medication Administration Records for October and November 2025, and R1's Residency Agreement. LPA also reviewed the Employee phone and camera policy in the Employee Handbook. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) Staff members are not allowed to take photos or videos while working and all residents have photo consents included in their Residency agreements. It was alleged that Staff engaged in inappropriate interactions with resident in care. It was reported that a former employee was texting inappropriate photos to a resident. LPA interviewed six of six residents who all denied this allegation. Two of six residents indicated they like to take photos with staff members and did not know there was a policy where staff were not allowed to take photos or videos while working. Six of six residents denied receiving inappropriate content on their cell phones. Thus this allegation is Unsubstantiated. It was alleged that Staff mismanaged resident's medication. LPA reviewed R1's October and November electronic Medication Administration Records (MAR) but no discrepancies were found on the eMAR. R1's medications are in bottles. Two of six staff members stated medications are occasionally mismanaged by staff, such as when medication needs to be refilled or that staff do not watch if residents take the medications. Four of six staff members denied this allegation. Thus this allegation is Unsubstantiated. It was also alleged that, Staff accessed resident's cellphone without proper authorization. LPA asked six of six residents if staff members access their cell phones without resident's permission. Six of six residents denied this allegation. LPA interviewed six of six staff members if they accessed residents' cell phones without their permission. Six of six staff members denied this allegation. LPA interviewed five of five witnesses if Staff accessed resident's cellphone without proper authorization. Two of five witnesses confirmed this allegation; stating staff members obtain a resident's cell phone to delete content without permission. Three of five witnesses could not confirm or deny this allegation. Lastly, it was alleged that Staff did not report resident incidents to appropriate parties, Two of five witnesses were not informed or included in meetings with Resident #1(R1) regarding mental evaluations or medications. LPA reviewed email communications between witnesses and facility. Mismanaged medications for R1 were not reported to licensing. LPA reviewed eMAR reports and did not find any discrepancies in documentation, thus it was not reported to licensing. . Staff members interviewed understood they were mandated reporters for resident incidents, including medication errors but did not feel R1's medications were (Continued from LIC 9099-C) mismanaged. LPA obtained documentation that staff were in-serviced on May 29, 2025 regarding resident rights, cell phone policies and phone etiquette. Three of five witnesses denied the allegation that Staff did not report resident incidents to appropriate parties. (Continued on LIC 9099-C1) Based on LPA's observations, record review and interviews, the allegations that: Staff engaged in inappropriate interactions with resident in care, Staff mismanaged resident's medication, Staff accessed resident's cellphone without proper authorization and Staff did not report resident incidents to appropriate parties are Unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of evidence to prove the alleged violations occurred. An exit interview was conducted with Executive Director, Tonya Reynolds, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 22-AS-20251113103336

Allegation investigated: Staff neglected resident and left them in the room.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint received in the Regional Office. LPA was greeted and granted entry by the Concierge. LPA met with Executive Director (ED) Tonya Reynolds and explained the purpose of the visit. It was alleged that staff neglected resident and left them in the room. On November 25, 2025, Resident #1 (R1), who resides in Villagio in the Memory Care, was left in the bedroom with an industrial fan and strong odors from the cleaning product used for carpets. R1 was observed to be cold and there were no windows opened in the room. On December 4, 2025, LPA reviewed Resident #1 (R1): Identification and Emergency Information, Physician's Report, and Needs and Services Plan. R1 has a diagnosis of dementia. LPA interviewed R1 who understood the carpet was cleaned but did not know who requested for the carpet to be cleaned. LPA (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) also interviewed R1's spouse, Resident #2 (R2) who was not present when the carpet cleaning occurred. R2 visits R1 every afternoon and did not smell odors during the afternoon visit on November 25, 2025. R2 also was not sure why the carpet was cleaned. Two of two residents could not confirm the allegation when questioned. LPA obtained the TELS work order; which can be entered for any cleaning or repair work by facility staff, residents or families. A work order was placed on November 20, 2025 to clean the carpet in R1's room. LPA interviewed three of three witnesses. One of three witnesses, Witness #2 (W2), observed R1 shivering in the room upon entry and confirmed the allegation. Two of the three witnesses were not present and could not confirm, nor deny the allegation that Staff neglected resident and left them in the room. LPA interviewed three of three staff members regarding the allegation Two of three staff members stated they asked Resident #1 (R1) if they wanted to exit the room while the carpet was cleaned but R1 did not respond. Staff offered assistance to R1 several times, in different ways, if R1 would like to leave the room but R1 did not want to move. Staff stated they were in and out of the room within thirty minutes. Three of three staff members denied the allegation that Staff neglected resident and left them in the room. LPA reviewed the Material Safety Data Sheet (MSDS) for the carpet cleaner. The cleaner is approved for facility use and according to the staff member who cleaned the carpet, is used frequently to clean carpets throughout the facility. After cleaning R1's carpet on November 25, 2025, staff left the apartment door open and used the industrial fan to quickly dry the carpet area. A second staff member checked on R1 and provided a blanket for the resident; when it was brought to the staff member's attention that R1 appeared cold. The staff member also quickly removed the industrial fan from the area. Based on LPA's record review, observations and interviews, the allegation that Staff neglected resident and left them in the room is Unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director, Tonya Reynolds, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 22-AS-20251201144751

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Samer Haddadin conducted a Case Management – Deficiency Visit at the facility. Upon arrival, LPA met with Memory Care Director (MCD), and and Excusive Director Tonya Reynolds who granted entry into the facility. Marisa Zamudio, who granted entry into the facility. The facility submitted a Special Incident Report (SIR) to Community Care Licensing regarding an elopement incident that occurred on September 26, 2025. According to the report, at approximately 6:40 p.m., R1 was observed missing from their room during a routine status check. An All-Call was initiated via walkie, and staff began a head count while searching for R1. At approximately 7:15 p.m., the facility received a call from the Brea Police Department advising that R1 had been located outside of the facility. Nursing staff and other employees immediately responded to assist R1. Upon return, R1 was assessed and showed no signs or symptoms of pain or injury. As a precautionary measure, 911 was contacted, and R1 was transported to UCI Medical Center for further evaluation. The resident’s primary care physician and power of attorney were subsequently notified. Based on the information obtained during this visit, deficiencies are being cited under Title 22, Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted, and copies of this report, including appeal rights, were provided to MCD, Marisa Zamudio.the state’s words, verbatim · CDSS document, Oct 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 6, 2025

87464(f)(1)Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).Based on record review, the licensee did not ensure required care and supervision when R1 was unaccounted for from approximately 6:40 p.m. to 7:15 p.m. on 9/26/2025 and was later located off premises by law enforcement. This failure to provide care and supervision posed an immediate health and safety risk to R1the state’s words, verbatim · CDSS document, Oct 3, 2025

Plan of correction: The licensee shall submit a written plan of correction to Community Care Licensing by the due date specified on this report. The plan must include the corrective actions taken to ensure adequate supervision of residents, measures implemented to prevent future elopements, and staff training specific to resident safety and monitoring.

Allegation investigated: Staff are not supervising residents resulting in resident-on-resident incidents.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in the Regional Office. LPA met with Marisa Zamudio, Memory Care Director (MCD) and Tonya Reynolds, Executive Director (ED). It was alleged that staff are not supervising residents resulting in resident-on-resident incidents. LPA reviewed the Unusual Incident Reports submitted to the Department on May 7, 2025 for an incident between Resident #1 (R1) and Resident #2 (R2). On May 28, 2025 LPA conducted a Case Management visit to follow-up with a similar incident with R2 and another resident. LPA reviewed R2's: Facesheets, Physician's Reports, Needs and Services Plans, Appraisals and documentation regarding follow-up care plan meetings and electronic files regarding behavior documentation. R2 has had a personal caregiver since May 6, 2025. R2 moved into the facility in March of 2025 from another community that did not have Memory Care. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) On today's date LPA reviewed R1 and R2's Facesheets, Physician's Reports, Needs and Services Plans, Appraisals and facility progress notes. Per facility progress notes, at 8:45pm on Monday, May 5, 2025, a staff member reported that R2 had their hand in R1's pants in the common area. R1 was asleep during the incident. The Med Tech immediately called 911, as well as R1 and R2's Power of Attorneys (POA)s, regarding the incident. R1's POA arrived at the facility within twenty minutes and remained with R1 through bedtime. Local law enforcement arrived on-site and spoke with staff and Health and Wellness Nurse (HWN) at approximately 9pm. The facility submitted an Unusual Incident Report with the Department on Tuesday, May 6, 2025. R1's POA met with Executive Director and HWN on May 6, 2025 to follow-up on the incident that occurred. On May 6, 2025, HWN spoke with R2's POA to follow-up with Primary Care Physician (PCP) regarding behavior. A private companion was recommended and a virtual appointment was scheduled with PCP at 3:30p on the same day. A private companion arrived at 2:30pm on May 6, 2025. LPA conducted a health and safety check and toured the facility. LPA observed residents eating breakfast and participating in activities. LPA also interviewed six of six residents regarding care provided and if they have been inappropriately touched by either another resident or staff. Five of six interviewed denied this allegation. One of six interviewed confirmed this allegation. LPA interviewed five of five staff members. Five of five staff confirmed that R2 has inappropriate behavior and a 24 hour personal companion arrived the day after the incident on May 5, 2025 occurred. Physician's Report for R2 does not document any behaviors. R2's Individualized Service Plan was updated on May 13, 2025 with a care plan meeting with R2's Power of Attorneys via telephone. Recently, R2's behaviors have stabilized and have been managed with medications. A personal companion remains from 8am to 8pm and R2 sleeps throughout the night. Staff continued to document R2's incidents in progress notes. LPA interviewed the LVN nurse and Med Tech who were present at time of incident. Staffing for the PM shift is the same as the day shift with one Med Tech and three caregivers per floor and one Nurse for the Villagio building. The incident took place in a common area and was immediately noted by staff. (Continued on LIC 9099-C1) (Continued from LIC 9099-C) Based on LPA's file review, observations and interviews, 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 that: Staff are not supervising residents resulting in resident-on-resident incidents is Unsubstantiated. An exit interview was conducted Marisa Zamudio,Memory Care Director and a copy of this report and LIC 811 was provided to the facility.the state’s words, verbatim · CDSS document, Sep 19, 2025 · control 22-AS-20250910161426

Allegation investigated: Resident sustained unexplained injuries while in care

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to continue a complaint investigation. LPA met with Marisa Zamudio, Memory Care Director (MCD) and Tonya Reynolds, Executive Director (ED). It is alleged that Resident #1 (R1) sustained unexplained injuries while in care. LPA reviewed the following documentation from Resident #1 (R1)'s file: Identification and Emergency Information, Physician's Report, and Needs and Services Plan. LPA also requested Care staff schedule from July 24-July 28, 2025, a staff roster with telephone numbers and additional documentation related to the incident that occurred during this time period. R1 has resided in the community and moved in on January 12, 2022. A medical assessment was done on March 27, 2025. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) The facility submitted an Unusual Incident Report to the Department for an incident that was reported on July 28, 2025. It was reported to staff that Resident #1 (R1) had a swollen right hand and scratches under both eyes. Staff immediately called 911 for R1 o be taken to the hospital for further evaluation and contacted the Power of Attorney (POA). POA refused for resident to go to the hospital. Facility staff continued to document discoloration of R1's eye since R1 has a history of pink eye per LPA's review of facility progress notes. Per review of physician fax reports Nurse immediately contacted PCP for antibiotic drops with a physician phone order on July 28, 2025. The Primary Care Physician (PCP) visited the next day, July 29, 2025 at 8am and mobile x-rays were ordered at 8:45am. X-ray results showed there were no fractures in hand. Per facility progress notes R1 was sent to the hospital for further assessment at approximately 1:07pm and returned at 5pm. Also on July 29, 2025 a meeting was held with Health Services Director, Memory Care Director and Business Office Director with Resident #1's POA and two other guests to address the incident. Facility stated they would continue to investigate and issues were unresolved at the conclusion of the meeting. On July 30, 2025 an internal investigation by the Regional team was conducted and no evidence was found to support allegation. Resident #1 (R1) moved out of the community on August 5, 2025. On August 14th and August 21st, 2025, LPA conducted visits to request documentation. Over the course of the investigation LPA interviewed five of five witnesses. Three of the five witnesses confirmed the allegation that R1 sustained unexplained injuries while in care. Two of the five witnesses denied the allegation. LPA interviewed four of four residents regarding staff and the quality of care provided. Four of four residents confirmed they are being cared for. LPA interviewed six of six staff members regarding the incident. Six of six staff members denied the allegation. Based on LPA file review, observations and interviews, although the allegation my 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 that: Resident sustained unexplained injuries while in care is Unsubstantiated. An exit interview was conducted with Tonya Reynolds, Executive Director, and a copy of this report and LIC 811 was provided to the facility.the state’s words, verbatim · CDSS document, Sep 19, 2025 · control 22-AS-20250813133028

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Case Management visit to follow-up on Unusual Incident Reports received in our Regional Office. LPA was greeted and granted entry into Villagio by the Concierge and met with Memory Care Director (MCD) Marisa Hernandez. The following documents were obtained and reviewed: Resident #1 (R1)'s Facesheet, Physician's Report dated 1/24/2025, Individualized Service Plan (ISP) dated 7/24/2025, Resident Assessment, Pre-appraisal Assessment and Hospice Plan of Care dated 7/18/2025. LPA interviewed two of two staff and Resident #1 (R1)'s Responsible Party. On July 2, 2025 R1 had an unwitnessed fall and was transported to the hospital for further evaluation. There were no medical issues noted at this time. On July 4, 2025 R1 had an unwitnessed fall in the community hallway. R1 was transported to the hospital and was diagnosed with a broken nose. R1 returned to the community and for four days family members remained at the community with R1 due to R1 trying to remove nasal tubes. On July 11, 2025 a 1:1 private caregiver was hired to remain with R1 and to help with tube removal behaviors. On July 18, 2025 R1 began receiving hospice services. On July 24, 2025 a care plan meeting was held with family regarding R1's change of condition and a new ISP was signed on 7/24/2025. On July 28, 2025 R1 was leaving the community with a family member for an outing when R1 fell. R1 was sent out to the hospital and was diagnosed with a hip fracture. (Continued on LIC 809-C) (Continued from LIC 809) LPA spoke with Responsible Party who stated they were happy with the care being provided to Resident #1 and that there are no issues at this time. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Marisa Hernandez, Memory Care Director and a copy of the report and files reviewed (LIC 811) were given at the time of the visit.the state’s words, verbatim · CDSS document, Jul 29, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Samer Haddadin Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPAs were greeted and granted entry by the Concierge. During today’s visit, LPAs met with Tonya Reynolds Executive Director (ED). The facility consists of two buildings which has a capacity of 200 with an approved fire clearance of 173 non-ambulatory residents of which ten may be bedridden and a hospice waiver for twenty. The facility currently has a census of 137 residents in care with 95 residents in the three-story, Independent/ Assisted Living building and 42 residents in the Villagio building; which is Memory Care. During today’s visit, LPAs toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in six of six resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 110.8 to 118.9 degrees Fahrenheit and all smoke and carbon monoxide detectors were operational and were tested on March 1, 2025 by an outside vendor. The fire extinguishers are charged and were serviced on March 27, 2025.. LPAs inspected the kitchen with the Executive Chef and observed a minimum of two days perishables and seven days nom-perishable food on hand. LPAs walked through refrigerator and freezers and both units were at the required temperatures. LPAs toured the Villagio building and the delayed egress was in working order. LPAs observed residents in activities and other residents relaxing after breakfast in both the upstairs and downstairs dining rooms. ED toured LPAs outdoors and the walking path was free of obstruction. There were koi ponds, a bridge and a locked pool area with various shaded seating areas. LPAs also observed a fenced dog area and observed (Continued on LIC 9099-C) (Continued from LIC 809-C) individual resident casitas to the north of building. The facility’s last fire drill was conducted on June 3, 2025. LPAs observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. Several First Aid kits were observed throughout the community with manuals. An evacuation chair was installed in the main lobby stairwell and the PUB 475, "See Something, Say Something" poster was displayed in prominent areas. There is a main dining room, Portofino, for residents in the main building with several adjacent dining rooms for families or events. LPAs also observed a bar/lounge for residents to enjoy in the evening. In the Villagio building there are dining areas on both floors. LPAs observed a theater, grand ballroom, a library, activities areas and a bistro in the lobby. LPAs reviewed six of six staff training and fingerprint records and reviewed eleven of eleven resident records. LPAs interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPAs confirmed that administrator has a current administrator certificate which expires on January 24, 2026. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Tonya Reynolds, Executive Director (ED) and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Jun 30, 2025

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility regarding an incident that took place on the evening of Friday, May 23, 2025. LPA was greeted and granted entry and met with Memory Care Director (MCD) Marisa Hernandez and explained the purpose of the visit. LPA toured the facility and observed residents in the large upstairs dining room preparing to listen to live music and to enjoy Happy Hour. LPA interviewed and conducted a Health and Safety check with Resident #1 (R1) and Resident #2 (R2) and spoke to three of three staff regarding the incident on the 23rd. The incident, involving inappropriate behavior between two residents, was unwitnessed. The next day one of the residents verbally shared with MCD what happened and a report was submitted to the Licensing Regional Office on May 24, 2025. LPA obtained a copy of the resident and staff rosters for Villagio, Capriana's Memory Care. Copies from R1 and R2's files include: Facesheets, Physician's Reports, Needs and Services Plans, Appraisals and documentation regarding follow-up care plan meetings and electronic files regarding behavior documentation. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Marisa Hernandez, Memory Care Director (MCD) and a copy of the report and files reviewed (LIC 811)) were given at the time of the visit.the state’s words, verbatim · CDSS document, May 28, 2025

Allegation investigated: Due to lack of supervision, resident was left on the floor for an extended period of time after an unwitnessed fall

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced complaint visit to present findings regarding the reported allegation mentioned above. Upon arrival, LPA Haddadin was greeted, granted access to the facility, and informed the staff of the visit's purpose. Executive Director (ED) Tonya Reynolds was later informed of the visit. During the investigation, LPA Haddadin toured the facility, interviewed staff members, and reviewed all medical records pertaining to the alleged incident involving resident (R1). The following allegation was investigated: "Due to a lack of supervision, the resident was left on the floor for an extended period following an unwitnessed fall." The findings of the investigation are as follows: Regarding the allegation, it was reported that Resident (R1), a memory care resident, was discovered on the floor in their private restroom after an unknown duration, exhibiting a bump on their head. Subsequently, R1 was transported to UCI Medical Center for an assessment of their overall stability following the unwitnessed fall. Unsubstantiated LPA Haddadin conducted four staff interviews, all of whom corroborated that the incident occurred. However, these interviews revealed that the facility conducts hourly rounds. R1 had recently concluded a family visit and had been returned to their room. The subsequent hourly round, during which R1 was found on the floor, took place 15 to 20 minutes after the visitation concluded. Furthermore, LPA Haddadin reviewed R1's medical record, physician's report, admission record, and discharge paperwork from UCI Medical Center, where the resident was taken after the incident. According to the discharge paperwork from UCI, specifically on pages 9 and 10, the findings of the CT head scan revealed "Hemorrhage: None. Brain parenchyma: Moderate generalized volume loss...No herniation. No hydrocephalus...No acute calvarial fracture." Therefore, based on the preponderance of evidence gathered through conducted interviews, medical record reviews, and all pertinent paperwork collected by LPA Haddadin, the allegation: "Due to a lack of supervision, the resident was left on the floor for an extended period following an unwitnessed fall," was found to be UNSUBSTANTIATED. This determination indicates that while the alleged incident may have occurred, or the concerns may be valid, there is not a preponderance of evidence to prove that the alleged violation took place. No deficiencies were cited during today's visit. An exit interview was conducted with the ED, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 9, 2025 · control 22-AS-20250219115828

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit regarding an Incident Report received in our office on October 4, 2024. LPA was greeted and granted entry by the Concierge. The facility's current census is ninety-four residents. The purpose of the visit is to follow-up on a Death Report received in our office. LPA requested Resident #1 (R1)'s: Identification Form, Physician's Report, Needs and Services Plan/ Appraisal, Pre-appraisal, Progress Notes as well as copies of the Staffing schedule for October 1, 2024. LPA spoke with Lizette Flores, Health Services Director (HSD) regarding the incident and the chronological order of events. An exit interview was conducted with Ashley Lee, BOD and a copy of this report and LIC 858 were provided at exit.the state’s words, verbatim · CDSS document, Oct 4, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with the Executive Director Tonya Reynolds and explained the reason for the visit. The facility has 2 buildings, building 1 is for assisted and independent living and building 2 is for memory care. Building 1 has 3 stories and building 2 has 2 stories. LPA and the Executive Director toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry way of the facility. LPA observed the fireplace in the lobby living room is screened. Facility has a capacity of 200 of which 173 can be non-ambulatory, 10 may be bedridden and a hospice waiver for 20. LPA did not observe an emergency evacuation chair in the lobby stairway. LPA and the Executive Director toured the kitchen and dining room. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The refrigerators and freezers were at the required temperatures. LPA observed the facility emergency food and water supply stored in a large utility closet. LPA observed all the fire extinguishers in the facility are fully charged. LPA observed that all of the stairwells in the facility had emergency evacuation chairs. The facility has multiple activity rooms and a theater for residents. There are games, puzzles and books for residents in the activity rooms and the theater plays movies every night for residents. LPA observed the facility has computers for residents to access the internet. There is also a fitness room for residents. LPA observed the medication room on the first floor is kept locked and medication is stored in a locked cart in the medication room. The first aid kit in the medication room has all the required elements. LPA toured 2 resident rooms on each floor in building 1. LPA toured 2 rooms on each floor in building 2 for a total of 10 rooms inspected. Smoke detectors/carbon monoxide detectors tested operational. Hot water measured from 105.0 to 116.6 degrees Fahrenheit in rooms inspected. LPA observed all rooms had the required furnishings. LPA tested the delayed egress doors in memory care (building 2) and all of the delayed egress doors are operational. LPA interviewed staff and residents. No obstacles or hazards observed in building 1 or building 2. The facility has an outdoor patio area which includes a pool which is fenced and kept locked. LPA observed a fountain and a koi pond in the patio area. This area is inaccessible to residents in memory care. No obstacles or hazards observed in the outdoor patio area. LPA reviewed 10 resident files and medications. No discrepancies observed. LPA reviewed 7 staff files. No discrepancies observed. All staff are background cleared and associated to the facility. All staff files reviewed had the required training. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Jul 31, 2024

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