Carlton Senior Living Sacramento

Type of visit: Required - 1 Year

On August 26, 2026, at 11:15 PM, Licensing Program Analyst (LPA) Sulma Lopez and Licensing Program Manager (LPM) Arielle Pascua arrived unannounced at the facility to conduct an annual required inspection. LPA Lopez and LPM Pascua met with Administrator Kassie Wimmer and explained the purpose of today's visit. The Administrator holds current certificate 7010128740 and expires on May 21, 2027. The facility is approved for 120 non-ambulatory and 65 ambulatory residents ages 60 and over. There is a hospice waiver approved for (20) residents. There are currently 131 residents who reside at this facility. At 12:00 PM, LPA reviewed (10) staff and (10) resident files. The files are maintained and kept current. The facility has a current Infection Control Plan and Emergency Control Plan which are being reviewed and updated on a regular basis. The facility conducts monthly fire drills and the most recent one took place on August 17, 2026. At 1:10 PM, LPA and LPM toured the facility with the administrator. The facility was clean, safe, and in good repair. The facility temperature was 75 degrees. The facility’s hot water temperature was 110 degrees. The facility’s fire extinguishers were last inspected on August 8, 2026. The facility carbon monoxide and fire alarms are located on the ceilings. LPA observed the dining area which was clean and free of hazards. The facility kitchen contained a 7- day supply of non-perishable foods, and at least 2 days of perishable food items. Facility cleaning supplies, toxins, and sharps are stored in the kitchen and made inaccessible to residents. Continued on LIC 809-C. The courtyard contained shaded seating areas for resident use. LPA observed the activity room in which residents were participating in structured activity. LPA toured the memory care side of the building and inspected resident rooms. The residents’ bedrooms were clean, free of odors, and contained furniture that was in good repair. LPA tested the delayed egress doors which were alarmed and opened after 15 seconds. at 1:50 PM, LPA conducted a medication administration record review with the Medication Technician Manager. The Medication Administration Records (MAR) are being recorded electronically. It was learned that medications are refilled at least 7 days prior to running out and overflow medications are stored to prevent missed doses. As a result of today's annual inspection, no deficiencies are being cited. The facility is in compliance with Title 22 regulations. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 26, 2026

Allegation investigated: Staff did not ensure the air conditioner was working in the medication room

On 08/24/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator. LPA met with Designee, Rose De La Garza. On 11/25/25, LPA Viarella went to the facility to open the complaint with the above allegation. Based on an interview with S1, the AC was out for a week and a half. It was reported immediately to the Maintenance Director, who submitted the work order to corporate who approved same day. Quote was received and approved but due to rain and company needed to use a crane to fix from the roof, repairs were delayed by a week until dry weather would permit. S1 stated that swamp coolers were brought in to keep staff comfortable until work could be done. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove Unsubstantiated the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. According to the California Code of Regulations, Title 22, no deficiencies were observed of cited during today's visit. A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Rose De La Garza.the state’s words, verbatim · CDSS document, Aug 24, 2026 · control 27-AS-20251125083956

Allegation investigated: Staff do not ensure residents hearing aides are charged. Staff are not following incontinent care plan for resident. Staff are not ensuring that resident laundry is being cleaned and returned to resident.

On 07/01/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation into the above allegations. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator / Executive Director, Kasie Wimmer. The two met and reviewed the report below. Regarding: Staff do not ensure residents hearing aides are charged. In an interview with the Memory Care Director, Rose De La Garza, she stated that the Medication Technicians (MedTechs) were responsible for taking hearing aids during bed time medication passes so they could be charged and locked in the medication room overnight and then returned in the morning by care partners. De La Garza further explained that if the resident did not require bedtime medications, their assigned care partner would take the hearing aids and give them to the MedTech to charge in the medication room where they would be safe. Substantiated This LPA reviewed care notes for the resident (R1) from 02/02/25 - 03/31/25 and observed the following entries: 02/02/25, S2 logged, "Resident hearing aid put into charge" 02/03/25, S2 logged, "Resident hearing aid put into charger" 02/06/25, S2 logged, "Resident hearing aid put into charger" 02/09/25, S2 logged, "Resident hearing aid put into charger" 02/10/25, S2 logged, "Resident hearing aid put into charger" 02/17/25, S2 logged, "Resident surrendered the hearing aid to MT" 02/20/25, S2 logged, "Resident hear aid and gave to MT" 03/21/25, S3 logged, “Resident lost hearing aid in the right side of his ear" 03/22/25, S4 logged, "Resident did not have their hearing aid when MT went to collect them before bed" 03/31/25, S2 logged that they “took R1's "hearing aids and gave them to the MedTech to charge" According the responsible party for R1, their hearing aids were supposed to be charged every night. There are 58 days from 02/02/25 – 03/31/25. During that time period, care notes mentioned taking the hearing aids to charge a total of 8 times. There was no explanation as to why the hearing aids were not taken and charged on the other 50 days. There also was no documentation stating when, or if, hearing aids were returned to R1 in the morning. Two of the logs above mention that R1 lost or did not have their hearing aids on 03/21/25 and 03/31/25. In separate interviews with the Directors of Maintenance and Memory Care, both stated that hearing aids have been found in the laundry on more than one occasion. The Director of Maintenance also stated that the hearing aids are usually brought to him after they have been washed and before they have been transferred into the large capacity dryers in the Assisted Living Building. The Memory Care Director stated that the first place they look for missing hearing aids, is the laundry room. The Director of Memory Care also stated in their interview that the system they have in place now, where Medication Technicians or Care Partners take the hearing aids to recharge them at night and return them in the morning, must have come about after this complaint was filed and they realized they needed to have a specific procedure in place. LPA reviewed the Individual Service Plan for R1 dated 9/27/24. This report stated, "Resident hearing needs will be known by staff, Speak slowly and clearly, get close to resident Remind resident to wear hearing aids." Under Frequency, it stated "Needed" and that these reminders were to be given by care partners. The report went on to state, "Check and see if hearing aids are in and working, Assist resident in applying hearing aids in the morning. Take out at night. Assistance provided by: Staff/At community Frequency: PRN /As Needed." It did not state where the hearing aids were to be put, if they were to be recharged, and when they were supposed to be taken or returned. LPA reviewed the resident's (R1's) service plan with an activation date of 2/26/26 and a last modified date of 4/16/25, the date this complaint was filed with Community Care Licensing. On page 3 of the Service Plan detail it stated," Hearing impairment- Resident's hearing needs will be known by staff. Speak slowly and clearly, get close to resident." The word care partner was next to this line to identify the person responsible for providing care. The service plan did not address the need for R1’s hearing aids to be charged or checked to ensure they were working properly. The second care plan provided less instruction than the first and did not allocate responsibility to anyone regarding these essential and expensive pieces of medical equipment. LPA requested the contact information for the responsible parties of 3 residents in memory care who utilize hearing aids. Two out of the three interviewed stated that their family members’ hearing aids were not charged regularly. Two of the three stated that they would visit, and their family member and they would not have their hearing aids in. Both families stated that their resident’s hearing aids had been lost on multiple occasions. If the hearing aids were lost, misplaced, or found in the laundry, then they were not being charged. Based on the documents reviewed and the interviews conducted, the standard for the preponderance of evidence has been met and the Department found "Staff do not ensure residents hearing aides are charged," SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. A Case Management visit will also be conducted to address protecting the residents property (hearing aids) from being sent to the laundry. Regarding: Staff are not following incontinent care plan for resident. LPA reviewed R1's service plan with an activation date of 2/26/26 and a last modified date of 4/16/25. R1's LIC 602 stated that R1 had both bowel and bladder impairments. Under Continence Care: "Continence Care - 60 min/day Staff will offer approximately 60 minutes of assistance per day while the resident uses the bathroom." LPA reviewed the Individual Service Plan for R1 dated 9/27/24. With regard to Continence Care the report stated the following: "Resident will be offered full assistance with toileting. Staff will offer approximately 60 minutes of full assistance while the resident uses the bathroom. Provided by Caregiver at the community. Frequency: Daily: Shift III - MC CP 2 NOC Shift I MC CP 7 AM Shift II MC CP 6 PM" In an interview with Hospice provider (H1), they reported that when R1 was visited in the morning by their staff for care, their adult briefs were "saturated." LPA requested notes from contracted care provider visits. The notes included the following logs: On 02/06/25, the log stated," Patient soaked form the waist down upon arrival." On 02/17/25, "provided bladder incontinent care." On 03/10/25,"Diapers and pants were saturated with urine." On 04/09/25, “Patient naked upon arrival, patient, bedsheet, underpants, and diapers wet with urine.” In an interview with staff, S8, they stated that the care plan was not always followed because they would run out for briefs for R1. Sometimes we would borrow them from other residents or from the storage closet, if there happened to be extra in there and if they had the right size. S8 stated "We did our best to keep R1 dry but R1 was one of the residents who would wake up in the middle of the night, sit up and walk to the bathroom even though we had changed R1. R1 would rip off their briefs because R1 had to urinate then they would run out of briefs." This LPA asked how R1 was running out of briefs and S8 stated that sometimes R1's briefs were taken for other residents who may or may not have been on hospice and didn't have enough. S8 stated that if another resident was on hospice we were told that it was OK for us to use other residents briefs that were also on hospice. S8 said that was why certain hospice supplies were running out for the specific residents. S8 went on to state that "Even if R1 had 5-10 at any point. They were being used up at night because R1 would rip them off in R1's room and walk naked to the bathroom. Then when we would go and check on R1, I remember R1 would be sitting there and saying that they had to use the bathroom. “ Based on the review of documents and the interview conducted, the standard for the preponderance of evidence was met and the Department found the above allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. A Case Management Visit will also be conducted to address the shortage of incontinence supplies and the need to conduct reappraisal so that care plans are updated to address the needs of the residents in care. Regarding: Staff are not ensuring that resident laundry is being cleaned and returned to resident. Based on interviews with S5 and S7, clothing often goes missing in memory care. Residents wander into one another rooms and take things that may look familiar or that they simply want. S7 stated that Laundry is done 7 days a week - beds and linens are changed every day. No washers and dryers are used in memory care so everything is moved to the laundry room in assisted living. Residents' clothing are all washed in individual mesh bags so they stay together. S7 stated that 2 - 3 staff take the laundry to the laundry room where they have 8 washer and dryers. They work on the laundry until 5pm and then there is just 1 worker who finishes up, Everything gets returned the same day. S7's staff doesn't usually check pockets because memory care residents don't usually have valuables with them. If someone notices something bulky or jingling, they will remove it and return it or bring it directly to him. S7 also stated that they have found hearing aids in the laundry. They find them when switching clothes from the washer to the dryer. S7 stated that he takes the batteries out and puts the hearing aids in the room across from the laundry room (it is very hot) to dry out, and they "Usually work after that." LPA asked if he could think of a time when they did not work and S7 replied, "No." On 06/17/26, LPA Viarella visited rooms in the memory care community. LPA observed that only 1 in 3 of the rooms she visited 132, 135, and 142, only 135 had a mesh bag for their laundry. LPA took photos for documentation purposes. One did not have a mesh bag or liner and one had a plastic bag. LPA asked S5 what was done with the clothes or bedding that were found and staff were not sure who they belonged to? S5 stated that they would bring all of these items out to the dining room and staff would go through them and return them to residents. S5 said, "Some of them even had the names on the inside!" Based on the observations made and the interviews conducted, the standard for the preponderance of evidence has been met and the Department found the allegation, "Staff are not ensuring that resident laundry is being cleaned and returned to resident. to be SUBSTANTIATED." This deficiency has been cited on the LIC 9099D page. LPA to conduct a Case Management regarding their theft and loss procedures. According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Wimmer. Based on the review of documents and the interviews conducted, the standard for the preponderance of evidence was not met and the Department found the above allegation to be UNSUBSTANTIATED. A finding of unsubstantiated does not mean that the allegation was untrue or did not happen, it means that there was not a preponderance of evidence to substantiate the allegation. According to the California Code of Regulations, Title 22 not other deficiencies were cited during today's visit, a copy of this report was provided and an exit interview was conducted with Wimmer.the state’s words, verbatim · CDSS document, Jul 1, 2026 · control 27-AS-20250416092323

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jul 2, 2026

Basic Services (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living... The above requirement was not met as evidenced by: Based on a document review of care notes and care plans along with interviews with H1, F1, and F3, hearing aids were not being charged and returned to residents on a daily basis as needed. This posed an immediate threat to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2026

Plan of correction: ED stated that they will send a message out in their monthly email explaining and promoting their hearing aid practices and procedures for the residents here at Carlton Senior Living. A copy of this email will be sent to CCL at their regional email by OCB 07/02/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(3) · Plan of correction due date: Jul 2, 2026

Managed Incontinence (b) In addition to… (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. The above requirement was not met as evidenced by: Based on a review of records and interviews with F1, H1, S8, and F3, incontinence care was not being done enough and residents were not kept clean and dry. This posed an immediate threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2026

Plan of correction: ED stated they will conduct an addtional in-service on reporting and escalated reported. ED will also reach out to hospice agences they partner with to ensure they have enough incontinent supplies.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a) · Plan of correction due date: Jul 31, 2026

Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. The above requirement was not met as evidenced by: Based on interviews with S8, F1, F2, F3, and H1 as well as with the Directors of Maintenance and Memory Care, the clothing and bedding were frequently lost in the laudry and not retuned to their proper owners. This posed a potential risk to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2026

Plan of correction: ED stated that they will conduct an audit of mesh laundry bags. There will also be an in-service for all laundry staff to check ALL pockets each time laundry is collected, and all resient laundry will be labeled going forward. ED will also communicate with families that there needs to be an inventory of items. ED will commnicate new laundry procedure in monthly email. ED will send copy of in-service signature sheets and a sample of laundry audit by COB 7/31/26

Type of visit: Case Management - Deficiencies

On 07/01/26, Licensing Program Analyst (LPA) Kimberly Viarella conducted a case management visit today to address the deficiencies learned through complaint investigation # 27-AS-20250416092323. This case management took place immediately following the delivery of the findings for the above complaint. LPA met with Memory Care Director/ Designee, Rose De La Garza. Residents' (R1 and R3) hearing aids were not safeguarded and were lost or destroyed. This deficiency was cited on the LIC 809D page. A reappraisal was not conducted for R1 when their incontinent care needs increased. Care plans for R1 and R3 also not reflect the need for residents to have assistance with charging and putting on their hearing aids. This deficiency has been cited on the LIC 809D page. The facility ran out of incontinent care products which directly impacted resident incontinent care. This deficiency has been cited on the LIC 809D page. LPA and the Memory Care Director discussed the deficiencies and corresponding plans of correction. According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit, a copy of this report along with APPEAL RIGHTS was provided and an exit interview was conducted with De La Garza.the state’s words, verbatim · CDSS document, Jul 1, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218 · Plan of correction due date: Jul 31, 2026

87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program...(2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse... The above requirement was not met as evidnced by: The facility did not Based on interviews F1 and F3's hearing aids were lost and Interviews with H1 and the Directors of Memory Care and Maintenance stated hearing aids were found in the laundry. These items were not safeguarded and no loss reports were completed. This posed a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2026

Plan of correction: Facility will conduct an in-service regarding theft and loss policy. Families will be educated regarding the theft and loss policy in the monthly newsletter and know that they are able to file a loss report with management. A copy of the inservice with signature sheets and a copy of the news letter will be sent to CCL by 07/31/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87625(a)(1)(D) · Plan of correction due date: Jul 30, 2026

(a) The licensee shall be permitted to accept or retain…manageable…incontinence condition under the following circumstances: (1)The condition…(D) The use of incontinent care products. The above requirement was not met as evidenced by: Based on a review of records and an interview with S8, it was documented that R1 had run out of adult briefs and wipes. This posed a potential risk to the health, safety ad personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2026

Plan of correction: Facility will condcut an in-service with staff to educate them to the multiple resources available at this location to ensure that residents incontinent care needs are met. Facility will send resource sheet with signatures of attendees to CCL by 07/31/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 874634(a) · Plan of correction due date: Jul 2, 2026

Reappraisals (a) The pre-admission… shall be updated in writing as frequently as necessary ... The above requirement was not met as evidenced by: The care plans for R1 were not updated to include their increased incontinent care needs. The plan also did not incude the need for staff to charge and safeguard R1's hearing aids. This posed an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2026

Plan of correction: Facility will condcut an audit of all care plans in memory care starting with those residents with hearing aids and classes to make them more person-centered. A draft of the audit starting with the residents who have hearing aids and glasses followed by the remainder of the residents in memory care will be emailed to CCL by close of business on 07/02/26.

Allegation investigated: Uncleared individuals are providing care and supervision.

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on April 28, 2026, at 7:00 AM to open and deliver complaint findings, LPA Martinez met with Christin Pannell and explained the purpose of the visit. Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed facility files. It was learned that staff 1 (S1) was allowed to work at this facility prior to obtaining criminal record clearance documentation and approval from Community Care Licensing Department (CCLD). S1 worked at this facility from December 12, 2025 to April 17, 2026. Violation of Section 87355(e) shall result in an immediate assessment of civil penalties. A civil penalty in the amount $500.00 shall be assessed on April 28, 2026. An exit interview was conducted, and a copy of this 9099 report, 9099-D Page, LIC421BG, and appeals rights documentation was provided to Christin Pannell. Substantiatedthe state’s words, verbatim · CDSS document, Apr 28, 2026 · control 27-AS-20260422152033

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(b)(e) · Plan of correction due date: Apr 29, 2026

87355(b)(e) Criminal Record Clearance:All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working...This requirement was not met as evidence by: based on record review and interviews, the Licensee did not ensure that S1 was eligible to work in a licensed care facility and did not obtain criminal record clearance documentation prior to S1 working at the facility. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 28, 2026

Plan of correction: Facility staff members are currently conducting an employee file audit. Facility staff agrees to conduct hiring in-service training for all care managers and hiring recruiter by May 01, 2026. Facility staff member agrees to email LPA Martinez Audit and training agenda by poc date April 29, 2026, by 5:00 PM. Facility staff agrees to email training documentation by May 01, 2026 by 5:00 PM.

Allegation investigated: Staff does not treat resident with dignity and respect

On 3/4/26 Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to complete and close the investigation into an allegation noted above. LPA met with Administrator, Kasie Wimmer(S1) and Director of Memory Care Rose De La Garza (S2), LPA stated the purpose of this visit. Allegation: Staff does not treat resident with dignity and respect It was alleged “staff yelled at resident”, this investigation focused on Resident 1 (R1). Throughout the process, the LPA conducted interviewed staff, collateral interviews, and reviewed all relevant documents related to R1. On 2/3/26, the facility received a report from a witness stating that Resident 1 (R1) was not treated with respect by staff 3 (S3). On 2/10/26, the facility self reported to the Regional Office via an incident report and SOC 341 that on 2/3/26, R1 wondered into another resident’s’ room in which a witnessed reported that they overheard S3 calling R1 “stupid” in a “frustrated” tone. It observed through video footage to assist R1 out of another residents room, however there is no audio in the video footage. The incident was reported to authorized representative, licensing (LPA, Kimberly Villarella), long term care ombudsman. CONTINUED ON 9099-C Substantiated Collateral interview with witness (P1) stated that on 2/3/26 at around 5:25PM they overheard Staff 3 (S3) yell the word “stupid” “why would you do that?” “you’re stupid”, “its so stupid”. Resident 1 (R1) was observed to face away from them in the hallway and it appeared they were trying to wheel their wheelchair way from S3. P1 stated they did not observe whether or not S3 handled R1 in a rough manner. Staff 1 (S1) and Staff 2 (S2) stated the facility did an internal investigation was initiated immidiatley on 2/3/26 which included reviewing video footage and interviews. The facility determined that S3 did not physically handle R1 in a rough manner. However, S1 stated the encounter observed does not meet the facilities’ standards. P1 stated S3 did not “yell” but they sounded frustrated and called them "stupid louder than regular speaking voice. It was determined by the facility that S3 did not treat R1 with dignity and respect, S1 stated this was an isolated incident in which no other staff has been observed not treat a resident with dignity and respect. S1 also stated preventative measures were taken prior to this incident and immediate measures were taken after the incident on 2/3/26 to ensure staff are trained on re-direction and resident's personal rights. S1 stated all staff including S3 received two days of dementia specific training focusing in redirection for individuals with wondering behaviors. S3 was immediately placed on leave on 2/3/26 and the investigation concluded on 2/10/26, in which it was determined S3's employment would no longer return to the facility. LPA reviewed video footage in which it was observed, in which it was corroborated that S3 was redirecting the resident out of room 139 and into the hallway. They pushed R1 down the hallway and released the wheel chair handle bars behind R1 simultaneously in which R1 proceeded to continue to wheel themselves down the hallway away from S3. S3 then turned away from R1 and opened the exterior door, it was reported there was someone knocking on the door and video footage confirms that S3 let the individual knocking into the facility. Video footage confirms S3 then proceeds to walk towards another hallway away from R3 and did not return to assist R1. In response to this incident, the facility held a mandatory meeting for all staff was held on 2/5/26 by S1 regarding Personal rights, expectations, positive approach, re-direction. An additional service was held on 2/4/26 called "Treating Residents with Kindness, Respect, and Professionalism". S1 reported that S3 was terminated as of 2/10/26 and has been disassociated from the facility. Based on interviews and record review of the LPA and review of records the allegation Staff yelled at resident is substantiated. Based on interviews and record review of the LPA and review of records the allegation Staff does not treat resident with dignity and respect is substantiated. As a result, the allegations above are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted S1 and S2 and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. Staff 1 (S1) and Staff 2 (S2) stated the facility did an internal investigation which included reviewing video footage and interviews. LPA observed through video footage that S3 was assisting R1 out of another residents room, however there is no audio in the video footage. There is not enough evidence that S1 yelled at R1, was not a preponderance of the evidence obtained to corroborate the allegation "Staff yelled at resident", however it was determined that S3 did not treat R1 with dignity and respect on 2/3/26. S1 stated this was an isolated incident in which no other staff has been observed not treat a resident with dignity and respect. S1 also stated preventative measures were taken prior to this incident and immediate measures were taken after the incident on 2/3/26 to ensure staff are trained on re-direction and resident's personal rights. Interview with witness (P1) stated that on 2/3/26 at around they overheard. Staff 3 (S3) yell the word “stupid” “why would you do that?” “you're stupid”, “its so stupid”. Resident 1 (R1) was observed to try to wheel their wheel chair way from S3. P1 stated S3 spoke to R1 in an volume higher than a regular speaking voice. The facility was unable to determined if S3 yelled at R1 as there was only one witness however it is determined the incident likely did occur In response, the facility held a mandatory meeting for all staff was held on 2/5/26 by S1 regarding Personal rights, expectations, positive approach, re-direction. An additional service was held on 2/4/26 called Treating Residents with Kindness, Respect, and Professionalism. The incident was reported to authorized representative, licensing (LPA, Kimberly Villarella), long term care ombudsman. An incident report and SOC 341 was completed. Based on interviews and record review of the allegation "Staff yelled at resident" is UNSUBSTANTIATED There are no deficiencies cited regarding this allegation per California Code Regulation, TITLE 22. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility. Exit interview was conducted with the S1 and S2. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 4, 2026 · control 27-AS-20260205131706

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Mar 5, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall ...(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on record review and interviews, it was found that Staff 3 (S3) did not treat R1 with dignity and respect, as they called R1 "stupid" and did not re-direct them using the training techniques received in "Dementia" Training. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2026

Plan of correction: The facility conducted a training on 2/5/26 regarding resident personal rights and has a plan in place to ensure all staff attend on-going dementia training. POC cleared on 3/4/26. The facility will also ensure there is an updated needs and services plan for residents with wondering behaviors available for review by the Department. Staff 1 (S1) stated P1 stated this was an isolated incident with one staff member and as a result the facility has terminated Staff 3 (S3) .

Allegation investigated: Staff do not ensure that placemats used for meal services are kept in a sanitary condition.

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility, to conduct an investigation into the above allegation. LPA met with Cal Mendiola to explain the purpose of the visit. LPA arrived during a dinner service and did observe a condition of general cleanliness with regards to the floors, cultery, plates, tables, and placemats. LPA also observed a roach trap in the kitchen managers office. LPA interviewed 5 clients, none reported a recent history of uncleanliness with regards to the kitchen, the dining area, or the staff. All found the staff to be responsive to sudden messes, and attentive to thier needs. LPA interviewed 4 staff, kitchen staff have a mix of statements regarding improvements in cleanliness, one in support of a potential risk to the development of bacterial colonies if the placemats are not allowed to air dry properly. Kitchen manager provided a statement that the placemats are chemically treated to prevent development of colonies and the roach problem is being dealt with aggressively. LPA reviewed most recent pest control, 10/10/25, the service is contracted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. A copy of the report was read and given to the staff. Appeal rights were provided, an exit interview was conducted. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 22, 2026 · control 27-AS-20250930151234

Type of visit: Required - 1 Year

On 10/08/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct the annual inspection. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meeting with the Designated Facility Administrator / Executive Director (ED) Kasie Wimmer. Wimmer was not available and LPA met with Designee, Cal Mendiola and a brief interview followed. LPA and the Maintenance Manager (MM) inspected the facility systematically beginning in the kitchen. The kitchen was inaccessible to residents in care. LPA observed the Chef's "Safe Serve" certification and observed that kitchen staff were wearing appropriate clothing, gloves, and long hair was secured appropriately at the time of this inspection. LPA inspected inventory of food and found it to be sufficient for 7-day perishable and 2-day non-perishable. All items were stored and dated appropriately and the fire extinguishers were last inspected on 01/15/25 by COSCO Fire Protection. LPA observed 7 residents finishing breakfast in the dining room in assisted living. LPA observed serving staff assisting residents. Tables were pre-set with plastic placemats and cleaned with a spray solution between dining guests. The MM and LPA proceeded to visit 2 resident rooms. All had the required furniture, furnishings and lighting to be in compliance at the time of this inspection. LPA inspected the bathrooms and observed hand soap, towels and trash cans along with grab bars and non-slip/skid surfaces in the showers. LPA measured the hot water in room 117 to ensure it was between the required 105 - 120 degrees Fahrenheit. The hot water measured 117.9 and was in compliance at the time of this inspection. LPA activated the call alert/pendant in room 266. Staff responded in 2 minutes 22 seconds. LPA inspected the Medication Room in Assisted Living. LPA reviewed destruction procedures with staff and observed overflow medications to be destroyed in a locked room within the medication room. LPA examined a sample of medications on the medication cart and compared them to the electronic medication recording system to ensure accuracy. LPA also inspected the first aid kit to ensure it had all the required elements. The inspection continued into the memory care community where the LPA then inspected their Medication Room and reviewed the centrally stored medication logs. LPA inspected the medication cart and reviewed a sample of resident medications contained in the locked unit. LPA observed 3 residents finishing breakfast, 1 reviewing a book and 6 residents in the TV room while staff supervised. LPA activated a call alert pendent in room 138. Staff responded in 2 minutes and 17 seconds. The following materials were posted in the facility: "If You See Something, Say Something" and Ombudsman contact information posters, Resident Rights, grievance policy, calendar of activities, and facility license. The MM and the LPA then inspected the exterior of the facility. All screens and gutters were in good repair at the time of this inspection. There were fenced in / courtyard areas for both assisted living and memory care with shaded areas and furniture for residents to enjoy. A file review was then conducted by the LPA. The staff roster was reviewed to ensure that all required employees had the appropriate background clearances. Files were then reviewed for 3 staff and 3 residents. All were in compliance at the time of this inspection. According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided and an exit interview was conducted with Mendiola.the state’s words, verbatim · CDSS document, Oct 8, 2025

Allegation investigated: Licensee did not ensure facility was adequately treated for pests Staff did not ensure resident was provided with bathing services Staff did not ensure residents room was kept in clean sanitary conditions

On 07/07/2025, Licensing Program Analysts (LPA) Arielle Pascua and Triel Lindstrom arrived unannounced to this facility to conduct a complaint visit. LPA met with FDR Rose Dela Garza and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current census was 131. A brief interview with FDR was conducted. Allegation: Licensee did not ensure facility was adequately treated for pests. It was alleged that the licensee failed to ensure the facility was adequately treated for pests. During the course of the investigation, the department conducted interviews, made observations, and reviewed facility records. On March 27, 2025, Licensing Program Analysts (LPAs) Kimberly Viarella and Sommer Hayes conducted observations in three adjacent bedrooms. No evidence of pests was found in one of the rooms; however, further inspection of the remaining two bedrooms revealed several small, flat, black bugs along the baseboards and behind the couch. Substantiated It was discovered that the infested bedroom had not been included in the facility’s routine pest control services. The maintenance director added the room to the pest control list at the time of the inspection. Staff interviews revealed that photos of additional bugs had been submitted to management earlier, but no action was taken at that time. Additionally, a review of pest control invoices from October 2024 through March 2025 showed that services were limited to a single bedroom and focused solely on treating for German roaches. No pest control treatments or follow-up inspections were conducted in adjacent rooms during that period. Based on the information gathered, the licensee did not ensure that the facility adequately treated for pests. Allegation: Staff did not ensure resident was provided with bathing services It was alleged that facility staff failed to ensure the resident (R1) received appropriate bathing services. During the investigation, the Licensing Program Analyst (LPA) conducted staff interviews and reviewed facility records. Staff initially reported that R1 had stopped taking showers. The facility stated they had agreed with R1’s responsible party to continue offering showers in an effort to assist R1, prior to formally updating the care plan. Staff claimed that attempts were made to offer showers, but that R1 continued to refuse them. However, a review of R1’s shower logs revealed no documentation indicating that showers were offered or refused. When questioned further, staff acknowledged that showers had not actually been offered to R1, despite previous claims. Based on the evidence obtained, it was determined that staff did not ensure that R1 was provided with bathing services, as required. Allegation: Staff did not ensure residents room was kept in clean sanitary conditions It was alleged that staff did not ensure residents room was kept in clean sanitary conditions. During the investigation, LPA conducted observations to assist with this allegations. Based on observations made it was found during a facility visit on 03/27/2025 by LPAs Viarella and Hayes it was observed that there was pet feces and bugs all throughout the room. In addition, items were asked to be moved to inspect other items of the rooms because there was limited space to move through all the items places throughout the room. It was also observed that the sofa against the wall had bugs, boxes, and other items such as wrappers and bags stored behind it. During this visit, LPAs had to ask maintenance to help assist move the items to inspect throughout the room and behind the sofa. Based on the information gathered, the staff did not ensure residents room was kept in sanitary conditions. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. An Exit Interview was conducted and a copy of this report and appeals rights was provided to the facility at the end of this visit. Allegation: Personal rights violation. It was alleged that the facility had a personal rights violation. During the investigation and interview with 5 residents and 5 staff members were conducted. 5 out 5 residents report no issues with the staff or the facility at this time. 5 out 5 staff members deny that they violate any resident rights and are aware of their rights at the facility. Based on this information, there is not sufficient evidence to prove that the facility violated the rights of a resident. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Jul 7, 2025 · control 27-AS-20250324141824

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 7, 2025

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met as evidenced by: Based on observation, interview, and record review the licensee did not ensure that the residents room was kept in a clean and sanitary manner. It was learned that the facility did not obtain pest services or maintain the room in a sanitary manner. This poses a potential health,safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2025

Plan of correction: Facility staff states that a statement of correction that outlines a plan to correct housekeeping documentation and pest control services by 08/07/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Aug 7, 2025

(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This is not met as evidenced by: Based on interview and records review the licensee did not ensure that R1 was provided showering services. This poses an potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2025

Plan of correction: Facility staff states that a statement of correction that outlines a plan to correct bathing services by 08/07/2025.

Allegation investigated: Staff are not meeting resident's care needs

Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility on 05/22/25 to continue this investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Cal Mendiola and a brief interview followed. Based on a review of records combined with information gathered from interviews, R1 was not receiving their necessary incontinent care. An entry made on 08/18/24 stated that R1 was not changed prior to the PM shift coming on duty and R1 and their bed “was soaking wet.” On 8/28/24, it was also noted that R1 had a large bowel movement and that R1 was not changed prior to the PM shift coming on duty. Additional care notes entered in the ALIS computer system, also described the following on 08/11/24 by 3 care partners. At 6:02, S3 wrote, “Care partners were not able to do last rounds because resident was unable to stand. Care partners decided to wait until AM were here to try and stand R1 up to try again.” LPA asked S3 to describe how they cleaned and changed R1. S3 stated that because of R1's body type/shape, that it now required, Substantiated "at least 2 people to hold R1 up and steady, otherwise R1 sways back and forth. R1 has slid down onto the floor before because we can't keep R1 steady - their legs are weak." The third person is the one who actually cleans and changes R1. LPA asked why they didn't change R1 when R1 was horizontal in bed. S3 responded that they have tried that but, “R1 is very heavy and difficult to move, especially when R1 is sound asleep. R1 is dead weight then, and some of the care partners are more petite than others. With an average person, that might not be an issue but R1 is big and heavy.” LPA observed care notes in logs which state, at 12:35 AM, during the NOC shift, , “We were not able to stand the resident up with 3 care partners. The resident was deadweight and was not assisting. Resident was very weak and was not understanding instructions. We contacted the med tech for advice. Alpha One assisted with continent care. Resident is becoming too heavy to turn and stand. The last observation made regarding weight/condition was in July. We have not received any updates regarding this issue. This issue continued as documented by another care partner on 08/13/24 when they logged, “The resident was hard to do continent care and we call help from assisted living. We checked R1 4 care partners at the bed.” LPA observed that an updated service plan was added to ALIS for R1 on 08/15/24. LPA noted the following upon reviewing the care plan dated 08/07/24. LPA observed from a review of records that from December of 2023, to October of 2024, R1 gained 18 pounds. LPA reviewed documents including discharge paperwork from Kaiser. R1 had a rash and swelling in their groin area and they were diagnosed with a urinary tract infection. On page 2 the new plan stated that the, “resident’s risk for falling will be noted by staff.” It went on to state, "the resident is encouraged to be out in the common areas during waking hours. Resident is encouraged to sit or lay down when feeling or staff sees resident fatigued. Resident wears proper footwear when awake and walking (tennis shoes) resident is on toileting services. Staff are to check on resident approximately every 2 hours for toileting assistance. Staff are to redirect resident back to the common areas, if and when, available.” LPA requested incident reports for R1. From 07/06/24 to 09/01/24, R1 had 1 witnessed and 4 unwitnessed falls. R1 was not getting their incontinent care needs met. R1's care plan should have been updated after the first fall to include a strategic fall prevention plan in order to prevent the following falls from occurring. The standard for the preponderance of evidence has been met and the Department finds the allegation, "Staff are not meeting residents care needs." to be SUBSTANTIATED. According to the California Code of Regulations, Title 22, this deficiency was cited on the LIC9099 D page. A copy of this report was provided along with appeal rights and an exit interview was conducted.the state’s words, verbatim · CDSS document, May 22, 2025 · control 27-AS-20241015143137

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(3) · Plan of correction due date: May 23, 2025

87625 Managed Incontinence (b) In addition to Section 87611...the licensee shall be responsible for..:3) Ensuring that incontinent residents are kept clean and dry ... The Licensee did not ensure that the above regulation was enforced as evidenced by: Based on a review of records, as well as interviews with staff carestaff documented at least 3 incidents when R1 was not changed or could not be changed. This posed(es) an immediate threat to the health safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: The Designee stated that since this complaint orignated, a hoyer lift was added to assist with this resident. Currently the resident utilizes a catheter. R1 will have increased monitoring by the nursing staff and all staff witll have addtional training on incontinent care skin checks and documentation. A plan for training will be submitted to CCL by the close of business 05/23/25 with an outlne and dates for completiong.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(g) · Plan of correction due date: May 23, 2025

87463 Reappraisals (g) The licensee shall ensure corresponding changes are made in the care and supervision provided to the resident. The licensee did not ensure the above regulation was met as evidenced by: Based on a records review, R1 had a total of 5 reported falls. Updated appraisals did not show changes to care and supervision. No strategic fall prevention plan was put into place. This posed(es) an immediate threat to the health safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Designee stated that the Director of Memory Care will update the Care Plan to include a strategic fall prevention plan, a plan for skin breakdown prevention, and any other concerns that have developed since this complaint was initiated. A draft of this plan will be completed and submitted by the close of business 5/23/25.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility on 05/22/25 to conduct a case management visit regarding and incident reported by the Memory Care Director. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Cal Mendiola and a brief interview followed. The Ombudsman was also present during this meeting as he was investigating the same incident in response to an SOC 341 that was sent. LPA Viarella received a phone call from the Director of Memory Care stating that R2 was found in R1's room and that R1 who was non ambulatory, was in bed, and naked from the waist down. During an interview with a staff member (S1), this LPA learned that R2 has a history of being aggressive and fixated on R1 who is non-verbal and unresponsive to R2's advances. S1 stated that R2 will sit with R1 and S1 has seen R2 stroke R1's leg and lap area. S1 told this LPA that when staff separate the two, R1 smiles and sits straighter in their chair. S1 stated that when R2 is with R1, R1 drops their head and does not make eye contact with R2. In care notes dated 02/08/25, another staff member (S2) had a conversation with R1's responsible party. The responsible party stated, "that R2 is controlling." They want to make sure, "that R2 does not take advantage of R1 in any way," During today's meeting the Ombudsman asked who was supposed to be watching to ensure the two were kept separated, since R1 did not have the capacity to give consent. S1 replied that S3 was assigned to R2 and was supposed to ensure that R2 did not go into R1's room. LPA Viarella interviewed S3 and learned that S3 went on break but did not tell anyone to take over watching R2. It was during this time period that R2 went into R1's room When S3 came back from their break, they heard voices in R1's room and S3 went and removed R2 from the room. According to the California Code of Regulations, Title 22, the facility was cited for a Personal Rights Violation which may be found on the LIC 809D page. The Memory Care Supervisor stated that she will be conducting an in service on personal rights and how to protect R1's personal rights as well as how to address the behavioral expressions of R2. Due to time constraints, this LPA will return to conduct a case management regarding reporting requirements. No other deficiencies were cited during today's visit, a copy of this report was provided. Exit interview.the state’s words, verbatim · CDSS document, May 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 23, 2025

(a) Residents in all residential care facilities...shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. The licensee did not ensure the above re- quirement was enforced as evidenced by: Based on interviews and a review of documents, R1's personal rights were violated when R1 was not accorded dignity in their personal relationships. This posed an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Designee stated they will conduct an in-serve regarding personal and how to address the behavioral expressions of R2. The schedule will be revaluated to ensure that R2 is kept apart from R1. A draft of the in-service and a date for the training will be provided to CCL by the close of business on 5/23/25. The facility will follow up by sending the LPA signature sheets for those who attended.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility on 05/22/25 to conduct a case management visit regarding and incident reported by the Memory Care Director. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with Cal Mendiola and a brief interview followed. The Ombudsman was also present during this meeting as he was investigating the same incident in response to an SOC 341 that was sent. LPA Viarella received a phone call from the Director of Memory Care stating that R2 was found in R1's room and that R1 who was non ambulatory, was in bed, and naked from the waist down. During an interview with a staff member (S1), this LPA learned that R2 has a history of being aggressive and fixated on R1 who is non-verbal and unresponsive to R2's advances. S1 stated that R2 will sit with R1 and S1 has seen R2 stroke R1's leg and lap area. S1 told this LPA that when staff separate the two, R1 smiles and sits straighter in their chair. S1 stated that when R2 is with R1, R1 drops their head and does not make eye contact with R2. In care notes dated 02/08/25, another staff member (S2) had a conversation with R1's responsible party. The responsible party stated, "that R2 is controlling." They want to make sure, "that R2 does not take advantage of R1 in any way," During today's meeting the Ombudsman asked who was supposed to be watching to ensure the two were kept separated, since R1 did not have the capacity to give consent. S1 replied that S3 was assigned to R2 and was supposed to ensure that R2 did not go into R1's room. LPA Viarella interviewed S3 and learned that S3 went on break but did not tell anyone to take over watching R2. It was during this time period that R2 went into R1's room When S3 came back from their break, they heard voices in R1's room and S3 went and removed R2 from the room. According to the California Code of Regulations, Title 22, the facility was cited for a Personal Rights Violation which may be found on the LIC 809D page. The Memory Care Supervisor stated that she will be conducting an in service on personal rights and how to protect R1's personal rights as well as how to address the behavioral expressions of R2. Due to time constraints, this LPA will return to conduct a case management regarding reporting requirements. No other deficiencies were cited during today's visit, a copy of this report was provided. Exit interview.the state’s words, verbatim · CDSS document, May 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 23, 2025

(a) Residents in all residential care facilities...shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. The licensee did not ensure the above re- quirement was enforced as evidenced by: Based on interviews and a review of documents, R1's personal rights were violated when R1 was not accorded dignity in their personal relationships. This posed an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Designee stated they will conduct an in-serve regarding personal and how to address the behavioral expressions of R2. The schedule will be revaluated to ensure that R2 is kept apart from R1. A draft of the in-service and a date for the training will be provided to CCL by the close of business on 5/23/25. The facility will follow up by sending the LPA signature sheets for those who attended.

Allegation investigated: Personal Rights

On 1/23/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. The LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator. LPA met with Kasie Wimmer and a brief interview followed. A resident (R1) sustained a fall on 5/28/24 in the common area of the facility while trying to transfer independently from a chair into their wheelchair. R1 was taken to Kaiser Permanente. R1 had a CT scan which showed no acute hemorrhage or calvarial fracture and no mass effect of herniation. Tylenol was given for pain. Discharge paperwork listed to monitor R1 and if symptoms got worse, to bring R1 back to the hospital. R1 returned to the facility. On 5/29/24, R1 entered a different resident's room and sustained a fall at approximately 1303 hours. R1 remained on the floor in a pool of blood until facility staff entered the room at approximately 1315 hours. Substantiated R1 was found after staff received a phone call from SafelyYou, a service that detected that a resident had fallen in that room. R1 was taken to UC Davis Medical Center. R1 was noted to have a large hematoma to the right side of their forehead. R1 sustained multiple head bleeds including "significant worsening" of an old intracranial hemorrhage. On 5/30/24, R1 passed away. R1's cause of death was listed as Intraparenchymal Hemorrhage due to a ground level fall. Facility staff, S3, stated that they were assigned to R1 on 5/29/24. S3 saw R1 in the common area of the facility before S3 went on break. All other facility staff interviewed stated that they were either taking care of another resident, or they were not in the common area at the time of the incident. The facility was unable to provide a staff schedule indicating which staff were present in the common area. This LPA reviewed the Personal Care Interview conducted on 3/28/19. On page 3 it stated that R1 “needed minor help transferring” and on page 4 a check mark indicated that R1 was a FALL RISK. In the notes from a care conference on 3/25/20, Staff checked off that there were concerns for R1: balance/gait, FALL RISK, and concerns were also raised about wandering and exit seeking behaviors. On page 3 it stated that R1 had a history of falls and on page 4 it stated that R1 had fallen twice in the past year. On page 5 of this report, when asked if R1 had a history of wandering and exit seeking, “yes” was checked. Individual Service Plans indicated that R1 was a fall risk and that R1's wandering would be addressed accordingly. However, the plan did not list any specific strategy to mitigate R1's fall risk and wandering behavior. The Individual Service Plan was not updated after R1's fall in April of 2024 or after R1's fall on 5/28/24. It was updated on 5/30/24 after R1's fall on 5/29/24. The LPA observed the following upon reviewing the R1's re-assessment dated 5/30/24. On page 2 number 6, it was noted that R1 was a FALL RISK. On page 3, section 2, number 1, under "Functional Capabilities, Ambulation, and Transfers," the fact that R1 was a fall risk was not mentioned. There were two boxes checked off. One indicated that R1 used a walker independently and was able to get in and out unassisted. The second box indicated that R1 was not able to walk and that R1 used a wheelchair. In the notes section it stated, "NON-AMBULATORY: Resident ambulates herself utilizing their wheelchair and has a walker that they can use to assist with transfers." Under section 2 it asked "Does the resident have any of these functional capability concerns?" Balance/Gait was checked but there were no notes provided or strategies listed under the notes section to address the concern. On page 6 question 6 asked, "Does the resident request or require ESCORT assistance to the dining room, activities, or anywhere (destinations) within community?" "Yes" was checked off to indicate that R1 needed assistance going to and returning from the dining room. Question 12 asked if R1 had fallen two of more times in the past year. "No" was checked off, which was incorrect; R1 had a documented fall on 4/21/24, another on 5/28/24 and the final fall on 5/29/24 which resulted in R1's death. R1 was sent out for evaluation for the first fall which resulted in a radius fracture. R1 was sent out for evaluation for the second fall as well. Because question 12 was answered incorrectly, the follow up questions were not answered. On page 7, as part of a fall risk assessment, staff were supposed to check off the appropriate box. Staff checked off that R1 had 1 fall within the last 3 months instead of the box that indicated R1 had 2 falls within the past 12 months. Page 9 also indicated that R1 had a history of exit seeking, a habit that, combined with being a fall risk would require increased checks. Upon reviewing the Individual Service Plan, this LPA observed that on pages 2 and 3, the plan indicated that R1 would receive round trip escorts by staff daily to R1's desired locations. The plan also stated that R1's "risk for falling would be noted by staff" and that staff were supposed to "note any changes in condition, balance problems or weakness, to supervisor." After the fall on 5/29/24, R1's care plan did not increase the frequency of checks on R1. Staff interviews revealed that the amount of time between resident checks varied amongst staff. S1 stated in an interview that when a resident returns from the hospital, they were put on alert charting and they were checked on every hour for 3 days. S1 went on to say that if a resident were a fall risk, they would be checked on every 10 - 15 minutes. S1 also added that most of the residents were in the common area and were "constantly" being checked on. S1 stated that R1 got the "standard" number of checks and did not require any additional checks or care. S2 stated that residents are checked on every 2 hours but if they have returned from the hospital, they were put on alert charting and checked every hour. S2 went on to say that R1 was checked on every 2 hours. Later during the same interview, S2 stated that R1 was on alert charting and being checked on every hour. S3 stated that residents were checked every 2 hours and that these checks were documented in the computerized system called ALIS. S3 stated that R1 required assistance with all levels of daily living activities. R1 utilized a wheelchair but would always try to stand up and get out of the chair on their own. Due to this, R1 was a fall risk. On 5/28/24 while the caregiver who was typically assigned to take care of R1 was on break, R1 attempted to get up on their own. R1 was in the common area and whoever is in the common area is responsible to supervise the residents. S2 stated that they did not know who was in the common area at that time, but R1 attempted to get up and they fell. R1 was sent out for evaluation at the hospital and returned the same day. It remains unknown as to who was supervising the residents in the common area that day. Those interviewed said that whoever was stationed there was responsible for supervising the residents. S5 stated that on 5/28/24, facility staff were having a team meeting, but that a staff person was in the common area watching the residents. S5 could not remember who was in the common area at the time. R1 attempted to transfer to a chair independently, fell, and hit their head. S5 also stated that it was common for residents to want to sit in a normal chair while eating in the common area. According to S5, facility staff were in the kitchen and the switch between shifts was taking place. Facility staff turned their head and when they looked back, R1 was falling. R1 was sent to the hospital and returned the same day. S6 stated that they were made aware of R1’s first fall on 5/28/24 by the Memory Care Director. The two reviewed video footage and saw R1 attempt to transfer from a chair back to their wheelchair. S2 saw R1 stand up, lose their balance, and fall. S6 said that facility staff were on their way to R1 when R1 stood up, but by the time they got there, R1 was on the floor. S1 stated that they did not know how no one saw R1 use their wheelchair to enter another resident’s room on 5/29/24. S1 stated they did not know who was watching the common area at the time. S1 added that it should be a team effort for who was watching the residents in the common area. S1 did not know who found R1 on the floor. S1 “definitely” believed that R1 should have had better supervision on 5/29/24. S4 stated that residents were checked on every two hours and that the residents mostly stayed in the common areas where they could be supervised by staff. S4 stated that R1 had a total of 5 falls at the facility and that R1 did not receive any extra supervision because the family would not pay for it. When asked who was watching R1 when they fell on 5/28/24, S4 stated, "all of us." On 5/29/24, S4 stated that they think R1 fell when staff were getting lunch ready. They had an issue with another resident that pulled some staff away. S4 thought the fall could have been prevented, "If the staff saw R1 go into a different resident's room, they would have went in there and taken R1 out." When asked if they thought that the facility was understaffed, S4 said yes. "If there had been more people working, then there would have been more people watching the common area". S5 did not feel the facility was understaffed and believed that the residents were checked on every hour. S5 stated that if a resident were determined to be a fall risk, then they were checked on every thirty minutes. S5 was asked if R1 was supposed to be watched more closely since they just fell and went to the hospital the day before. S5 said "yes", R1 should have been on high watch. "It's not a policy, just common practice with them to watch them 24/7 after coming back from the hospital." S7 reported that R1 liked to wander after lunch. "It was like clockwork," S7 said, " R1 would wheel themselves around after lunch." S7 said that R1 was allowed to wander between their room and the common area. The records reviewed showed that as far back as 3/28/19, there were documented concerns regarding R1 being a fall risk. The report from 3/25/20 stated that R1 had 2 falls within the past year. The records reviewed showed that a comprehensive, strategic plan was not developed or communicated to the staff caring for R1. The functional assessment conducted had unanswered and incorrect answers included, which in turn, were used to calculate R1's fall risk. The staff did not understand how often to check on R1 as evidenced by the varying answers of those interviewed. The care plan indicated that the resident was to be redirected if they attempted to stand by themselves. In order for that strategy to be effective in preventing a fall, the staff person needed to be close enough to communicate with the resident and able to intervene if R1 ignored the redirection. The facility did not supervise R1 which led to R1 wandering into another resident's room, standing, falling, and sustaining a serious head injury, which resulted in R1’s death. Under Basic Services, California Code of Regulations 87464(d), “a facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident’s needs…” The standard for the preponderance of evidence has been met and the department finds the above allegation SUBSTANTIATED. This deficiency is included on the LIC 9099D page. This report has been amended on 1/28/25 to include the following: A civil penalty in the amount of $500 is hereby assessed due to a violation resulting in injury to a resident, as described above and is cited on the LIC 421IM page. Additional civil penalties are currently being evaluated by the Department, pursuant to Health and Safety Code § 1569.49(f). An exit interview was held with Wimmer. Appeal rights, a copy of the civil penalty assessment, and a copy of this amended report were left with Wimmer.the state’s words, verbatim · CDSS document, Jan 23, 2025 · control 27-AS-20240624162127

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Jan 24, 2025

Basic Services CCR 8764(d) (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs.... The licensee did not ensure these needs were met as evidenced by: Based on a records review and information gathered from interviews, it was documented that R1 was a fall risk as far back as 3/28/29. A plan to mitigate these falls was not put into place.This posed an immediate threat to the health, safety and/or personal rights to residents in care.the state’s words, verbatim · CDSS document, Jan 23, 2025

Plan of correction: The Administrator stated that following this event a new protocol was enacted where floor time to cover the common area is scheduled into all carestaff assignments for the day thus eliminating ambiguity and confusion. The Administrator will provide an example of one of these schedules to Community Care Licensing by the close of business 1/25/25.

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 9/17/24 at 12:00pm. LPA met with Kasie Wimmer and stated the purpose of todays visit. Administrator certificate expires 5/21/25. License fees are current. The facility is licensed for a capacity of 185 residents of which 120 maybe non-ambulatory and 20 may receive hospice care services. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. There is 8 resident receiving hospice care services. The most recent emergency drill was conducted on 8/29/24. LPA observed 2-day perishables and 7-day non-perishables. Facility has required postings which include Oxygen in Use. The temperature thermostats inside was observed to be at 75*F throughout the facility which is within the required range of 68-85*F. The hot water temperature was measured 114.2*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air and exit alarms in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.the state’s words, verbatim · CDSS document, Sep 17, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 9/17/24 at 12:00pm. LPA met with Kasie Wimmer and stated the purpose of todays visit. Administrator certificate expires 5/21/25. License fees are current. The facility is licensed for a capacity of 185 residents of which 120 maybe non-ambulatory and 20 may receive hospice care services. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. There is 8 resident receiving hospice care services. The most recent emergency drill was conducted on 8/29/24. LPA observed 2-day perishables and 7-day non-perishables. Facility has required postings which include Oxygen in Use. The temperature thermostats inside was observed to be at 75*F throughout the facility which is within the required range of 68-85*F. The hot water temperature was measured 114.2*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air, exit alarms, and delayed egress in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 4 staff and 4 resident files during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Licensing fees-Current Criminal Record Clearances LIS536-Current Administrative Organization LIC309-Current Designation of Administrative Responsibility LIC308-Submit Personnel Report LIC500-Submit Affidavit Regarding Client/Resident Cash Resources LIC400-NA Surety Bond LIC402-NA Facility Floor Plan/Plot Plan LIC999-Current Fire Clearance (consistent with terms and limitations of license)-NA Qualifications of Administrator/Facility Manager-Submit Articles of Incorporation/Organization, Constitution and bylaws-NA Partnership Agreement-NA Control of Property-Submit Emergency Disaster Plan LIC610-Submit Plan of Operation (Restricted Health Care Plan)-NA Admission Policies and Procedures-NA Health Screening Report-Facility Personnel LIC503-NA Bacteriological Analysis of Private Water Supply-NA In-service Training Program-NA Medication Procedures-NA Transportation Procedures-NA Job Description/Personnel Policies-NA Exemptions/Waivers and Exceptions-Current First aid/CPR certificates-Current Liability Insurance-(if applicable)Submit Infection Control Plan-Submit if applicable Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.the state’s words, verbatim · CDSS document, Sep 17, 2024

Allegation investigated: Staff mismanaged resident medication Staff did not obtain a hospice care plan for resident Staff did not maintain a comfortable temperature for resident

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to open the initial investigation of the above mentioned allegations on 9/10/24 at 3:15p. LPA met with Kasie Wimmer and stated the purpose of the visit. LPA obtained information that the resident does not reside at this facility. Based on interview with Exective Director/Administrator Kasie Wimmer the allegation(s) are deemed Unfounded."The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint." Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided. Unfoundedthe state’s words, verbatim · CDSS document, Sep 10, 2024 · control 27-AS-20240905163918

Allegation investigated: Facility staff sexually abused resident in care

On 6-20-24 at 2:50pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss findings for the complaint allegation noted above. LPA met with Administrator Kasie Wimmer and explained the purpose of the visit. During this investigation, the Department conducted interviews with resident1 (R1) and additional witness. The department also reviewed facility file documentation including SOC 341 abuse report, resident and services agreement, physician's report for R1, Activities of Daily LIving (ADL) questionnaire for physician review, resident health identification information, key lock audits, observation notes dated 4-2-2024 to 5-6-2024, resident roster, staffing roster, staff schedules for April 2024 to May 2024, and assisted living/memory care staff contact information. Based on interviews and record reviews, it was determined that R1 was unable to identify a suspect male or female. Interviews conducted further revealed facility staff performed duties to R1 including checking the location of R1’s call button and checking R1 for any needed incontinence care. {Cont. on 9099C} Unsubstantiated Additionally, interviews further revealed that the information received did not result in a credible source to determine if facility staff sexually abused a resident in care. As a result, the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator and a copy of this report was provided to Administrator. Appeal rights provided. LIC 811 provided.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 27-AS-20240506161153