Carlton Plaza of Elk Grove

Allegation investigated: Staff did not allow resident to go outside. Staff did not keep resident safe from harm.

On 07/21/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with the facility administrator Jennell and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 143. Allegation: Staff did not allow resident to go outside It was alleged that staff did not allow resident to go outside. This investigation consisted of interview residents and facility staff. On 06/16/2026, LPA Hughes conducted a visit to the facility and spoke with the Resident Services Director, who stated that the facility has a policy encouraging residents to remain indoors during inclement weather or when temperatures exceed 85 degrees Fahrenheit. The Resident Services Director further stated that residents ultimately determine whether and when they wish to leave the facility. During the visit, LPA observed inclement weather posters displayed throughout the facility advising residents of the facility’s policy regarding outdoor activities during periods of extreme weather. Continuation 9099-C Unsubstantiated LPA interviewed resident (R1), who stated they had never been told by care companions or facility staff that they were not permitted to leave the facility. LPA also interviewed three (3) residents, who stated they are aware that staff prefer residents to stay indoors during inclement weather, however all (3) residents stated they were permitted to go outdoors if they choose to do so. Additionally, LPA interviewed an outside reporting source, who stated they no longer had information supporting the allegation and were unaware of the facility’s policy regarding residents going outdoors during inclement weather. Based on the information and evidence obtained, there is insufficient evidence to support the allegation. Therefore, the allegation is unsubstantiated. Allegation: Staff did not keep a resident safe from harm It was alleged that staff did not keep a resident safe from harm. This investigation consisted of interviews with facility staff, and residents. On 06/16/2026, LPA Hughes conducted a visit to the facility and spoke with the Health Services Director, who stated that staff present during the incident immediately intervened by separating the residents and providing assistance. On 07/21/2026, LPA Hughes conducted a follow-up visit to the facility and interviewed facility staff (S1) who stated that during the incident on 06/11/2026, she observed staff promptly remove resident (R1) from the area, redirect the resident, and spoke with the care companion regarding the incident. LPA also interviewed three (3) residents in care who stated they had no concerns regarding facility staff handling residents or themselves in a rough manner or failing to maintain a safe environment. Based on the information and evidence obtained during the investigation, there is insufficient evidence to corroborate this allegation. Therefore, the allegation is unsubstantiated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 27-AS-20260612145210

Type of visit: Required - 1 Year

On 07/21/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA Hughes met with Jennell Revera the facility designated administrator. The current census is 143 with 42 facility staff present. This facility is a single story building licensed to serve (155) non-ambulatory and (25) bedridden residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature in resident bedrooms was measured at 112.8 degrees Fahrenheit in residents bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. LPA observed fire extinguishers located throughout the facility last serviced on 7/02/2026. LPA observed the facility has a public telephone at the front desk and the facility has the required posters posted. Facility thermostat was observed at 74 degrees Fahrenheit. LPA observed toxins located in the facility laundry room inaccessible to residents. LPA observed sharp knives kept locked in the kitchen and inaccessible to residents. Continuation 809-C LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 7 residents medications and the medication administration record (MAR) was complete. The first aid kit was checked and contained the required components. LPA requested resident and staff files for review. LPA reviewed 10 resident files and they were complete. LPA reviewed 5 staff files, and it was complete. LPA reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared. The following documents were provided: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (3) LIC 610 Current Emergency Disaster Plan (4) Proof of Current Liability Insurance (5) LIC 500 Current Personnel Report As a result of this annual visit, the facility is in compliance with Title 22 Regulations, and a copy of the LIC 809 reports was provided to the facility.the state’s words, verbatim · CDSS document, Jul 21, 2026

Allegation investigated: Staff are not administering medication(s) to resident in care as prescribed.

Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to open this complaint. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit. This investigation consisted of record review and interviews. LPA Moleski interviewed Revera and two staff members (S1-S2). In an interview, the facility's medication manager (S1) admitted that there had been a medication error for a resident (R1). S1 said that R1 had not been receiving a medication used to treat Parkinson's disease for several days due to an error in transcribing the prescription order into the facility's medication administration records (MARs). S1 said that R1 missed four daily doses of the medication between September 18 and September 25. [continued on 9099-C] Substantiated LPA Moleski reviewed R1's MARs. LPA Moleski observed that R1 had been taking the medications four times daily between September 13 and 17. R1 received one dose on the morning of September 18, at which point the medication was marked discontinued in R1's MARs. The medication was started again at 3 p.m. on September 25, and R1 continued to receive their medications as prescribed for the rest of the month. LPA Moleski reviewed a fax sent to R1's prescriber dated 9/29/25 reporting the error. The fax stated that R1 received an order to increase a different order for the same medication on 9/18/25. "However, the order was not transcribed correctly," the fax read." As a result, the existing order ... was inadvertently discontinued. This led to [the medication] being missed from 9/18/2025 at 10:00 a.m. until 9/25/2025 at 12:00 p.m." In an interview, S2 admitted to incorrectly transcribing the order. LPA Moleski reviewed fax and email records and observed that no incident report was received by the Community Care Licensing Division (CCLD) regarding this error. S2 said no report was sent to CCLD. 22 CCR Section 87211(a)(1)(D) requires that licensees report "any incident which threatens the welfare, safety or health of any resident..." This reporting error will be addressed in a separate case management report. The department has determined the following as it relates to the allegation that staff are not administering medication(s) to a resident in care as prescribed: Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Section 87465(a)(4). An exit interview was held with Revera. Appeal rights and a copy of this report were left with Revera.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 27-AS-20251003122158

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 10, 2025

"(4) The licensee shall assist residents with self-administered medications as needed." This requirement was not met as evidenced by: Based on interviews and record review, a resident (R1) did not receive their regularly prescribed medication for more than six days, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Oct 9, 2025

Plan of correction: Licensee agrees to notify LPA Moleski of a planned training date regarding medication order transcriptions by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to open a complaint, but discovered an unrelated deficiency during the course of the investigation. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit. This investigation consisted of record review and interviews. LPA Moleski interviewed Revera and two staff members (S1-S2). In an interview, the facility's medication manager (S1) admitted that there had been a medication error for a resident (R1). S1 said that R1 had not been receiving a medication used to treat Parkinson's disease for several days due to an error in transcribing the prescription order into the facility's medication administration records (MARs). S1 said that R1 missed four daily doses of the medication between September 18 and September 25. LPA Moleski reviewed R1's MARs. LPA Moleski observed that R1 had been taking the medications four times daily between September 13 and 17. R1 received one dose on the morning of September 18, at which point the medication was marked discontinued in R1's MARs. The medication was started again at 3 p.m. on September 25, and R1 continued to receive their medications as prescribed for the rest of the month. [continued 809-C] LPA Moleski reviewed a fax sent to R1's prescriber dated 9/29/25 reporting the error. The fax stated that R1 received an order to increase a different order for the same medication on 9/18/25. "However, the order was not transcribed correctly," the fax read. "As a result, the existing order ... was inadvertently discontinued. This led to [the medication] being missed from 9/18/2025 at 10:00 a.m. until 9/25/2025 at 12:00 p.m." In an interview, S2 admitted to incorrectly transcribing the report. LPA Moleski reviewed fax and email records and observed that no incident report was received by the Community Care Licensing Division (CCLD) regarding this error. S2 said that no incident report was sent to CCLD. 22 CCR Section 87211(a)(1)(D) requires that licensees report "any incident which threatens the welfare, safety or health of any resident..." This facility is hereby cited per 22 CCR Section 87211(a)(1)(D). An exit interview was held with Revera. Appeal rights and a copy of this report were left with Revera.the state’s words, verbatim · CDSS document, Oct 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 17, 2025

"A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified ... Any incident which threatens the welfare, safety or health of any resident..." This requirement was not met as evidenced by: Based on interview and record review, an incident report was not sent to CCLD regarding a medication error, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Oct 9, 2025

Plan of correction: Licensee agrees to notify LPA Moleski of a planned training date regarding medication order transcriptions by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Vincent Moleski and Regional Manager (RM) Stephenie Doub arrived unannounced to conduct a case management visit. LPA Moleski and RM Doub met with facility administrator Jennell Revera and explained the purpose of the visit. LPA Moleski reviewed an incident report received by the Community Care Licensing Division (CCLD) on July 28, 2025. The incident report stated that a resident (R1) was taken to a medical appointment on July 22, 2025. R1 had been experiencing "scant bleeding and foul odor when urinating." The physician reported that five medication-releasing intravaginal rings were removed from the resident's vagina during the visit. LPA Moleski and RM Doub reviewed a signed order from R1's physician dated April 7, 2023. R1 was ordered to have a new ring inserted every 90 days. The manufacturer of the intravaginal ring indicates on their product webpage that the devices should be removed after 90 days of use. Revera said there was no documentation to suggest that staff nurses were given initial training on the use of the devices. Staff nurses had been inserting the devices since July 2024, according to R1's medication administration records (MARs). LPA Moleski reviewed R1's MARs and observed that R1 was given four intravaginal rings by facility staff and one by skilled nursing staff between July 2024 and June 2025. Staff were trained on the use of intravaginal rings on July 24, 2025, after R1 had been seen by her physician. The training material included instructions from the manufacturer of the ring, which specify that the rings should be removed after 90 days. This facility is hereby cited per 22 CCR Sections 87465(a)(4) and 87411(d). Because this deficiency resulted in a resident's injury and/or illness, an immediate civil penalty of $500 is hereby assessed. Appeal rights and a copy of this report were left with Revera.the state’s words, verbatim · CDSS document, Aug 12, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 13, 2025

"(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed." This requirement was not met as evidenced by: Based on record review and interview, a resident's medication was mismanaged, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Aug 12, 2025

Plan of correction: Licensee has already conducted a training regarding this product, dated July 24, 2025. This POC will be cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(d) · Plan of correction due date: Aug 22, 2025

"(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:" This requirement was not met as evidenced by: Based on record review and interview, staff nurses were not trained in the use of a medication-releasing intravaginal ring which they had been inserting for a resident, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Aug 12, 2025

Plan of correction: Licensee agrees to provide a written plan regarding how and when training is conducted for LVNs regarding medical devices or interventions. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with executive assistant Olivia Sterba and explained the purpose of the visit. LPA Moleski reviewed an incident report which was received by the Community Care Licensing Division (CCLD) on 7/19/25. According to the incident report, on that same date, a resident (R1) was discovered missing at the time of their evening medication pass, around 5 p.m. Facility staff reviewed surveillance footage and observed that R1 left the facility that day at 1:33 p.m., according to the incident report. In an interview, the facility's director of resident services (S1) said they called 911 after searching for R1, and were informed that police had already contacted R1 in a residential neighborhood following reports made by nearby citizens. S1 said that R1 was found without their pants or shoes on, and had blisters on their feet. In an interview, R1 said they normally go for walks with their "friend." S1 said that R1 has a third-party companion from 1 p.m. to 5 p.m. daily who was absent on 7/19/25. LPA Moleski reviewed R1's medical assessment. The medical assessment did not contain some information which is found on CCLD's LIC 602, such as the ability of the resident to travel in the community unsupervised. The resident's primary diagnosis was listed as "possible major neurocognitive disorder due to Alzheimer's disease." Active problems were identified as "visual hallucination," "osteoporosis," and "lumbar muscle strain." [continued on 809-C] LPA Moleski reviewed a needs and services plan for R1 dated 3/19/25. R1 is "unable to leave the building unattended," and staff are to "provide assistance to resident when exiting the building," according to the needs and services plan. The needs and services plan also identified R1 as "non-ambulatory" and requiring support from staff "as appropriate due to resident's non-ambulatory status." LPA Moleski reviewed the footage taken of the incident. LPA Moleski observed a staff member (S2) at the front desk at the time R1 left the facility. S2 appeared to be looking down, and did not appear to notice R1 as they walked out the front door. This facility is hereby cited per Health and Safety Code Section 1569.312(d). Appeal rights and a copy of this report were left with Sterba.the state’s words, verbatim · CDSS document, Jul 23, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(d) · Plan of correction due date: Jul 24, 2025

"Every facility required to be licensed under this chapter shall provide at least the following basic services: ... Being aware of the resident's general whereabouts, although the resident may travel independently in the community." This requirement was not met as evidenced by: Based on interviews, record review, and observation, a resident's location was unknown for a period of approximately four hours while they were unsupervised in the community, which poses/posed an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Jul 23, 2025

Plan of correction: Licensee agrees to send LPA Moleski a written plan regarding forthcoming training for any front desk personnel. vincent.moleski@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit. LPA Moleski reviewed seven resident files (R1-R7) and seven staff files (S1-S7). LPA Moleski toured the facility with Revera and inspected common areas, kitchen areas, resident bedrooms, bathrooms, and outdoor areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 118 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, fully-charged and up-to-date fire extinguishers, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locking room for the storage of medication. LPA Moleski observed locked closets for the storage of cleaning solutions. LPA Moleski interviewed five staff members (S8-S12) and five residents (R8-R12). No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Revera.the state’s words, verbatim · CDSS document, Jul 10, 2025

Allegation investigated: Resident suffered injuries due to staff neglect

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit. This investigation consisted of interviews, observation and record review. LPA Moleski interviewed Revera, 18 staff members (S1-S18), and one resident (R1). LPA Moleski reviewed an incident report log for R1 dating between 5/22/24 and 10/19/24. On 5/22, R1 was using their wheelchair as a walker, causing R1 to lose their balance and fall. R1 did not hit their head but had some bruising on their left hand and right leg and some redness on their back. On 7/28, R1 suffered a fall which was captured on camera. R1 tried to sit in their wheelchair, but missed and fell on their left side. R1 had no apparent injuries at the time. However, on 7/30, a staff member observed some bruising on R1's left hip. [continued on 9099-C] Unsubstantiated Another staff member observed this same bruising on R1's left hip on 8/1. On 8/6 at 3:07 a.m., R1 was trying to use their wheelchair as a walker in the hallway, and while a staff member (S18) attempted to redirect R1, R1 stood up and lost balance. R1 "gradually fell down as their hand was holding into the railing," according to S18’s note. R1 did not hit their head, but felt pain in their left arm. R1 suffered a skin tear on their elbow. First aid was provided. A few hours later, at 6:57 p.m., S8 noted R1 had a "big purple bruise on their neck." S8 made a second note at 8:48 p.m., noting that the bruise was bigger and R1 was feeling pain in their left arm. On 8/10, S15 observed "a lot of bruises" on R1's neck down to their left breast, and a bruise on their left hip. Ongoing progress notes for R1 also describe the appearance of bruises on R1's neck and chest between 8/6 and 8/10. On 8/18, R1 suffered an unwitnessed fall while attempting to transfer from bed to their wheelchair. R1 was sent to the hospital. LPA Moleski reviewed an incident report for R1's fall on 8/18/24. According to the incident report, R1 was attempting to transfer from bed to their wheelchair when R1 fell, and later complained of hip pain. R1 was admitted to a hospital for a hip fracture, and was transferred to skilled nursing afterward, per the incident report. LPA Moleski reviewed video footage of this fall, and observed that staff promptly responded to R1. None of the 18 staff members interviewed had observed caregivers of this facility committing any acts of abuse or any acts of neglect resulting in injuries to any residents. In an interview with S18, the caregiver present for R1’s fall on 8/6/24, S18 said that R1 did not hit their neck, face, chest, or head, and had no explanation for the bruises later observed on R1. Several other staff members observed the bruises on R1’s neck described in the notes from 8/6/24, but none were aware of the precise cause of the injury. None of the 18 staff members interviewed voiced any significant concerns for R1’s care at this facility. In an interview, R1 said they were well taken care of at this facility. Assessments from prior to R1's hospitalization indicate R1 was able to independently use their walker and transfer themselves. The department has determined the following as it relates to the allegations that a resident suffered injuries due to staff neglect: Based on interviews, observation and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Revera.the state’s words, verbatim · CDSS document, Jan 16, 2025 · control 27-AS-20240823101614

Allegation investigated: Staff did not ensure that resident's room was kept clean

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit. This investigation consisted of interviews and record review. LPA Moleski conducted interviews with Revera, a resident (R1), three family members of R1 (R1’s RPs 1-3) and 11 staff members (S1-S11). LPA Moleski reviewed an internal facility incident report, dated 8/8/24, which described R1 experiencing increased confusion. R1’s responsible parties called for emergency medical services, and R1 was taken to the hospital for treatment, according to the internal incident report. The Community Care Licensing Division did not receive an incident report regarding this incident, as required per 22 CCR 87211(a)(1)(D). This deficiency will be addressed in a subsequent case management visit. [continued on 9099-C] Substantiated In interviews, two family members of R1 (R1’s RP 1-2) said they visited this facility on 8/8/24. R1’s RP 1 said that when they arrived at R1’s room, they observed cat feces on the floor, which R1 had stepped in and tracked all over the apartment. R1’s RP 1 described a “stench” in R1’s room from the feces. R1’s RP 2 said they also observed cat feces on the floor, as well as on R1. R1’s RP 1 said that after this incident, R1’s cats had to be rehomed. LPA Moleski reviewed R1’s resident records. R1’s care plan at the time, dated 8/5/24, indicated that R1 was to receive assistance from facility staff with cleaning a litter box for cats three times per week. R1’s RP 2 said that there had been numerous previous instances wherein R1’s litter box was not cleaned. R1’s RP 1-2 both said that R1’s box appeared as if it had not been scooped for several days at the time of their visit on 8/8/24. LPA Moleski reviewed progress notes for R1 and observed a note authored by a staff member (S6) dated 8/5/24. In the note, S6 described checking on R1, and upon entry to R1’s room, observing cat feces on the floor. The note reads in part: "… as I was in there I noticed cat poop everywhere. [R1] has dried cat poop on [R1’s] feet, it's on the carpet by [R1’s] bed, it's dried and smashed on [R1’s] bathroom floor and it's all under [R1’s] nails. We spent 10 minutes washing it off [R1’s] nails. I washed it off [R1’s] feet with a towel as well. Notified manager [R1] needs some additional help getting [R1’s] room cleaned up." In an interview, S6 said that the events described in the note occurred on the day that R1 was sent to the hospital, 8/8/24. S6 reiterated the events as described in the above note, and added that S6 did not know how long the feces had been on the floor and on R1, but said that the feces was dry and difficult to remove from R1. S6 said that R1 was very confused at the time and did not even know the feces was there. LPA Moleski reviewed R1’s care tracking sheets from the time of the incident as described above. LPA Moleski observed that staff members had signed off on 8/2/24, 8/5/24, 8/6/24, and 8/7/24 that they had provided assistance with cleaning R1’s litter box. LPA Moleski reviewed recorded care reports for R1’s pet care and observed that on 7/22/24, a staff member indicated they were “not able to get to” the pet care. [continued on 9099-C] In an interview, S1, who had signed off on R1’s pet care tracking sheet on 8/2/24 and 8/7/24, said that they were aware that the litter box was not consistently cleaned. “It was not a task people were doing,” S1 said. S1 said that they would often observe the litter box “very full” with feces and “saturated” with urine. S1 said that staff were “constantly” reminded that the litter box was not being cleaned regularly. In an interview, S2, who signed off on R1’s pet care tracking sheet on 8/5/24, said that the litter box “wasn’t being cleaned a lot.” S2 said that the litter box often presented a “foul odor.” S2 said there was frequently litter and cat hair all over R1’s room. S2 said they would often need to open a window in R1’s room due to the strong smell of urine. S2 said that although they did not observe the incident described by S6 wherein cat feces was on the floor in R1’s room, they were aware that R1’s carpets needed to be shampooed afterward. In an interview, S3 said they would “barely set foot” in R1’s room due to the smell from the litter box. S3 was not sure if R1’s room was clean or not, because they usually did not want to enter. S3 said they would have R1 come to the door to give R1 their medications. In an interview, S4 said that R1’s room was “a bit of a mess” on 8/8/24. S4 said that, based on their observations, it did not appear that R1’s litter box was being cleaned. S5 said that they had previously observed cat feces on the floor in R1’s room, but was not sure if it was 8/8/24, or a different day. S5 said that R1’s room usually smelled from the litter box. S11 said that R1’s room had “strong odors” from R1’s litter box. The department has determined the following as it relates to the allegation that staff did not ensure that a resident’s room was kept clean: Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Section 87303(a). An exit interview was held with Revera. Appeal rights and a copy of this report were left with Revera. Later in this same assessment, R1’s lactic acid elevation was said to be "likely due to poor oral intake plus diarrhea due to Paxlovid and COVID-19 viral infection." Notes regarding R1’s diarrhea indicated that it is a "noted side effect of Paxlovid and also could be COVID related as well." Nowhere in R1’s medical records from this hospitalization was R1 diagnosed with sepsis. For this reason, the allegation on this complaint regarding sepsis is determined to be unsubstantiated. However, additional deficiencies regarding R1’s care during this same time period will be addressed in a separate case management report. Additionally, The Community Care Licensing Division did not receive an incident report regarding R1’s hospitalization, as required per 22 CCR 87211(a)(1)(D). This deficiency will be addressed in the same case management report, which will be delivered today. LPA Moleski reviewed R1’s medication administration records dating from R1’s COVID-19 quarantine period. R1 received all medications as prescribed, according to the MARs. None of the staff members interviewed (S1-S11) were aware of any issues with R1’s medication during their quarantine period. LPA Moleski interviewed the medication technician who was scheduled to provide R1 with their medications the day R1 was hospitalized, 8/8/24 (S3). S3 said that they did give R1 their medications on that date, and R1 took them all without incident. In an interview, R1 said they have never missed a dose of their medications, and has had no issues with their medication administration. The department has determined the following as it relates to the allegations that, due to negligence, a resident became dehydrated and developed sepsis, which resulted in hospitalization, and that staff did not administer a resident’s medication as prescribed: Based on interviews and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Revera.the state’s words, verbatim · CDSS document, Dec 30, 2024 · control 27-AS-20240813084041

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Dec 31, 2024

“(a) The facility shall be clean, safe, sanitary and in good repair at all times…” This requirement was not met as evidenced by: Based on interviews and record review, a resident’s room was not safe or sanitary, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Dec 30, 2024

Plan of correction: Licensee agrees to schedule out a staff training regarding pet care requirements. Licensee agrees to provide LPA Moleski with a date or dates for this scheduled training by POC due date, and further agrees to provide LPA Moleski with a copy of a staff sign-in sheet after the training. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit. During the course of a complaint investigation related to the care of a resident (R1), LPA Moleski conducted interviews with Revera, a resident (R1), three responsible parties for R1 (R1’s RPs 1-3) and 11 staff members (S1-S11). See complaint # 27-AS-20240813084041 for more details. This report addresses deficiencies discovered during that investigation. LPA Moleski reviewed R1’s progress notes from the days preceding R1’s hospitalization on 8/8/24. A note authored by S5 dated 8/1/24 indicated that R1 was tested positive for COVID-19. A note authored by S7 dated 8/2/24 indicated that R1 had a video appointment with their primary care physician. The note further indicated that during this appointment, R1’s physician "asked [R1] to keep [themselves] hydrated and report to staff any changes." Per S7’s note, R1 was “only having a cough, no sore throat and a runny rose [sic]” at the time. S7 also indicated that R1 was prescribed and given Paxlovid to treat R1’s COVID-19. LPA Moleski reviewed an internal facility incident report, dated 8/8/24, which described R1 suffering from increased confusion. R1’s responsible parties called for emergency medical services, and R1 was taken to the hospital for treatment, according to the internal incident report. The Community Care Licensing Division did not receive an incident report regarding this incident within seven days, as required per 22 CCR 87211(a)(1)(D). LPA Moleski reviewed medical records related to R1’s hospitalization on 8/8/24. According to R1’s medical records, R1 was diagnosed with lactic acidosis, acute renal insufficiency, hyponatremia, and leukocytosis upon admission to the emergency room. [continued on 809-C] R1 was given intravenous fluids and was prescribed an antibiotic while in the hospital. R1’s was assessed to have "severe intravascular volume depletion causing lactic acidosis" and "acute renal insufficiency due to poor oral intake and med/viral syndrome induced diarrhea due to Paxlovid and COVID-19 viral infection." Later in this same assessment, R1’s lactic acid elevation was said to be "likely due to poor oral intake plus diarrhea due to Paxlovid and COVID-19 viral infection." Notes regarding R1’s diarrhea indicated that it is a "noted side effect of Paxlovid and also could be COVID related as well." In an interview, Revera said that R1 was independent at the time, and did not have any care tasks regularly assigned to caregivers. Revera said that during R1’s quarantine, R1 was not receiving regular check-ins from caregivers, but was visited daily by medication technicians to pass R1 their medications. Revera said that additional check-ins from nurses and caregivers have since been arranged for residents not receiving regular care while on quarantine in order to monitor their condition. In an interview, S7 said that R1 had voiced during their video appointment on 8/2/24 that they were not drinking much water. LPA Moleski interviewed S3, S8, S9, S10, and S11, medication technicians who visited R1 during their quarantine period prior to their hospitalization on 8/8/24. S3, S8 and S9 said they were not aware of any reason that R1 would have been dehydrated, and were not aware of any need to remind R1 to stay hydrated. S9, who said they visited R1 on all five days of R1’s five-day quarantine, described R1 as “really, really sick” during their quarantine. S9 said that throughout the five-day quarantine, R1 was not eating or drinking much. S9 said that they noticed from the first day of R1’s quarantine that R1’s food trays were untouched. S9 said they would have kitchen staff prepare a smoothie for R1 daily in an attempt to encourage R1 to eat and drink, but R1 would only have one or two sips. S9 said that they did not feel R1 needed to be sent to the hospital earlier, but added that they informed their manager, S7, about R1’s condition. S9 said that R1 was able to sit up and take their medications with encouragement, but it was difficult for R1 because they were very tired. S9 said R1 was sleeping a lot during quarantine. [continued on 809-C] S11 passed medications to R1 four times between 8/2/24 and 8/7/24, according to R1’s medication administration records (MARs). S11 said that R1 was “not looking normal” and “not looking good” on one of those days. S11 said that R1 had a reduced appetite, and said that R1 told S11 that R1 did not want to eat. S11 said they did not check R1’s food trays to see how much R1 was eating. S11 said they did not feel R1 needed to be sent to the hospital sooner. S11 was not aware of any reason why R1 would be dehydrated, or why R1 might need reminders to stay hydrated. R1’s RP 1-2 said that they decided to visit R1 on 8/8/24 because they were not receiving responses to text messages sent to R1. R1’s RP 1-2 expressed surprise at seeing R1’s condition on 8/8/24. R1’s RP 2 said that R1 was unresponsive when they arrived. R1’s RP 1 said R1 looked so ill they thought R1 had died. R1’s RP 2 said they then called R1’s physician, who instructed them to call 911. This facility is hereby cited per 22 CCR Sections 87211(a)(1)(D) and 87466. An exit interview was held with Revera. Appeal rights and a copy of this report were left with Revera.the state’s words, verbatim · CDSS document, Dec 30, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Dec 31, 2024

“The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.” This requirement was not met as evidenced by: Based on interviews and record review, appropriate assistance was not provided to R1 during their quarantine period, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Dec 30, 2024

Plan of correction: Licensee agrees to provide LPA Moleski with a written plan regarding monitoring and observation of residents on quarantine by POC due date. Licensee agrees to include details in this written plan regarding the scheduling of a future staff training regarding observation of residents. Licensee further agrees to send LPA Moleski a sign-off sheet after this training is held. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Jan 3, 2025

“Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: … A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified … Any incident which threatens the welfare, safety or health of any resident…” This requirement was not met as evidenced by: Based on record review, an incident report was not sent to LPA Moleski regarding R1’s hospitalization on 8/8/24, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Dec 30, 2024

Plan of correction: Licensee agrees to conduct a staff training with managerial staff regarding reporting requirements and procedures by POC due date. Licensee further agrees to submit to LPA Moleski a sign-off sheet after this training is completed. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit. LPA Moleski reviewed death reports for two residents (R1-R2) dated 12/27/24 and 11/14/24, respectively. LPA Moleski reviewed R1's and R2's resident records. LPA Moleski interviewed Revera and a staff member (S1) regarding these reports. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Revera.the state’s words, verbatim · CDSS document, Dec 30, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit. LPAs Moleski and Williams reviewed 10 resident files (R1-R10) and five staff files (S1-S5). R1's latest LIC 602 on file was dated 6/15/22. R1 was diagnosed with dementia, according to the LIC 602. R2 was seen by their physician on 2/28/23, according to their most recent LIC 602. R2 has dementia, according to the LIC 602. LPA Moleski reviewed a staff roster and Guardian records. LPA Moleski observed that S6 was separated from this facility in January 2024. According to Revera, S6 has continued to work at this facility from April to present, but has not been re-associated. Another employee, S12, had not been fingerprinted. However, S12 is under the age of 18 and therefore does not need to be fingerprinted. 22 CCR Section 87411(b) states that staff members who "supervise or care for residents" must be at least 18 years of age. LPA Moleski reviewed S12's job description and did not observe any duties relating to care and supervision of residents. LPA Moleski toured the facility with Revera and inspected common areas, the kitchen, bedrooms, bathrooms, and outdoor areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 72 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 113 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. [continued on 809-C] LPA Moleski observed first aid supplies and fully-charged fire extinguishers. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed locked cabinets for the storage of cleaning solutions. LPA Moleski interviewed five staff members (S7-S11) and five residents (R11-R15). This facility is being cited per 22 CCR Sections 87355(e)(3) and 87705(c)(5). A civil penalty in the amount of $500 for a total of five days worked by S6 was assessed. An exit interview was held with Revera. Appeal rights and a copy of this report were left with Revera. This report was amended on 8/2/24. LPA Moleski had previously erroneously stated in this report that S12 and other under-18 employees must be fingerprinted, which is not correct. Civil penalties regarding S12 will not be assessed, and an updated copy of the civil penalty assessment will be provided to the licensee at a later date.the state’s words, verbatim · CDSS document, Jul 31, 2024

Allegation investigated: Staff did not provide adequate food service Staff did not meet resident's toileting needs Staff did not meet resident's showering needs Staff did not treat resident with respect Staff overcharged resident Staff mismanaged resident's medication

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit. This investigation consisted of interviews, observation and record review. LPA Moleski interviewed Revera, 10 staff members (S1-S10), four residents (R1-R4), and a resident’s responsible party (R1’s RP). In an interview, R1 said that R1 liked the food at the facility, and always gets enough to eat. R1 said they had not missed any meals at the facility. R1 said that they preferred to have meals delivered to their room, rather than going downstairs to eat. R1 said staff assisted them with showers, and said they received showers about once every other day. R1 said they received enough showers, and in fact would prefer fewer showers, as R1 is often tired in the mornings. [continued on 9099-C] Unsubstantiated R1 said that staff assist them with toileting, and will clean them up if they can’t make it to the toilet. R1 said staff do a good job, but sometimes R1 has to wait up to an hour or two for assistance. R1 said that the staff are kind to R1. R1 reported no issues with medications, and said that staff give PRN medications when R1 asks for them. LPA Moleski reviewed R1’s file. R1 is scheduled to receive showers twice a week. Interviews with staff indicate that R1 often refused showers and other care. None of the staff members interviewed reported concerns over R1’s hygiene, or over the frequency of R1’s showers. LPA Moleski reviewed one months’ worth care notes for R1 and observed R1 received six showers between 3/9/24 and 4/8/24. A refusal of a shower is documented in the notes. LPA Moleski reviewed R1’s MARs dating from August 2023 to May 2024. LPA Moleski observed no indication that R1’s medications were mismanaged. R1 appeared to have received all prescribed medications as needed. LPA Moleski did not observe any indication that R1 had received any laxatives during night shifts, as alleged. LPA Moleski observed one dose of PRN laxative given on the afternoon of 9/25/23, and a note on the MAR indicates that it was given at the request of R1’s RP. None of the staff members interviewed knew of any incident wherein PRN laxatives were given without authorization. LPA Moleski reviewed R1’s billing information, invoices, meal tickets, and tallies of R1’s room service deliveries. LPA Moleski reviewed several weeks’ worth of meal tickets and observed that R1 was regularly receiving meals. LPA Moleski did not observe any indication that R1 was overcharged for room service. LPA Moleski observed that the documented number of room service deliveries matched the amount charged, per the rate of $15 per delivery after 6 deliveries per month. Staff interviews indicate that R1 usually did not want to come down for meals and preferred room service. None of the staff interviewed had observed any other staff members acting rudely or disrespectfully to R1. LPA Moleski interviewed three residents (R2-R4) who liked to eat meals with R1 when R1 was able to come down into the dining room to eat. None of the residents interviewed had observed any staff members acting rudely or disrespectfully to R1. [continued on 9099-C] LPA Moleski reviewed 30 days’ worth of call button response times for R1 dating from 3/9/24 to 4/8/24. The average of response times is approximately nine minutes. None of the response times range over an hour. None of the staff members interviewed were aware of any situation wherein R1 needed to wait for toileting assistance for over an hour. The department has determined the following as it relates to the allegations that staff did not provide adequate food service, that staff did not meet a resident’s toileting needs, that staff did not meet a resident’s showering needs, that staff did not treat a resident with respect, that staff overcharged a resident, and that staff mismanaged a resident’s medication: Based on interviews, observation and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Revera.the state’s words, verbatim · CDSS document, Jul 1, 2024 · control 27-AS-20240327145359

Allegation investigated: Facility staff did not safeguard residents belongings

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with director of resident services Andrea Quintanilla and explained the purpose of the visit. This investigation consisted of observation, interviews, and record review. LPA Moleski interviewed facility administrator Jennell Revera, two staff members (S1-S2), and a former resident’s responsible party (R1’s RP). LPA Moleski reviewed a death report for a resident (R1) dated 4/17/24. The death report states that R1’s RP notified the facility on 4/7/24 that two of R1’s rings were missing. Staff searched various areas for the missing rings, but were unable to locate the rings, according to the death report. Local law enforcement was notified and a report number was provided. LPA Moleski reviewed an incident report dated 4/25/24, stating that R1’s RP notified staff that three of R1’s rings were missing. [continued on 9099-C] Substantiated LPA Moleski reviewed a police report dated 4/22/24. In this report, officers wrote that their case was closed “pending further investigative leads.” Per 22 CCR Section 87218, “the licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in [HSC] Section 1569.153.” LPA Moleski took the following actions to determine whether this facility had made efforts to meet each requirement of that section: LPA Moleski observed that the facility’s theft and loss policy is posted near the main entrance to the facility. LPA Moleski toured R1’s former apartment. The doors to the room cannot lock, and R1 had a roommate. LPA Moleski observed locking cabinets available for the storage of personal property. According to Revera, all caregivers have access to these cabinets. In an interview, R1’s RP said they had not requested any other secured, locked storage space for valuables. LPA Moleski reviewed R1’s file. R1 was diagnosed with dementia and lived in the facility’s memory care unit. LPA Moleski observed information regarding the facility’s theft and loss prevention program present in R1’s admission agreement and in the resident handbook provided to new residents. However, the contents of HSC Sections 1569.152 through 1569.154 were not present in the materials provided to R1 and/or R1’s RP, as required per HSC 1569.153(k). The resident handbook states that employees are provided these sections. LPA Moleski observed that R1 and/or R1’s RP declined to establish an inventory of personal property upon admission. HSC Section 1569.153(d) states that “The facility shall not be liable for items which have not been requested to be included in the inventory.” In an interview, R1’s RP said they did not recall having established an inventory of property for R1. This facility’s declination form clearly indicates that the facility is not liable for items not included in the inventory. LPA Moleski requested records of semiannual reviews of theft and loss procedures and policies, pursuant to HSC Section 1569.153(g). Records were not available as semiannual reviews have not been conducted, according to Revera. [continued 9099-C] LPA Moleski reviewed this facility’s written theft and loss policy. The policy states that the facility shall “document loss of personal property within 72 hours of the discovery of the loss or theft” and that “documentation will be made and maintained on Licensing Form #9060.” In an interview, Revera said these forms were not used to document the missing items as described above. The facility’s existing documentation regarding the missing rings does not contain estimated values for the items, as required per HSC Section 1569.153(c)(2), despite estimates of the missing rings having been given to police on 4/22/24. Additionally, R1’s RP told LPA Moleski that a chair owned by R1’s family was not present in R1’s room upon R1’s death. LPA Moleski interviewed the facility’s memory care director (S1), who was aware that the chair had been reported missing. S1 did not know the location of the chair, and said that it may have been moved out of the room at some point to prevent falls. A report of this missing chair was not included in any of the incident reports received by LPA Moleski, and no report was made on an LIC 9060 form as specified in this facility’s theft and loss policy. Based on the above findings, this facility shall not be liable for repayment or replacement of the missing items, as they were not entered into an inventory of personal property. However, the facility has not implemented several required elements of its theft and loss program: The facility did not document the missing items described above as stipulated in its theft and loss policy, did not include estimated values of the rings, did not document the missing chair, did not conduct semiannual reviews of theft and loss procedures and policies, and did not provide R1 and/or R1’s RP with HSC Sections 1569.152 through 1569.154 upon admission. Therefore, based on interviews, observation, and record review, the above allegation is SUBSTANTIATED, which means that the preponderance of evidence standard has been met. This facility is hereby cited per HSC Section 1569.153. An exit interview was held with Revera. Appeal rights and a copy of this report were left with Quintanilla.the state’s words, verbatim · CDSS document, May 9, 2024 · control 27-AS-20240501152638

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.153 · Plan of correction due date: Jun 6, 2024

"A theft and loss program shall be implemented by the residential care facilities for the elderly within 90 days after January 1, 1989. The program shall include all of the following [subsections (a) through (m)]." This requirement was not met as evidenced by: Based on observation, interviews, and record reviews, all required elements of the theft and loss program per 1569.153(a)-(m) were not implemented, which poses a potential health, safety, and personal rights risk.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: Licensee agrees to update theft and loss policies and procedures and to provide LPA Moleski updated documentation when completed. vincent.moleski@dss.ca.gov

Type of visit: POC

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced in order to conduct a case management visit to follow up on the plan of correction for a citation issued on October 10, 2023. LPA Moleski met with facility administrator Jennell Revera and explained the purpose of the visit. LPA Moleski interviewed Revera and staff. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with sales assistant Krystal Cosaino.the state’s words, verbatim · CDSS document, Jan 8, 2024