Casa Dorinda

Type of visit: Required - 1 Year

On 10/26/2023 Licensing Program Analyst (LPA) Brian Phillips arrived at the facility unannounced to conduct a required 1-Year Annual facility site inspection visit at the facility above. When the LPA arrived, they were greeted by Administrator Brian McCague and Senior Director of Health Services Therese Brown. LPA informed the facility representatives of the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This facility is a Residential Care for the Elderly (RCFE) Continuing Care Retirement Community (CCRC) that consists of assisted living, independent living, and memory care portions of the facility. The facility has an age range of 60 years and older for all residents in care. The facility fire clearance is approved for one hundred forty-four (144) non-ambulatory residents. A hospice waiver is approved for six (6) residents. The facility is approved for delayed egress in the memory care unit section of the facility. KITCHEN(S): The facility has 2 main kitchens for residents of the facility in the main dining room building. There are also individual kitchen areas in the memory care segment of the facility and the assisted living segment of the facility. The facility additionally has a kitchen in the “Grill” building which serves as a more casual dining experience for residents. The LPA inspected the kitchen/food service areas and observed that knives/sharp instruments are stored in the kitchen are inaccessible to residents. Kitchen appliances were in operable condition and looked clean/in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last 7 days. Additional perishable food items were maintained on a shelf and/or an extra freezer. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation. Heating devices such as stoves are inaccessible to residents, as are sharps/other items that could constitute a danger to residents. The kitchen(s) were all clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. Continued on 809-C The freezer and refrigerator were both in the appropriate temperate Fahrenheit. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. The freezer and refrigerator were both in the appropriate temperate Fahrenheit. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. COMMON AREAS: At the time of the visit, the main lounge(s) and dining room(s) were observed to be appropriately furnished, with all furniture in good condition. All the lounge areas for residents were appropriately furnished, with all furniture being in good condition. There are multiple fireplaces on the premises, which were all covered and inaccessible to residents. There are numerous rooms for residents such as a billard room, auditorium, and life enrichment center building that includes arts/crafts rooms as well as exercise/gym rooms for residents. The facility maintained a comfortable temperature in all of the separate buildings inspected. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit in each of the buildings inspected. The fire extinguishers in all buildings inspected were fully charged and were last serviced in 2023. The LPA observed required postings throughout all common spaces including Resident Personal Rights and Resident Council Rights. There are activity supplies and equipment, including reading materials for the residents in all common areas inspected. All window screens were in good repair in all the buildings comprising the facility. There is appropriate lighting in all the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all stairways are well-lit with sturdy hand railings/stair chair accessibility devices. As the facility has more than 16 residents and is multiple stories, there is a signal system in place which was functional at the time of the inspection by the LPA. OUTSIDE/LAUNDRY/MISCELLANEOUS: The facility is comprised of a large number of separate buildings for multiple uses, including a life enrichment building with fitness center and art/craft rooms, pool(s) with jacuzzi(s), resident clinic, mailroom, and specific activity rooms such as pottery and jewelry making. There is a main entrance road into the facility and an administrative entrance area for visitors. The facility has fences surrounding the backyard area of the memory care portion of the facility, with electronic combination delayed egress entrances/exits. The facility has an outdoor patio area for residents outside of the resident restaurant grill. The pool/body of water and jacuzzi comply with all safety instructions per the regulations. Outdoor activity spaces and the dining patio for residents are equipped with furniture for resident use. Electronic devices are in place to monitor exits of the memory care building in the facility, if exiting presents a hazard to any resident. Continued on 809-C All outdoor areas with stairways, inclines, ramps, or open porches have accessibility ramps for residents, are well-lit, and have hand railings/grab bars. This is a facility with over 16 residents, therefore there are multiple designated laundry rooms where cleaning products are stored, which are kept locked. The laundry rooms are accessible through the different segmented buildings in the facility including memory care, assisted living, and independent living. There was emergency food and water in a storage room/area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to residents are kept in areas inaccessible to residents. There are multiple first aid kits that include sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport residents are in safe operating condition with appropriate insurance information. BEDROOMS: The facility has resident bedrooms in the memory care, assisted living, and independent living segments/buildings. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are hundreds of designated resident rooms in the facility, with the LPA inspecting multiple rooms in each building that houses residents. The bedroom(s) for residents consist of a restroom in the room, a closet area for storage, a bed, and room for a couch and/or television with furniture. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assistive device such as a wheelchair or a walker. Each room has at the least a chair, nightstand, chest of drawers, and sufficient lighting. Each resident bedroom in the independent living segment of the facility is furnished with a smoke alarm/fire alarm system, emergency call system, and appliances for the residents. RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are non-private restrooms in the common areas of the facility as well as private restrooms in the resident’s bedrooms in specific buildings of the facility. All restrooms inspected by the LPA had assisting equipment for residents including grab bars and/or non-skid surfaces. The bathrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees Fahrenheit. There are an adequate number of toilets and tubs/showers per resident in the facility. Nightlights are installed in the hallways outside of the common area restrooms. Continued on 809-C INFECTION CONTROL: Upon entry to each building, the facility has a central entry point for symptom screening and a sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate isolation rooms if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. The facility maintains COVID-19 Health Care System Mitigation from the California Department of Public Health as well as an Emergency Preparedness Informational Form and Interim Guidance for Outbreak Management in Long-Term Care and Post-Acute Care Facilities. The facility maintains an Infection Control Plan as well as an Emergency Operations Program and Plan Manual with aspects pertaining to infection control. This required annual 1-year facility site inspection visit will need a continuation visit to conclude the aspects of the visit constrained by time limitations. These aspects include Facility Records compromising Staff member files for LIC 501 personnel records, LIC 503 health assessments with Tuberculosis (TB) test results, Personnel Action Notice, Job Description with date of employment, LIC 9052 Employee Rights, LIC 508 criminal record Statements, criminal record clearances, first aid/CPR certification that is not expired, and the appropriate training. Additionally, Resident records need to be reviewed for LIC 603 Pre-Admission/Placement appraisals, LIC 602 Physicians Reports, Consent Forms, Personal Rights for Residents, LIC 601 Emergency Information, LIC605A Release of Medical Information, PRN Authorization, Needs and Services Plan (ANS), Resident Assessments, Mini-Mental State Exam (MMSE) for residents with dementia, Self-management of medications if applicable, Medication Orders, Medication Logs, Advance Directives, Conservatorship Documentation, and Physician Orders for Life-Sustaining Treatment (POLST). Facility medications also need to be audited for a locked centralized storage area for resident medications as well as the Centrally Stored Medication and Destruction Record for residents. No deficiencies cited. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 26, 2023

Allegation investigated: Residents are left in soiled diapers for an extended amount of time Staff do not provide proper medication assistance to residents in care Staff do not have adequate medication training Resident records are not properly maintained

Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint visit to issue final findings for the allegations above. LPA arrived at the facility and announced the purpose of the visit. LPA met with Therese Brown, Director of Health Services. On the allegation: Residents are left in soiled diapers for an extended amount of time. It is alleged that residents have been observed walking around the facility with diapers full of urine and have also been left in soiled diapers overnight. On 04/26/2023, LPA interviewed staff members and residents in the facility. No staff member nor resident confirmed the allegation. Residents interviewed stated they were not left in a soiled state for a long period of time, and staff help when needed. Continued on 9099-C Unsubstantiated Staff interviewed stated they had not observed any residents soiled for a long period of time, and when a resident is soiled staff immediate assist the resident with incontinence care ana clothing change if needed. LPA did not observe any evidence of the allegation while at the facility. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, it is deemed Unsubstantiated at this time. On the allegation: Staff do not provide proper medication assistance to residents in care. It is alleged that staff members do not give residents their correct medications. On 04/26/2023, LPA reviewed the Centrally Stored Medication and Destruction Record for the assisted living portion of the facility. LPA also obtained copies of resident medication records and physician order reports for residents, maintained in each resident’s record/file. LPA observed that all the correct/proper medications were logged as having been given to each resident, and an audit of the actual medications stored in the assisted living portion of the facility matched the records maintained by the facility. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, it is deemed Unsubstantiated at this time. On the allegation: Staff do not have adequate medication training. It is alleged that staff members who assist the residents with medication do not have any training. On 04/26/2023, LPA interviewed staff members and obtained records/documentation of medication training for staff members authorized to dispense medication and/or assist with giving medication to the residents. LPA also reviewed the Training Requirements for RCFEs relating to the hours of medication training required by staff members who assist or dispense medication to residents. Documentation of staff medication training included a competency checklist in setting up medications, assisting with oral/buccal/subdermal/sublingual/eye drop/topical medications, hand washing, assisting with inhalers/nasal sprays etc. The facility switched from an older documentation of medical training for staff to a modern computerized online video software system uniform for all employees. Continued on 9099-C Therefore, the facility has both medication training records from an online source and from the facility itself using qualified trainers. S1 told the LPA that all staff that are required to help with medication for residents undergo a training process that is an online/video system. This program offers online, staff compliance training based on published accreditation standards. It is designed to ensure staff competence and meets OSHA and other regulatory requirements. S1 provided LPA a copy of the manual to the medication training program for staff at the facility. S3 provided information about the training process to dispense or assist with medications for residents. S3 told LPA about the guidelines, shadowing, online learning, procedures, and medication management/assistance that meet Title 22 Regulations. S3 provided LPA a form that staff receive titled 24-hour medication aide training verification form, and multiple certificates of completion regarding medication training. All staff members whose records were reviewed for assisted with medication have documented records of adequate medication training. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, it is deemed Unsubstantiated at this time. On the allegation: Resident records are not properly maintained. It is alleged that that staff members of the facility log incorrect medications and/or physician orders in the resident records. According to interviews, in March 2023 a resident was ordered by a physician to have a medical scan/test at a hospital, but the administrator sent the resident to the appointment with incorrect resident records. This caused the resident discomfort, distress, and a refusal to go back for the scan/test after the administrator corrected the resident records. On 04/26/2023, LPA reviewed electronically submitted physician orders for the resident from 03/24/2023 and 03/29/2023. LPA also reviewed the Requisition for Services for a medical scan/test, and the documented physician report of consultation for the resident from 03/14/2023. All records are properly maintained for the resident by the facility, there are no missing or incomplete records regarding medical scans/tests for the resident. The facility maintains the records of clients in assisted living and memory care in hard copy folders, segmented by document type. LPA reviewed the resident records and they were maintained with all required regulatory and resident information. The information in the documents revealed doctor’s orders for the medical test/scan, and asked that the scan be performed on both legs of R1. Based on interviews and documentation, there was no evidence that the facility provided incorrect information to R1’s doctor about which leg should have been scanned/assessed. Continued on 9099-C Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, it is deemed Unsubstantiated at this time. Exit interview conducted, copy of investigation findings emailed and printed.the state’s words, verbatim · CDSS document, Jun 1, 2023 · control 29-AS-20230420091544

Allegation investigated: Staff is financially abusing residents in care

Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint visit to issue final findings for the allegation above. LPA arrived at the facility at approximately 11:30am and announced the purpose of the visit. LPAs met with Therese Brown, Senior Director of Health Services and Glynn Caberte, Chief Financial Officer.During the visit, LPA conducted in-person interviews on 2/13/2023 from 9:15am through 11:50am and obtained copies of documents pertaining to the investigation. LPA conducted additional interviews with responsible parties and visitors 3/20/2023 from 9:15am to 11am, and responsible party on 3/23/2023 at 9:00am. On the allegation: Staff is financially abusing residents in care. It was alleged that Staff 1 (S1) was financially abusing Resident 1 (R1) and Resident 2 (R2). It was alleged S1 told residents they had financial problems, and R1 and R2 gave S1 money “under the table” to help them out. According to the reporting party, S1 was allegedly moved to the Skilled Nursing Facility (SNF) at the facility due to collecting money from residents (the SNF is not licensed by CCL). Contd. on 9099-C Unsubstantiated Staff interviewed stated they had heard rumors of another staff expressing their financial difficulties to residents. Some staff interviewed were not aware of any residents actually giving staff money. Some staff interviewed stated they had heard stories of staff receiving money from residents on occasion, including if a staff got married. LPAs interviewed R1 and R2 about the allegation. R1 and R2 indicated everything was fine at the facility and did not have any issues, and did not want to discuss the issue further. LPA interviewed other residents, who indicated they had heard rumors of residents giving staff money. LPA interviewed Power of Attorney (POA) for R1 and R2. POA indicated they have total control over the financial of both residents. POA receives credit card statements and bills for the residents and indicated there were no issues with their accounts. On 2/13/2023 from 11:25am to 11:50am, LPAs Brian Phillips and Jenny Olson conducted a collateral visit to the SNF onsite to interview Resident 3 (R3) who was allegedly also financially abused. R3 indicated they had not given staff money but had heard the rumors of staff asking for money and had heard rumors of residents giving it. LPA interviewed visitor of R3, who frequently visited R3. Visitor indicated R3 had shared with them the rumors about S1 asking residents for money, but they never observed it and R3 was never solicited for money first-hand. LPA interviewed responsible party for R3, who indicated R3 needed clothes and S1 bought R3 between $500 to $700 worth of clothes. Responsible party thought S1 may be being taking advantage of R3 for the clothing, and thought S1 may be taking some of the clothing for themselves or resale purposes. However, responsible party stated there was no evidence to confirm these suspicions. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, it is deemed Unsubstantiated at this time. Exit interview conducted. Copy of report sent via email and printed.the state’s words, verbatim · CDSS document, Mar 28, 2023 · control 29-AS-20230209083049

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA's) Cortez and Olson conducted an unannounced infection control annual inspection. LPA's met with Administrator and Senior Director of Health Services around 10:20 AM and explained purpose of the visit. Currently, there are 346 residents living within the community. There are 312 residents residing in Independent Living, 25 residents residing in the Assisted Living area of the community, and 9 residents residing in the memory care unit of the community. LPA's Olson and Cortez took a physical plant tour of the facility with Assisted Living and Memory Care from 10:30 AM to 11:30 AM This facility consists of Independent Living section and Memory Care. Medications are kept in a locked medication room. Main kitchen, dining rooms, various activity rooms were toured. The kitchen was inspected for cleanliness and sanitary condition. The facility has multiple areas spaced to accommodate as much space as possible for social distancing. The staff screen residents for symptoms and temperature at least once a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature.. Continued on 809-C Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility have areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Senior Director of Health Services is in charge of infection control and provides training and education to staff, residents and visitors. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility has plans for delivering medications and meals to any quarantined/isolation resident rooms. Senior Director has a plan in place for when and whom to notify in an outbreak or other emergencies. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in locked cabinets/offices. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. Administrator Certificates are valid. Fire extinguishers were charged and inspected annually. The facility has hardwired smoke and carbon monoxide detectors throughout the facility. No deficiencies were observed during the visit and all infection control policies are being followed. Exit interview conducted. Report issued via email.the state’s words, verbatim · CDSS document, Oct 12, 2022

Allegation investigated: Uncleared staff worked at facility

Licensing Program Analysts (LPAs) Olson and Cortez conducted an initial complaint visit to initiate the investigation. LPAs met with Administrator, Brian McCague, and explained the reason for the visit. On the allegation: Uncleared staff is working at facility. It was alleged that Staff 1 (S1) was working at the facility without fingerprint clearance, starting in December 2021. On 9/21/2022, LPA Kontilis conducted a case management visit to confirm an excluded staff was not present or working at the facility. During that visit, LPA Kontilis reviewed the facility fingerprint clearance roster and determined additional staff were working in the facility without fingerprint clearance, including S1. LPA Kontilis cited for fingerprint clearance on 9/21/2022 and issued a civil penalty. S1 was removed from the facility schedule on 09/21/2022.uintil fingerprint clearance is obtained. Administrator stated S1 was terminated on 10/04/2022. Continued on 9099-C Substantiated Based on the information obtained, this allegation is Substantiated. A citation and civil penalty will not be issued, because this was cited on the 9/21/2022 Case Management Visit. Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Oct 4, 2022 · control 29-AS-20220927134346

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kristin Kontilis made an unannounced case management visit to the facility to follow up on a confirmation of removal notification for one staff, and review fingerprint clearance. Administrator Brian McCague arrived at approximately 1:35 pm. LPA met with Administrator and explained the purpose for the visit. A Decision and Order regarding Staff 1’s (S1's) exclusion from the facility was effective 9/16/2022. Documents were served to S1 and the Licensee on 9/6/2022. In an email dated 9/6/2022, Administrator Brian McCague confirmed S1 was hired on 5/24/2021 and would be terminated as of 9/6/2022. LPA verified S1 was disassociated from the facility’s fingerprint roster. During this visit, LPA obtained a staff roster/schedule and confirmed S1 was not present. Administrator McCague provided termination documentation to LPA to verify S1 was terminated effective 9/6/2022. Based on the evidence obtained during today's visit, the LPA has verified that Individual S1 is not present, employed, or residing at the facility. Verification of removal is complete. LPA observed on the staff roster dated 9/8/2022, ten (10) additional staff did not have fingerprint clearance to work in the facility. In an email dated 9/8/2022, Administrator Brian McCague confirmed three (3) of the staff with pending clearance were still pending and were working in the facility. LPA confirmed through interview and documentation that four (4) staff (S2, S3, S4, S5) were working in the facility prior to receiving fingerprint clearance including S1. On 9/8/2022, Administrator stated in an email, he thought S5 had DOJ clearance and was cleared to work. Administrator Brian McCague stated he thought PIN 20-09-CCLD was still in effect. PIN 20-09-CCLD waived fingerprint clearance requirements during the COVID-19 lockdowns in 2020. However, the fingerprint clearance requirement was reinstated on 7/6/2020 in PIN 20-24-ASC, which states on Page 1 that “background check waivers…are not being extended.” Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D), and civil penalties are issued. Exit interview conducted. Copy of report and appeal rights issued via email.the state’s words, verbatim · CDSS document, Sep 21, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Sep 21, 2022

87355(e)(1) 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, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department… This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the above cited section in 5 of 5 staff (S1-S5) worked in the facility prior to obtaining fingerprint clearance, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 21, 2022

Plan of correction: On 9/8/2022, Administrator submitted a written statement that S1 was terminated; S2 was removed from the schedule. Administrator agrees that staff will not work until they are cleared. POC cleared during visit.

Allegation investigated: Staff failed to ensure resident was supervised while taking a shower. Staff did not wash resident's/residents' hair. Staff is not providing laundry service to resident(s). Staff speaks inappropriately to resident(s). Staff took a personal item(s) belonging to a resident.

On 12/20/2021, Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced subsequent complaint visit to issue final findings for this complaint. LPA met with Jackie Castaneda, Director of Personal Care and Therese Brown, Senior Director of Health Services and announced the purpose of the visit. During the investigation, LPA interviewed seven residents and five staff on January 24, 2020 between 9:45 am and 3:20 pm. On the allegation: Staff failed to ensure resident was supervised while taking a shower and Resident's/Residents' hair was not washed: Residents interviewed stated staff assist them as needed with showers and did not have any issues with showers or other needs being met. Staff interviewed stated they assist residents with showers if they need assistance, including assistance with hair washing. Staff stated some residents only get their hair washed at the beauty salon, based on their preference. Staff interviewed stated residents have the right to refuse hair washing. Staff stated their protocol is not to leave residents alone while in the shower, even if another resident requests assistance. One staff gives one shower at a time to ensure coverage. Staff Please continue to 9099-C, Page 2. Unsubstantiated interviewed stated they have not received complaints about assistance with showers. Based on the information obtained, the allegation is Unsubstantiated at this time. On the allegation: Resident's/Residents' laundry is not being done. Residents interviewed stated their needs were met and had no issues with laundry. Staff interviewed stated they are assigned specific residents to provide laundry assistance. Staff interviewed stated they did not have any complaints from residents about laundry not being done. Based on the information obtained, the allegation is Unsubstantiated at this time. On the allegation: Staff speaks inappropriately to residents. Residents interviewed stated staff speak kindly, respectfully, and have witnessed staff speaking to others with respect. Residents interviewed believed staff met their needs and have not spoken harshly to them. Staff interviewed stated they have not witnessed other staff speak harshly to residents and would report it to a manager if they observed a staff member speaking harshly. Staff interviewed stated they address residents by “Mr.” or “Mrs.” and their last name as a sign of respect. Based on the information obtained, the allegation is Unsubstantiated at this time. On the allegation: Staff stole resident's property. Some residents interviewed stated they have not lost anything while others stated they have misplaced certain items, including scarves and bands. Staff interviewed stated one resident lost their phone as it was left on a bus. Other staff interviewed stated they help residents search for missing property and report anything of value to the police. Based on the information obtained, the allegation is Unsubstantiated at this time. Exit interview conducted. Report issued via email.the state’s words, verbatim · CDSS document, Dec 20, 2021 · control 29-AS-20200117170115

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) K. Kontilis conducted an unannounced onsite one-year infection control annual visit to the above-named facility. LPA met with Brian McCague, Administrator and explained the purpose of the visit. Entrance interview conducted. The facility has submitted a Mitigation Plan to the Department. The Personal Care section of the facility consists of Assisted Living residents. There are 38 apartments in the Personal Care section. There is an entry station at the main entrance. Upon entry, staff, visitors, and residents who have returned from an outing are required to sign-in, complete a symptom questionnaire, and have a temperature screening at least once a day. All documentation is kept in log books located in the Nurse’s station on the second floor and near the lobby on the first floor. The entry station has PPE gear, hand sanitizer, disinfecting wipes, and a thermometer. LPA toured facility with Administrator. This facility is licensed for 325 residents, 30 of the 48 acres of the property are buildings consisting of residents’ apartments, dining areas, library, game room, music room, Pacific room, a life enrichment building (arts and craft studios and health and fitness studios) and outdoor common spaces and patios. The facility license includes independent living and assisted living at this time. The independent living area has 228 apartments. Independent living includes villas, cottages, and apartments. There is one outdoor pool surrounded with a locked gate and fully fenced. The pool is located on the southwest corner of the property near the Medical Center (Skilled Nursing facility). A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. Exit interview conducted. No deficiencies noted. No citations issued. Copy of report issued via email.the state’s words, verbatim · CDSS document, Oct 12, 2021

Type of visit: Case Management - Licensee Initiated

Licensing Program Analyst (LPA) Kristin Kontilis conducted an announced Case Management visit with Administrator Brian McCague. The purpose of the visit was to inspect existing Assisted Living (AL) recently remodeled apartments and newly constructed Independent Living (IL) villas, cottages, and apartments. LPA inspected 17 remodeled apartments converted from 21 pre-existing studio apartments in the AL unit. There are 10 one-bedroom apartments and 7 studio apartments. Each apartment has at least one private bathroom with sink, toilet, shower, and grab bars. The AL unit consists of a nurses’ station with a locked medication closet, lobby, movie theatre, fitness room, and living room. Residents’ records will be kept in the locked medication closet. A locked medication cart will be kept in the nurses’ station. Fire clearance has been approved for a capacity of 17 non-ambulatory residents. LPA inspected 7 villas, 5 cottages, and 6 apartments in the IL wing of the campus. Each residence has a minimum of two full bathrooms, a laundry room, and a full kitchen. The bathrooms have a sink, toilet, shower, and grab bars. The laundry rooms are equipped with washers and dryers. The kitchens are equipped with stove, refrigerator, dishwasher, microwave, and a sink. Each residence has a private patio or a balcony. The IL unit with 5 cottages and 6 apartments is a two-story building with underground parking. The fire clearance has been approved for 22 non-ambulatory residents. The fire clearance for seven (7) villas has been approved for 14 non-ambulatory residents. All units throughout the campus have carbon monoxide/smoke alarms that are hard wired and are monitored by Santa Barbara County Fire Department. All units throughout the campus have a nurse-call system in each bathroom and each bedroom. All public bathrooms throughout the campus have a nurse-call system. LPA determined that the facility campus is in compliance with Title 22 regulations at this time.the state’s words, verbatim · CDSS document, Aug 24, 2021