Casa De Flores

Allegation investigated: Staff impersonated resident with the intent to deceive family members Staff prevented resident from having visitors Staff prevented resident from talking on the phone Staff prevented resident from leaving the facility

Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above. LPA met with Administrator Jonathan Roberts and explained the purpose of the visit. LPA requested the following records: a staff roster with telephone numbers, staff schedule for September 2026, Resident Roster, Lic. 602A Physician Report, Appraisal Needs and Services Plan, Emergency ID form, Any POA/fiduciary/Conservator paperwork, Morro Bay Police Department (MBPD)contact case numbers and phone numbers, San Luis Obispo Long Term Care Ombudsman (LTCO) contact information. LPA interviewed staff and resident. On the allegation: Staff impersonated resident with the intent to deceive family members. LPA interviewed Resident 1 (R1) which revealed R1 knows how to use email and cell phone. Continued 9099-C Unsubstantiated R1 has sent emails to family members. R1 stated no one has sent any emails on R1’s behalf and all emails have been sent to family members by R1. R1 stated the LTCO has been involved and R1 knows how to contact the LTCO if R1 needs any assistance. MBPD came out to the facility for welfare checks twice over this past year to check on R1, R1 has been fine with no issues on both occasions. R1 stated R1 was fine and does not want to communicate with R1’s family member at this time and R1 will contact R1’s family member when R1 is ready. R1 stated R1 can block calls on R1’s phone and does so when R1 needs time away from the calls by family members. R1 stated staff or the facility has not had any involvement with R1’s choices to email, talk, visit, or leave the facility at anytime. LPA spoke with LTCO and LTCO said LTCO contacted R1 and R1 does not want LTCO involvement at this time, R1 is very alert, oriented and able to make R1’s own decisions. R1 understands how to contact LTCO in the future if R1 needs LTCO assistance. Based on the evidence this allegation is Unsubstantiated at this time. On the allegation: Staff prevented resident from having visitors. LPA interviewed R1 which revealed staff have not kept R1 from visiting anyone. R1 said recently R1 was going to have a visit and cancelled that visit due to R1’s choice. R1 would like to visit a family member with no one else present, if that can happen, that is what R1 wants. R1’s family member has a full-time caregiver and not sure if a visit alone can happen but if so that is R1’s preference. R1 stated the staff honor R1’s decisions. Based on the evidence this allegation is Unsubstantiated at this time. On the allegation: Staff prevented resident from talking on the phone. LPA interviewed R1 which revealed R1 has R1’s own cell phone, the staff do not take or use R1’s cell phone, R1 can use R1’s cell phone whenever R1 wants to. R1 has blocked a family member on a few occasions and unblocks when R1 wants calls to resume. R1 said staff have never prevented R1 from talking on the phone and have always honored R1’s decisions. Based on the evidence this allegation is Unsubstantiated at this time. On the allegation: Staff prevented resident from leaving the facility. LPA interviewed R1 which revealed R1 can leave the facility when R1 wants to leave the facility. R1 stated the staff have never prevented R1 from leaving the facility and the staff have always honored R1’s choices. LPA reviewed R1’s LIC. 602A Physicians report dated 03/07/2019 which revealed R1 is non-ambulatory, uses a walker for assistance when needed, able to leave the facility unassisted, able to communicate needs, able to follow instructions, is in good overall physical health and does not have any cognitive impairment marked. Based on the evidence this allegation is Unsubstantiated at this time. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Sep 28, 2026 · control 29-AS-20260918144444

Type of visit: Case Management - Other

On 08/26/2026, Program Analyst (PA) Lovina Aquino and Financial Analyst (FA) Arne Bracchi arrived at the facility and met with Executive Director (ED) Jonathan Roberts, Finance Director (FD) Patrick Woolpert, and Director of Operations (DOO) Corina Segundo to complete the required triennial visit for Casa de Flores Bayside Care Center, a Continuing Care Retirement Community (CCRC). Prior to the visit, the PA and FA reviewed documentation requested from and provided by the ED to ensure that the provider is operating the CCRC in compliance with the statutes and is performing the services specified in its continuing care contracts. During the visit, the PA, FA, ED, FD, and DOO discussed the documentation received prior to the visit and toured the CCRC to ensure that all required postings and documents were accessible to residents and visitors. This included the Certificate of Authority, which remains valid and is properly displayed near the mailroom. CCCB staff observed the assisted living units and verified that the required postings and meetings, as outlined in H&SC Sections 1771.7 and 1771.8, were in place and compliant. As a result of the visit, no compliance issues pursuant to the Continuing Care Contract Statutes were cited. CCCB staff will follow up with a thank-you letter and summary, which will be provided to the ED within seven days of the visit. An exit interview was conducted with the ED, FD, and DOO. Due to connectivity issues, CCCB staff completed the LIC 809 upon return to HQ and emailed the ED for signature.the state’s words, verbatim · CDSS document, Aug 26, 2026

Allegation investigated: Staff is verbally abusive towards other staff in the presence of residents

Licensing Program Anlayst (LPA) De Leon conducted a 10-day complaint visit to the facility above. LPA met with Administrator Jonathan Roberts and explained the purpose of the visit. LPA requested the following records: Staff Roster, Staff Schedule for March 2026 for Wellness Department, Wellness staff diciplinary records for 2025-2026, CNA certification and training for Wellness Staff 1 (S1), LPA conducted interviews with staff at 11:43pm, 12:03pm, 12:12pm, 12:50pm, 1:02pm, 1:20pm, 1:26pm, 2:00pm, and 2:45pm. On the allegation: Staff is verbally abusive towards other staff in the presence of residents. LPA reviewed records and conducted staff interviews which revealed that 9 out of 9 staff did not feel Staff 1 (S1) was verbally abusive to staff or to any staff in the presence of residents in care, the facility does hold staff meetings regualary and discussion on resident care is brought up to staffing but a staff is never singled out in those meetings in front of their peers. Continued 9099-C Unsubstantiated S1 stated when a meeting needs to take place with a staff for performance review there is always another director or lead staff or HR is present, S1 can be direct when talking to staffing regarding residents care but it has to be done for the safety of the residents and it is never done in a deeming or abusive way. A few staff stated S1 can be very matter of fact and some staff might get offended or feel that S1 is not as easy to talk to as some other Directors at the facility, some staff said S1 is not as easy to approach when calling in sick then other directors can be. S1 is the director over S1's department and has several lead staff working in that department. LPA reviewed 5 staff disciplinary records for the previous year of 2025 nothing has been reported for 2026, records reviewed had nothing to do with verbal abuse of staff in the presence of residents in care. 9 out of 9 interviews did not give any evidence that S1 was verbally abusive to staff in front of residents in care, therefore this allegation is Unsubstantiated at this time. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Mar 16, 2026 · control 29-AS-20260311091654

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 11:00 am to conducted a 1 year annual visit to the facility above. LPA met Administrator Jonathan Roberts and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted an Infection Control Plan to the department. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Staff are trained on infection control and the use of Personal Protective Equipment (PPE) upon hire and annual there after. Physical Plant & Environment Safety: The facility has 91 bedroom with 91 private bathrooms and 5 common areas restrooms currently occupying 87 residents and employs 53 staff and 1 Administrator. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has dual smoke, carbon monoxide detectors and sprinkler system. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid textured floors or mats. Toilet, hand washing and bathing facilities are operational and grab bars are present. LPA toured 10 bedrooms and 3 common area restrooms. The facility has a pendant signal system.. The pathways are clear of any obstruction. Emergency evacuation chair are present on each stairwell. Continued 809-C Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training with all subjects covered over a 3 year period, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements and Quarterly Disaster Drills. Staff handling medications had initial and/or annual training. Kitchen staff had training on facility policy and procedures for food handling and preparation as well as infection control requirements, staff have valid food handler certificates. Trainers met the requirements to train staff with required information present in files. Hospice and Home Health care plans had training records on file. Staffing: The facility employes 53 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 random staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate expires 08/2027. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. 5 files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. Facility does submit incident reports to the department when required. Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license along with CCL reports and PIN's were posted. Internet is provided in each resident room for confidentiality and privacy. Planned Activities: The facility offers activities to all residents in care. The facility employs an Activities Director and a monthly calendar with all activities is posted. The facility also offers additional activities to include books, magazines, newspapers, television, daily walks, group discussions and communications, games and puzzles. The facility has a piano for resident use and musicians come into the facility and perform for the residents. The facility has sufficient space to allow for activities indoors and outdoors as well as an activity room. The facility has a gym, movie theater, ice cream parlor, Salon and Library for residents use. Continued 809-C Food Service: The facility employs food service staff. The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. A menu is posted for residents in care. Modified diets prescribed by a physician are followed for those residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. Incidental Medical & Dental: The facility has a medication room that is kept locked as well as two medication carts which are kept locked. Facility provides transportation to medical and dental appointments when needed. the facility uses a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR) for residents in care. The facility has a mini locked refrigerator for medication and an ice chest for emergency use. The facility has a red sharps container for disposal of syringes. Medication Destruct is done by with Administrator, Wellness Director and Wellness Coordinator.. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 04/10/2025. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does not accept dementia residents in care. All items that could pose a danger, sharps, cleaners were inaccessible to residents in care. The facility does not have delayed egress. The facility does have residents with oxygen and required signs are posted. The facility has hospice residents in care. Hospice care plans are kept on file and up to date. The facility currently has residents on Home Health services. Home Health services records are kept on file. LPA conducted interviews with 4 Residents and 4 Staff. Exit interview conducted, no deficiencies cited, copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Feb 23, 2026

Type of visit: Required - 1 Year

At 9:15 a.m. Licensing Program Analysts (LPA) Melisa Rankin arrived at the facility unannounced to conduct a required annual visit. LPA met with Administrator Jonathan Roberts and informed him of the reason for the visit. From 9:36 a.m. - 11:35 a.m. LPA conducted a tour of the physical plant with Administrator to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was noted: Facility is a two story residence. LPA observed all required postings near the entrance area and the ombudsman poster near the elevator. Emergency Disaster Preparedness plan is current, and forms were posted. The facility provides disaster drills monthly. LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 4/25/2024, and 7/25/24. The facility provided an annual fire alarm test and inspection report as well as an alarm system review and sprinkler check, all done in 2024. Two evacuation stair chairs were observed on the 2nd floor in the common area and in the stairwells. Kitchen: During the facility tour, the kitchen appeared clean and the appliances and fixtures functional. LPA observed sufficiently stocked food storage with two-day perishable and seven-day non-perishables. Food is prepared based on the menu. Snacks including fruit is available in the second-floor activities room and beverages are available for residents in the large dining room as well. Common Bathrooms: LPA observed common bathrooms throughout the facility, which were properly supplied, with required signs and all had functional fixtures and grab bars. Continued on LIC809-C. Common Areas: These included the fitness center, Frannies Ice Cream Shop, and dining areas. The common areas were checked for cleanliness and furniture was observed to be in good condition during time of visit. Surrounding Grounds (Outdoors): LPA observed appropriate outdoor furniture in multiple areas which had umbrellas and shaded area for residents. Parking is available for residents and visitors. Infection Control: The community's policies and procedures pertaining to infection control was reviewed prior to the visit and is appropriate. Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for Medical Assessments, Needs and Service plans, Signed Admission Agreements and Pre-appraisals. There were no issues with resident files reviewed. Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations/and current First Aid. Submission of a newer staff who has scheduled training will be provided to LPA. All required annual and introduction training has been completed. Residents with Special Health Needs: The facility does not accept dementia residents in care. The facility has a license for 120, all may be Non-Ambulatory. The facility does have hospice and home health visits to the facility for residents in care. Hospice waiver approved for 11. LPA interviewed 5 staff. Due to time restraints LPA will need to return at a later date. Exit interview conducted and copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 23, 2025

Allegation investigated: Staff interfered with a resident's medical decisions Staff mishandled a resident's medications while in care Facility Staff failed to provide requested records to designated representative Facility staff failed to provide current medical information to emergency responders

Licensing Program Analyst (LPA) Miller made a subsequent visit to facility on September 3, 2024, to deliver complaint findings. LPA met with Administrator and explained the purpose of the visit. LPAs Olson and Miller conducted an unannounced initial complaint visit to the facility above on January 30, 2024. LPA interviewed staff and residents and obtained relevant documentation. On the allegation: Staff interfered with a resident's medical decisions. It was alleged that Staff changed pharmacy of choice without resident’s (R1) consent. It was alleged that residents have a limited choice in home health services. LPAs Miller and Olson interviewed residents from 1:29 p.m. to 2:35 p.m. The majority of residents interviewed stated that they did not experience staff interference with medical decisions. One resident could not explain how staff was interfering with their medical decisions. None of the residents expressed any concerns about a limited choice in home health services. (Continued on 9099-C) Unsubstantiated Staff (S1) stated that dementia residents are not accepted at the facility. S1 stated that R1 makes their own decisions and confirmed that R1 does not use a cane. S1 stated that there is no obligation to contact the POA for any reason. S1 stated that once residents no longer have mental faculties to make decisions, they may no longer reside at facility. S1 further stated that no prescriptions were delivered from Pill Save to R1. Administrator stated that at no time was R1’s prescription order transferred to Pill Save. Administrator provided prescription order packing slips from Model Drug orders during the period of September 25, 2023, through November 24, 2023. R1’s prescriptions continued to be delivered from Model Drug. There is no evidence to support that R1 prescriptions were filled by Pill Save. Administrator stated that they spoke to residents about using the facility’s preferred pharmacy, Pill Save, as it is it is a local pharmacy that provides 24 hour delivery and more responsive customer service. Administrator stated that a care conference was arranged with residents to express their complaints or concerns. Administrator spoke with residents as well as primary care providers. Administrator stated approximately 40% of residents rolled their prescription order to Pill Save. Administrator stated that residents that wanted to change their pharmacy did so in writing. It was verbally verified that roll-over could take up to a week. Administrator further stated that he provides residents with a menu of 5 local Home Health Services options, but there is no obligation to choose from the 5 presented. 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. On the allegation: Staff mishandled a resident's medications while in care. It was alleged that staff did not follow doctor’s order on prescriptions as R1 was overly medicated and that lorazepam should have been discontinued. It was alleged that the Medication Administration Record (MAR) Reports reflect a sedative was prescribed as a PRN and was not properly recorded by Med Techs. LPA Miller conducted a review of documents including a physician’s letter dated 10/30/2023, requesting that R1 discontinue lorazepam. This request was notated in R1’s file. LPA reviewed all medications in cart for Resident 1 and compared it to the MAR. There is no record of lorazepam being administered to R1 during the period of November 2023 through February 2024 or being over medicated. LPA observed a printout in R1’s file from a hospital visit on 12/20/23 from Sierra Regional Medical Center. (Continued on 9099-C) The printout lists current medications that included the lorazepam, as the hospital had a list of old medication orders on file. There was no evidence to indicate the facility provided lorazepam to R1 after the medication was discontinued. 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. On the allegation: Facility Staff failed to provide requested records to designated representative. It was alleged that Staff did not provide all records as requested by responsible party. Responsible party confirmed they received documents from the facility, but did not feel it was complete based on the number of documents provided. Administrator stated that all requested records were provided to the responsible party. Administrator was unclear what additional documents were being requested. Administrator stated the responsible party acknowledged receipt of the records in December 2023 and no further requests were made. 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. On the allegation: Facility staff failed to provide current medical information to emergency responders. It was alleged that Staff sent R1 to the hospital with an outdated Physician Order for Life-Sustaining Treatment (POLST). During the initial visit, Staff 1 reviewed the emergency services binder at the front desk and R1 did not have a POLST in the file. Staff 1 then reviewed R1’s file and found that R1 had two different POLSTs, but the directives indicated were identical. Administrator stated they remove outdated POLSTs from resident files, to ensure only the most current is in the file. LPA reviewed a copy of R1’s POLST dated 12/18/2023 and only observed one POLST on file. 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. An Exit interview conducted and a copy of this report issued.the state’s words, verbatim · CDSS document, Sep 3, 2024 · control 29-AS-20240122095800

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Miller made a subsequent visit to facility on 9/3/24, to conduct the annual inspection that was initiated on 1/30/24. LPA met with Administrator and explained the purpose of the visit. LPA interviewed staff and obtained relevant documentation. LPA conducted a cursory tour of the facility and visited 3 resident rooms and one vacant room. Rooms are well lit, clean and free of odor. LPA noted that the facility is clean and in good repair, exits are clear and free of all hazards. LPA previously conducted a medication audit and found that Centrally Stored Medication Record (CSMR) and Medication Administration Record (MAR) to be current and accurate. LPA did not find any violations, during the physical tour walk through. LPA conducted 4 of 5 staff interviews, and zero resident interviews. The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2023 and 2024. No citations or violations were issued on this annual inspection. Exit interview conducted, report read, and report printed for Administrator.the state’s words, verbatim · CDSS document, Sep 3, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rankin conducted an unannounced case management visit in response to incident reports received for Resident 1 (R1). LPA met with Jonathan Roberts and explained the purpose of the visit. LPA interviewed staff and residents at the facility. R1 did not need assistance with care and was very independent. CCL received multiple SIRs for R1 in July 2024, alleging falls with injuries, but R1 refused medical attention initially. R1 did eventually agree to go to the urgent care , urgent care told R1 they needed to go to the hospital. Hospital staff, APS, and law enforcement were involved with R1’s case. Although R1 told the facility they fell, other agencies were told by R1 “they jump on my toes while assaulting me.” R1 also stated they had been sexually assaulted but did not provide any additional details or indicate it occurred at the facility, stating it was law enforcement’s job to investigate. Due to the lack of supporting evidence, physical evidence was not collected by the hospital or law enforcement and a case was not pursued. After hospital discharge, facility followed up with R1's physician to get R1 a urgent follow-up visit. Based on this visit R1’s physician wrote an order that R1 should be moved to a psychiatric facility. On 7/18/2024, the administrator and another staff witnessed R1 self-harming and causing injuries to themselves. R1 was transported to the hospital and will be discharged to a higher level of care. Documents collected during visit were Physician Report's for 2012, 2015, and 2023 showing R1's physician noting resident was able to manage their own medication. Facility respected R1's personal rights in wanting privacy regarding R1's independence. When a change in behavior was noted in 2023 facility requested the physician complete a new Physician Report, this did not result in a change in medication management, but facility did their due diligence in notifying primary care of concerns and initiating an updated medical review. Based on resident and staff interviews conducted, no citations were issued on this visit. Exit interview, report given.the state’s words, verbatim · CDSS document, Aug 20, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA's) Jenny Olson and Erika Miller arrived at the facility unannounced to conduct a required annual visit. LPA's were greeted by Administrator and informed them of the reason for the visit. From 10:50-11:50 a.m. LPAs conducted a tour of the physical plant with Administrator and Director of CCRC Operations to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double-story residence that consists of an assisted living unit. LPAs observed fire extinguishers throughout the facility, which were fully charged and last serviced on 4/25/2023. The Administrator provided an annual fire alarm testing and inspection report done on 04/27/2023 where all smoke alarms were tested and functioned properly. LPA observed all required postings near the entrance area. Carbon Monoxide detectors were tested and operational at the time of the visit. Kitchen: During the facility tour, the kitchen appeared clean and the appliances and fixtures functional. LPAs observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Fruit is available in the second floor media room and beverages are available for residents in the large dining room. Bedrooms: During today’s visit, LPA Olson observed ten (10) randomly selected resident units. The resident bedrooms were properly furnished. Bathrooms: LPA Olson observed all bathrooms, which were properly supplied and had functional fixtures. LPA observed non-skid shower floors in all bathrooms. Out of the ten (10) bathrooms observed, two (2) toilets required cleaning. Upon observation, staff cleaned the areas. Continued on LIC809-C. Common Areas: These included the beauty salon, library, activity room, theater, fitness center, Frannies Ice Cream Shop, and dining areas. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Fireplaces were properly screened. Surrounding Grounds (Outdoors): LPAs observed appropriate outdoor furniture in multiple areas which had umbrellas and shaded area for residents. Parking is available for residents and visitors. Infection Control: The community's policies and procedures pertaining to infection control were adequate. Record Review: A review of facility files was initiated. LPA Olson reviewed five (5) of seventy nine (79) Resident files. All resident files were complete. MEDICATION AUDIT: A medication audit for two (2) residents was initiated and the following was observed. The medications were stored in the medication carts, which was locked and inaccessible to the residents. LPAs interviewed 5 residents and one staff. Due to time restraints LPAs will need to return at a later date. Exit interview conducted and copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 30, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) De Leon conducted a follow-up Case Management-Incident visit to the facility above. LPA met with Administrator Jonathan Roberts and explained the purpose of the visit. On 12/26/2023 LPA Olson conducted the initial visit to the facility to follow up on a self reported incident by the facility. LPA Olson collected the following records: Staff Roster, Staff Schedules, R1's LIC 602A Physicians Report, R1's incident reports for 2023, R1's Preplacement Appraisal, R1's Appraisal Needs and Services Plan, R1's Care plan, R1's Admission Agreement, R1's discharge paperwork from Hospital visit on 12/21/2023. LPA's reviewed records and according to R1's LIC 602A Physicians report had no history of suicide/self-harm or depression. According to R1's Care Plan, R1 was an assisted living resident admitted on 08/04/2023 was independent and only had a care plan to assist with medication management, R1 did not need assistance with any other ADL's. R1's death had no indication of neglect or lack of care and supervision by facility. Based on the the evidence the facility is not culpable for R1's death. Facility submitted incident and death reports for R1 to Community Care Licensing (CCL). Facility contacted the following agencies to report the incident CCL, Law Enforcement and Long Term Care Ombudsman (LTCO). Exit interview and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Dec 28, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Jenny Olson conducted an unannounced Case Management - Incident inspection. At 2:27 p.m., LPA met with Administrator Jonathan Roberts and explained the reason for the visit. The reason for today's inspection is to follow up on a self-reported incident report received via email on 12/25/2023. The report pertains to Resident #1 (R1) found deceased from a suspected suicide. An interview was conducted with the Administrator. The LPA also reviewed records and obtained copies of pertinent documents. No immediate health and safety concerns were observed during today's inspection. Further investigation is needed. A referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB). Exit interview conducted, copy of the report was emailed and printed.the state’s words, verbatim · CDSS document, Dec 26, 2023