Casa De Manana

Type of visit: Case Management - Incident

Licensing Program Analyst(LPA) Janet Ngallo conducted an unannounced case management - incident visit. LPA was greeted by and discussed the purpose of the visit to Executive Director Marivel Johnson. This visit is in response to the self-reported incident submitted to the department on 09/01/2026 regarding a resident(R1) found sitting in a hot tub and unresponsive to verbal stimuli. R1 was sent to the hospital for evaluation. Interviews and records review revealed that R1 was independent and did not require supervision. R1 experienced a change in condition and was brought back to the facility on hospice. No deficiencies were cited during the visit. An exit interview was conducted with Executive Director Marivel Johnson and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, Sep 25, 2026

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Janet Ngallo and Patrice Bazemore conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPAs was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) Marivel Johnson. The facility's license shows a maximum capacity of 249 residents, 85 of whom may be non-ambulatory. Additionally the facility is approved for twelve (12) hospice waivers and approved for twelve(12) bedridden waivers. During today’s inspection there were 212 residents in care. Note, LPAs did step out for lunch from 12-1pm. LPAs, and ED Johnson toured the interior and exterior of the facility and inspected a sample of occupied and unoccupied rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at sampled taps accessible to residents were all compliant. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and residents activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. The facility is undergoing a remodeling of their main kitchen and a temporary mobile kitchen was developed is being used during construction. [Continued from LIC 809] No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. The facility maintains two (2) separate medication rooms and LPA examined the one belonging to the Casa Loma building and in the wellness center.. One pool does exist on the premises and LPA observed it to feature a secured perimeter as required per regulation. Additionally the facility features a small fountain display in an open courtyard, though no pool or body of water is part of it, thus not making it a drowning risk. Per ED Johnson, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months -- dated for August 2026. Last staff emergency drills were conducting on 05/05/2026. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed residents and staff, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with ED Johnson to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Sep 10, 2026

Allegation investigated: Staff did not provide the resident with appropriate sleeping accommodations. Staff did not prevent the spread of scabies for residents in care.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above-mentioned allegations. LPA identified themselves and met with Executive Director Marivel Johnson to discuss the purpose of the visit and elements of the complaint. On 07/23/2026, it was alleged that staff did not provide the resident with appropriate sleeping accommodations, and that staff did not prevent the spread of scabies for residents in care. The department's investigation consisted of interviews, records review, and LPA observations. [Cont. on LIC 9099-C] Unsubstantiated [Cont. from LIC 9099] Regarding the allegation that staff did not provide the resident, (R1) with appropriate sleeping accommodations, R1 had an unconfirmed contagious skin condition, and the facility took precaution under physician recommendation by following infection control protocols, including accommodating the request for R1's mattress to be washed. interviews reported that temporary beds are available on site and are typically set up by housekeeping or maintenance staff. Staff interviews indicated that R1 was offered multiple options for temporary accommodations while their bedding was being cleaned, including relocation to another furnished room, which R1 declined. Staff reported that the temporary bed was provided while R1’s mattress was being cleaned and dried, and no concerns were raised by R1 at the time. Interviews could not confirm who exactly set up R1's temporary bed. Additional staff interviews reported knowledge of how to properly setup the temporary bed. LPA, accompanied by the Executive Director, observed a storage room with multiple roll away beds for temporary use. LPA observed Executive Director and housekeeping staff demonstrate the setup of the temporary beds, and LPA observed the bed with a mattress, and black cot. The cot appeared sturdy and properly assembled, with no safety concerns observed. Regarding the allegation that staff did not prevent the spread of scabies for residents in care, more specifically, that residents were not notified of the potential outbreak, interviews revealed that several residents experienced symptoms within the same timeframe, however, no confirmed outbreak was identified by public health, and cases were treated based on visual assessment by medical providers. Staff interviews confirmed that environmental cleaning, laundering of clothing, bagging of linens, use of Personal Protective Equipment (PPE), and disinfection procedures were conducted according to guidance provided by public health and medical providers. Maintenance and housekeeping staff confirmed following protocols, including bagging items for the recommended duration and witnessing cleaning companies assist with environmental disinfection. Interviews with residents reported receiving notifications in their mailboxes informing them of potential cases, preventive steps, and cleaning schedules. [Cont. on LIC 9099-C pg. 1] [Cont. from LIC 9099-C] Records review revealed that the facility submitted an incident report to the department regarding the potential outbreak and consulted with public health, which determined no additional follow-up was required unless a significant increase in cases occurred. Records also confirmed that two written notifications were provided to all residents, advising them of potential cases, cleaning plans, and prevention measures. Invoices reviewed showed professional cleaning services for affected apartments and common areas, and records review revealed orders of mite-control spray. Review of the facility’s infection control plan showed established procedures for outbreak response, PPE use, and environmental cleaning. LPA observed PPE supply carts available at the facility containing infection control items such as gloves, gowns, shoe covers, hand sanitizers, and masks. Based on interviews, records review, and LPA observations, the preponderance of evidence standard has not been met, therefore, these allegations are found to be unsubstantiated. An exit interview was conducted with Director of Health Services Ada Navarrete and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, Jul 30, 2026 · control 08-AS-20260723132831

Allegation investigated: Resident is being over charged for smaller accomodations. Staff are not following resident's admission agreement.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above mentioned allegations. LPA identified themselves and met with Executive Director Marivel Johnson to discuss the purpose of the visit and elements of the complaint. On 06/17/2026, it was alleged that a resident(R1) is being overcharged for smaller accommodations, and that staff are not following R1's admissions agreement. The department's investigation consisted of interviews and records review. [Cont. on LIC 9099-C] Unsubstantiated [Cont. from LIC 9099] Regarding the allegations, interviews reported that residents temporarily relocated during the elevator outage were not charged for two rooms, even when belongings remained in their original apartment. Interviews stated that relocation was offered at no additional cost, and residents were informed of available accommodations such as wellness checks, personal assistance, meal delivery, mail delivery, and transportation support. Staff stated that rate adjustments or refunds were not authorized due to residents occupying two rooms. Staff also stated that the resident was offered assistance transporting personal belongings to their temporary apartment, and offered the option to bring R1's bed down to the temporary apartment as well. Interview with R1 reported paying the one bedroom rate while temporarily relocated to a studio due to the elevator outage. R1 expressed frustration that a reduced rate or reimbursement was not provided for the inconvenience, and reported difficulty accessing belongings left in the original apartment. R1 confirmed being offered assistance and the option to bring belongings to the temporary apartment, but declined. Review of the admissions agreement showed a section permitting substitution of apartments when necessary due to emergencies, lawful orders, or reasonable purposes determined by the licensee. The agreement states that residents will pay the monthly fee applicable to the substituted apartment. Review of the resident’s medical assessment and preplacement appraisal confirmed mobility limitations affecting the ability to use stairs during the elevator outage. Based on interviews and records review, the preponderance of evidence standard has not been met, therefore the above allegations are found to be unsubstantiated. An exit interview was conducted with Executive Director Marivel Johnson and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, Jul 14, 2026 · control 08-AS-20260617114316

Allegation investigated: Licensee does not ensure elevator is in working order.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above mentioned allegation. LPA identified themselves and met with Executive Director Marivel Johnson to discuss the purpose of the visit and elements of the complaint. On 06/09/2026, it was alleged that the licensee does not ensure that the facility elevator is in working order. The department's investigation consisted of interviews and records review. [Cont. on LIC 9099-C] Unsubstantiated [Cont. from LIC 9099] Regarding the allegation, interviews with staff reported that the elevators have had intermittent issues historically and were repaired as problems occurred. Staff stated that when an elevator was unexpectedly out of service beginning in May 2026, an elevator vendor was contacted, parts were ordered, and notifications were provided to residents and families. Staff stated that residents who wished to relocate were offered temporary rooms, and accommodations such as wellness checks, personal assistance, meal delivery, mail delivery, and transportation support were provided. Staff stated the elevator was restored to service once repairs were completed and cleared by the appropriate inspector. Interviews with residents reported that the elevator outage lasted several weeks and caused inconveniences. Residents stated the facility offered relocation options, provided meal delivery and mail, and communicated updates through written notices and meetings. Some residents expressed frustration with the duration of repairs and the impact on daily routines, but also stated that staff were helpful and attentive during the outage. Review of elevator permits showed valid certification for operation. Review of inspection and maintenance invoices from the elevator service company indicated regular quarterly maintenance and identified items requiring repair, including electrical and mechanical components. Review of repair proposals showed scheduled replacement of aging parts, including generators and other components. Review of facility notifications confirmed written communication to residents regarding elevator outages, expected timelines, available accommodations, and updates on repair progress. During a facility tour, LPA observed elevators in the affected buildings to be operational. LPA also observed the availability of a stair-assist chair for mobility support. Based on interviews, observations and records review, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. An exit interview was conducted with Executive Director Marivel Johnson and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, Jul 14, 2026 · control 08-AS-20260609151807

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management visit to follow up on a resident death reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Ada Navarrete, Director of Health Services. Community Care Licensing received a Death Report on 4/22/26 in which it was reported that a resident (Identified as R1) had passed away on 4/19/26 following an unwitnessed fall and being sent out to the hospital. Per the report, R1 was found by the side of their bed with their nose bleeding and a hand laceration and complaint of pain. Emergency personnel was called due to head trauma and hospice was notified by facility staff. R1 was transported to the hospital where R1 later passed away with a diagnosis of closed wedge compression fracture of T4 and T7 Vertebrae . During today's visit, LPA conducted file review and interviews, and provided consultation with Navarrete, Director of Health Services. Per review of R1's records, R1 was able to come and go from the facility unsupervised. At this time, LPA observed no immediate health and/or safety concerns and no deficiencies were cited during today's visit. Additional visits and follow-up may be necessary for complete review of this incident based on additional information from the Death Certificate once obtained. An exit interview was conducted with Ada Navarrete, Director of Health Services to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Apr 24, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to inspect the facility for an increase in bedridden capacity from zero (0) to twelve (12). LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director Marivel Johnson. On September 12th, 2025, the licensee submitted an application (LIC 200) and Facility Sketch (LIC 999) to request an increase of their bedridden capacity from zero (0) to twelve (12) residents. Fire Safety Inspection Request was approved by the local Fire Marshal on January 15th, 2026, which granted the bedridden capacity to increase from zero (0) to twelve (12). Per the inspector, bedridden may reside throughout the facility property with special staffing and emergency operational considerations required per proposed resident unit. LPA, along with Executive Director Johnson, conducted a walk-through of the Casa Loma building, where one (1) bedridden resident currently resides. Facility sketch provided by the Fire Marshal was consistent with the current layout of the facility, and no issues were noted by LPA. This portion of the application process is complete and will be forwarded to management for final review and approval. The Licensee will then be notified of managerial approval by phone and the new license will be mailed to the Licensee. No deficiencies were cited during today's visit. An exit interview was conducted with Executive Director Johnson to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jan 26, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) Marivel Johnson. The facility's license shows a maximum capacity of 249 residents, 85 of whom may be non-ambulatory. Additionally the facility is approved for twelve (12) hospice waivers. During today’s inspection there were 222 residents in care. Note, LPA did step out for lunch from 12-1pm. LPA, ED Johnson, and Director of Environmental Services Arturo Vega toured the interior and exterior of the facility and inspected a sample of occupied and unoccupied rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at sampled taps accessible to clients were all compliant: Bathroom sink in a unit of the Villas building was read at 105.6F and water temperature in a bathroom sink of the Casa Loma building read at 106.8F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. The facility is about to undergo a remodeling of their main kitchen and a temporary mobile kitchen was developed and will be used during construction. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. The facility maintains two (2) separate medication rooms and LPA examined the one belonging to the Casa Loma building. One pool does exist on the premises and LPA observed it to feature a secured perimeter as required per regulation. Additionally the facility features a small fountain display in an open courtyard, though no pool or body of water is part of it, thus not making it a drowning risk. Per ED Johnson, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. During the tour of the property, LPA observed fire alarms being tested in the Cottages building. Fire extinguishers were serviced within the last 12 months -- dated for August 2025. Last staff emergency drills were conducting on 9/10/25 for the topics of fire and earthquakes. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed zero (0) staff and three (3) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with ED Johnson to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Sep 25, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on a series of incidents reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Director of Resident Services (DRS) Coco Feng. Within a 2 week period (July 7th-21st, 2025), Community Care Licensing received four (4) incident reports regarding three (3) separate resident falls, with one (1) resident falling twice within that period. That resident, (identified as R1) had an unwitnessed fall on 7/7/25 in their unit, resulting in a head injury requiring staples. R1 had another unwitnessed fall in their unit two (2) weeks later on 7/21/25, but sustained no acute injuries, per the report. The next resident (identified as R2) had an unwitnessed fall in the dining area on 7/15/25, resulting in an upper extremity fracture. The final resident (identified as R3) had a fall in their unit on 7/17/25 and it was reported to staff by R3's spouse. Per the report, R3 refused emergency transport and was driven by their spouse to the hospital where a hand fracture was discovered. Emergency services were contacted for R1's and R2's falls, and responsible parties and Primary Care Physicians (PCPs) were notified for R1, R2, and R3. During today's visit, LPA conducted file review, a health and safety visit with R1 and R3, and provided consultation with DRS Feng. LPA was informed that R2 remains out of the community at this time. R1 is an identified fall risk and file review and interviews revealed implementation of actions taken to reduce/mitigate risk. Initial fall encounter for R2 and R3. No Deficiencies were cited during the visit. An exit interview was conducted with Director of Resident Services Feng to whom a copy of this report was provided. Their signature below confirms receipt of this document.the state’s words, verbatim · CDSS document, Jul 28, 2025

Allegation investigated: Staff is financially abusing a resident while in care

Licensing Program Analyst (LPA)Tiffany Holmes contacted the facility to deliver findings for a complaint investigation via tele-virtual. LPA identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Marivel Johnson, Executive Director. LPA previously conducted interviews with residents, staff, and outside sources, made observations, and obtained and reviewed pertinent records. LPA conducted the initial visit on March 20, 2025 and conducted a tour of the facility. It was alleged that the staff is financially abusing a resident while in care. Interviews and review of medical records revealed that Resident 1 (R1) did not have any cognitive impairment, and did not require assistance with money or activities. Interviews with R1 revealed the person they loaned the money too was a long time family friend. Interviews revealed that it was a loan, and that the person also gave R1 a rolex watch to hold on to as collateral until the loan was paid back to them. Interviews revealed that facility staff was made aware of the incident when the police came to the facility. Unsubstantiated Continued on LIC9099-C page. Interviews with staff revealed that the person R1 went to the bank with and loaned the money too was a former employee. Interviews revealed that at the time of the incident the employee had been off of work on Workers Compensation for an undisclosed amount of time. Interviews with staff revealed they interviewed R1 and they stated they knew this person for a long time and that they felt comfortable loaning the money to them. Interviews also revealed a date the family friend/staff will pay R1 back. Interviews revealed R1 was supposed to receive a cashiers check for 7 thousand dollars on 4/5/2025. Interviews with the Executive Director revealed the resident showed them a check for half of the money. Interviews also revealed that the remaining balance would be paid back/ paid off on or before 5/31/2025. Interviews revealed that on 5/31/2025 the administrator called LPA Holmes and advised LPA that the full amount of money that had been borrowed had been paid back in full to the resident. Interviews with outside sources revealed they were worried about the transaction as well. The police were called and they came and took a report after speaking with R1. Outside resources revealed that the resident is able to make financial decisions and did not have any restrictions. The Department has investigated the above-mentioned allegation and based on interviews, LPA observations, and records review, it was determined that the complaint allegation is Unsubstantiated. 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 Executive Director Marivel Johnson via face time and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided via email. An electronic email read receipt confirms the documents were received.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 08-AS-20250313133703

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Rita Moreno Director of Health Care Services & Brian Care Supervisor to whom LPA discussed the purpose of the visit. According to the facility’s license, the facility has a maximum capacity of two hundred and forty nine (249) elderly adults. During today’s inspection, two hundred and eleven(211) residents were at the facility. LPA, accompanied by the Director of Health Care Services, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was comfortable. Hot water temperature in residents' rooms were measured between 105 degrees Fahrenheit and 119.5 degrees Fahrenheit through a sample of Assisted Living units and Independent Living units. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] The pool area on the premises was locked. Per Administrator Director of Health Care Services, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher has been serviced. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff present and residents at the facility during the visit. LPA reviewed multiple staff and resident records/files. Files reviewed contained required documents. Confidential records were stored in locked areas. Director of Health Care Services presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Rita Moreno Director of Health Care Services & Brian Care Sup to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 11, 2024

Allegation investigated: Staff mishandled the residents medications Staff do not take universal precautions while providing care Staff do not properly maintain the facility Staff did not prevent a resident from wandering Resident sustained an unexplained injury while in care Staff did not ensure a resident consumed an appropriate amount of fluids while in care Staff did not meet a resident's incontinence needs while in care

Licensing Program Analyst (LPA) Tiffany Holmes conducted a complaint investigation visit to deliver findings for the above-mentioned allegations. LPA met with Catherine Sullivan, Executive Assistant & Rita Moreno, Director of Health Services and shared the findings. The Department’s investigation consisted of interviews and records review. It was alleged staff mishandled the residents medications . Interviews revealed that the staff carry a secured case that holds the residents medications. They deliver the medications to each resident from a pre poured cup. The staff wear gloves and sanitize/wash their hands when working with the medications and while dispersing them. Interviews revealed the staff give the residents the medications and make sure the residents have something to drink along with taking the medications. It was also alleged that staff do not take universal precautions while providing care. (continued on LIC 9099-C) Unsubstantiated Interviews revealed the facility staff use universal precautions while working at the facility. The residents clean and sanitize the counter areas and flooring and tables along with anything else that needs to be sanitized. The staff wear gloves to be safe and masks as well. The gloves are worn while dispensing medications, changing residents, and assisting residents with incontinence. It was alleged that staff do not properly maintain the facility. Interviews revealed the staff clean and maintain the facility. The facility uses bleach or antibacterial wipes for disinfecting surfaces and cleaning in the resident rooms. Interviews did not report any odors in the facility. It was alleged that staff did not prevent a resident from wandering. Interviews revealed most residents are able to leave the facility unassisted. The residents that are not allowed to leave on their own are supervised and live in the assisted portion of the facility. The staff redirect the resident they know that usually wander. When a resident does wander off from the facility the staff will look for the resident and bring them back and file a report of them AWOLing. At the time the complaint came in there were no AWOLs reported nor did any happen. It was alleged that the resident sustained an unexplained injury while in care. Interviews revealed around the time the complaint in, there were no incidents reported to the facility staff regarding any residents having or sustaining any injuries while in care. When there is an incident that takes place the staff immediately notify the family, then they put it in writing, how the incident took place and then after the staff report it, they complete the electronic report and a fax to the doctor, then the report will go to the director of health services and then they review and make sure all the charting and details are there and that the staff have notified all responsible parties. Director of residents services will put out any reports if it verified that the resident has had an injury. They document when the resident come back to the facility and the nurses will chart again how they are feeling and anything that is observed. It was alleged that staff did not ensure a resident consumed an appropriate amount of fluids while in care. Interviews revealed the facility staff continuously offer resident fluids to keep them hydrated. The residents that have been diagnosed with major neuro cognitive disorder need constant reminders to drink. The facility has water stations around and the residents can grab water on their own and for the others they are offered the water throughout the day. Interviews revealed each caregiver at the beginning of their shifts they check 6 items to make sure the residents are okay, they make sure they have water, have their pendant on, their remote, have their tray table close to them and if they need to be repositioned and toileting. It was alleged that staff did not meet a resident's incontinence needs while in care. Interviews revealed the residents that are incontinent are assisted with their toiletry needs. The residents are changed timely and once they request needing a change they are changed as soon they are notified which is included in each round. Due to lack of corroborating evidence, the findings regarding the above allegations were established to be unsubstantiated. This finding means although the allegations may have happened or could be valid, there is not a preponderance of evidence to prove that the alleged violations occurred. LPA Holmes conducted an exit interview with Catherine Sullivan, Executive Assistant & Rita Moreno, Director of Health Services and they were provided with a copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058 03/22) and their signature on this report acknowledges receipt of the rights.the state’s words, verbatim · CDSS document, Jul 2, 2024 · control 08-AS-20220920143303

Allegation investigated: Facility does not provide reasonable accommodation for resident to receive phone calls. Facility failed to provide food of good quality.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude a complaint investigation regarding the above-mentioned allegations. LPA Correia was greeted by Marketing Receptionist Wilson, identified herself and met with Executive Director (ED) Kurt Norden and explained the purpose of the visit. The Department’s investigation consisted of facility, outside source, and resident records reviews. The investigation also included outside source and staff and interviews. It was alleged the facility did not provide reasonable accommodations for Resident (R1) to receive phone calls. A resident records reviews revealed R1 was admitted to the facility on September 30, 2011, with a primary diagnosis of Hypertension and Congestive Heart Failure (CHF). R1 resided in a private room located in the independent unit of the facility. An interview conducted with the ED revealed resident rooms all have a personal land line with their own phone number. Unfounded It was also revealed that staff had no control over phone calls made or received by residents in care. An interview conducted with an outside source 1 (OS1) revealed R1 would screen their calls due to receiving calls from an individual that would cause them to become distressed. It was also alleged the facility failed to provide food of good quality. Records reviews of facility, resident, and an outside source agency revealed R1 had experienced a decline in health and on March 13, 2020, R1 was placed on Hospice. An interview with the ED and Staff 1 (S1) revealed at the time of the complaint due to the COVID-19 pandemic facilities had ceased communal dining and facility staff began delivering residents three meals a day with an option of two choices. A facility records review revealed the meals offered were of nutritional value. Additionally, a resident record review dated, December 3, 2020, disclosed R1 experienced a change in condition and hospice was also treating R1 for anorexia due to a lack of appetite. The records also disclosed R1 did not require a special diet, however due to their lack of appetite R1’s meals were to be reviewed by a caregiver. R1’s Responsible Party (RP) requested no changes to be made to R1’s care plan. [See LIC 811 for Confidential Names] Based on records reviews and interviews, the above-mentioned allegations were determined to be unfounded, meaning that the allegations were false, could not have happened and/or were without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with ED Norden who was informed they will be provided a copy of this report and Licensee Rights (LIC 9058), whose signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Mar 26, 2024 · control 08-AS-20201215143254