Casa Dorinda

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during Complaint Control #29-AS-20260714150634. The Case Management visit is being conducted to address CCLD’s concerns that were observed during the course of the investigation. LPA Kontilis met with Administrator Brian McCague and explained the purpose of the visit. Therese Brown, Senior Director of Health Services participated in the visit. During the complaint investigation, interviews conducted and records reviewed revealed on 7/7/2026 an altercation between two residents occurred resulting in Resident 1 (R1) sustaining a skin tear injury. Record review revealed the incident was not reported to Community Care Licensing Division (CCLD) as a Serious Illness/Serious Injury report and/or a SOC341 Report for Suspected/Alleged Dependent Adult/Elder Abuse as a “resident on resident” altercation. Staff 1 (S1) stated they were not aware that such reports were not required to be submitted to CCLD. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Copy of report and Appeal Rights issued via email.the state’s words, verbatim · CDSS document, Jul 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jul 20, 2026

87211(a)(1)(D) Reporting Requirements:(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to…(1)(D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: This requirement was not met as evidenced by: Based on record review and interviews conducted, the licensee did not comply with the section cited above when the facility did not submit a written incident report to CCLD within 7 days, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 17, 2026

Plan of correction: Administrator agrees to submit a written statement acknowledging CCR 87211 in its entirety via email directly to LPA no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Upon arrival, LPA was greeted by Therese Brown, Senior Director of Health Services and explained the purpose of the visit. Executive Director Brian McCague participated in the inspection. The facility is a Continuing Care Retirement Community (CCRC) that consists of Independent Living, Assisted Living, and Memory/Dementia Care. The facility is licensed for a capacity of 360 residents of which there can be 144 non-ambulatory residents and a hospice waiver for six (6) residents. There are zero (0) residents currently on hospice. Entrance interview conducted. LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors, and floor coverings throughout the facility were checked. The facility was seen to be in good repair inside and outside. LPA observed eight (8) fire extinguishers last serviced on 5/21/2025. There is a fire pull alarm system with pull alarms throughout the facility. The pull alarms ring directly to the local fire department. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. At approximately 12:20 pm, LPA conducted a tour of the facility’s dining areas. LPA observed The Grill, an eatery consisting of patio seating, indoor/outdoor seating, and barista style seating. Lunch and dinner are served Wednesday through Sunday. The Grill’s dining capacity is 80. Please continue to 809-C, Pg 2. LPA observed the main dining room includes indoor seating and an outdoor dining area. Breakfast is served in the formal dining area seven days/week including a morning brunch one day/week, lunch is served two days/week including the morning brunch one/day/week; and dinner is served six evenings/week. The facility’s dining services also include a “Take-Out Buffet” which consists of “grab and go” seven days/week from 7:30 am through 6 pm. Director of Dining Services stated the facility receives food deliveries each day of the week. LPA observed a sufficient amount of perishables for two days and seven days of non-perishables. Each level of care has its own activity calendar although residents from all levels are welcome to participate in all activities. Activities include outings to parks, restaurants, museums, theaters, scenic drives, sports activities, and other local attractions. The Life Enrichment program covers the seven dimensions of wellness including spiritual, physical, emotional, vocational, intellectual, social, and financial topics. The facility maintains a close relationship with local music and art organizations aimed to enhance the residents’ experience. Residents have access to an in-house television station that includes documentaries, self-help programs, movies, and guest speakers. Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Medication Administration Records (MARs). On 9/17/2025, CCLD received LIC624 Unusual Incident/Serious Injury Report stating on 9/15/2025, Resident 1 (R1) was administered the wrong medication during the morning medication pass. The incident report states Staff 1 (S1) handed R1 the wrong medication container containing four (4) medications. The incident report states R1 “self-administered medications” before S1 was able to intervene. The incident report states S1 completed additional training on proper medication administration. S1 was scheduled for oversight medication pass by Staff 2 (S2), however S1 decided to return to their previous role and decided not to resume a role to include medication administration. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D). Due to time restraints, LPA will return at a later date to continue the inspection. Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Oct 8, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management visit to the facility in response to an incident/death report received on 2/18/2025. LPA met with Brian McCague, Administrator, Therese Brown, Senior Director of Health Services, and Nicole Caines, Director of Personal Care and explained the purpose of the visit. LPA toured the Assisted Living building and obtained relevant documents for Resident 1 (R1). LPA conducted interviews from 1:45 pm through 2:45 pm with Administrator, Senior Director of Health Services, and Director of Personal Care about R1. On 2/19/2025, LPM Burley interviewed Therese Brown, Senior Director of Health Services by phone. The Santa Barbara County Sheriff’s Department was also contacted. Based on the information obtained through record review and interviews, there was no evidence found to suggest neglect or lack of supervision resulted in or contributed to R1’s death, at this time. No citations will be issued at this time. Exit interview, copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Feb 20, 2025

Type of visit: Required - 1 Year

On 10/23/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility above to conduct an unscheduled, required inspection evaluation visit. When the LPA arrived, they were greeted by Senior Director of Health Services Therese Brown. LPA informed facility representatives of the reason for the visit upon entry. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE) Continuing Care Retirement Community (CCRC). This facility is approved for a maximum capacity of three hundred and sixty (360) residents. Of these residents, one hundred and forty-four (144) may be non-ambulatory. The facility has an approved hospice care waiver for six (6) residents in care. The facility is approved for delayed egress entry and exit in the memory care unit of the facility. The LPA inspected the food service areas in the facility including two (2) main kitchens for residents of the facility in the main dining room building. There are also individual kitchen areas in the memory care unit of the facility and the assisted living area of the facility. The facility additionally has a kitchen in the “Grill” building which serves as a more casual dining experience for residents. LPA observed that knives/sharp instruments are stored in locked drawers inaccessible to residents. All appliances were in operable condition and looked clean/in good repair. Appliances such as microwaves, refrigerators, stoves, etc. are clean and operating properly. Food utensils, dishes, glasses, etc. are clean and in good repair with no cracks or chips. Furniture is room/resident appropriate, clean and in good repair. All rooms are appropriately furnished for their intended use such as bedrooms, dining rooms, kitchens, living rooms, etc. Hot water temperature is maintained between 105-120 degrees Fahrenheit as per Community Care Licensing (CCL) Title 22 regulations. Outdoor activity spaces have shaded areas and furnished for outdoor use. Each resident has an adult bed with a mattress, pad, bedsprings, and pillow, which are clean and in good repair. Each bed is fitted with sheets, pillowcase, blankets, and bedspread that are clean and in good repair. Continued on 809-C Each resident has adequate dresser and closet space for clothing and other belongings that includes at least two drawers or adequate dresser space. The facility has a sufficient supply of linens to permit weekly changing or more often to always insure clean linens for residents. Equipment and supplies for resident personal hygiene is available and on site. Activity supplies are available for residents. As the facility has an approved fire clearance for hundreds of residents, there is a signal system required and observed by LPA. Refrigerators and freezers are maintained at an appropriate temperature Fahrenheit as per CCL regulations. Food storage and preparation areas, including pantries, cupboards, counters, etc., are clean and appropriate for food preparation. The food service areas are 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. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. Multiple locked storage areas for central storage of medications were observed by LPA, depending on the area of the facility. Cleaning supplies are kept in areas separate from where food supplies are stored. Walls, ceilings, floors, carpeting, window screens, and areas around the facility are clean, painted and/or in good repair. There are locked storage area(s) for poisons, toxic, cleaning solutions, disinfectants, etc. Fire extinguishers and smoke detectors operate properly. Doors and passageways are unobstructed. There are no pools/bodies of water on the physical plant of the facility as observed by LPA. During the inspection, LPA did not observe any firearms that would require trigger locks, locked and inaccessible, or firing pins removed. At the time of the visit, all common areas/interior rooms of the facility were observed to be appropriately furnished, with all furniture in good condition. There are multiple fireplaces on the premises, which were all covered and inaccessible to residents. The facility contains common areas such as a billiard room, auditorium, and life enrichment center building that includes arts/crafts rooms as well as exercise/gym rooms for residents. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguishers were fully charged and are serviced annually. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity materials in the common areas of the facility in good repair and operating condition. The facility maintained a comfortable temperature in all areas inspected. 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 changes in incline are well lit with sturdy hand railings/stair chair accessibility devices. All window screens were in good repair. Continued on 809-C There is a pool area in the facility, which is appropriately fenced and gated with adequate supervision. LPA did not observe any noticeable outdoor hazards. Outdoor activity spaces in the facility are shaded and equipped with furniture for resident use. All outdoor areas with stairways, inclines, ramps, or open porches have accessibility ramps for residents, and are well-lit. The facility has adequate storage of additional supplies/emergency supplies. The designated laundry area in the facility has appropriate storage of cleaning products, which are kept locked and inaccessible to residents. Emergency food and water in storage were observed to be in good condition by the LPA. Cleaning supplies, disinfectants, and other items that could pose a danger are kept in areas inaccessible to residents. Vehicles used to transport residents are in safe operating condition with appropriate insurance information. The facility is comprised of many 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. The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms in the facility were sufficiently stocked with soap, paper towels, required postings, and clean trashcans with closed lids. Towels and washcloths are not shared by residents in the facility. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per Title 22 regulations between 105-120 degrees Fahrenheit. There are an adequate number of toilets per residents in the facility. Nightlights are installed as observed by LPA. All toilets and hand washing areas are maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences are available accommodate any physically handicapped residents who need such items. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Each resident bedroom has a bed, nightstands, and lights and nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms can store or has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. Continued on 809-C The resident bedrooms are big enough for all beds, furniture, and any resident assisting device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. The facility has provisioned to each resident of furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. An emergency exiting plan and emergency phone numbers are posted in an appropriate place. A current disaster and mass casualty plan maintained at the facility. The facility’s policies and procedures as it pertains to infection control are adequate. First-aid supplies, which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual, are maintained. Administrator’s records, employees and resident records are maintained at the facility and available for review by the LPA as employees are hired and residents accepted into the facility. The facility complies with CCL standards for health screening, TB clearance, staff training, criminal background clearance and transfer requests. Admission agreements and needs and services (ANS) plan are maintained for each resident and/or their authorized representative. Resident records are maintained on the facility premises in a secured area. Centrally stored medications are locked in secure locked cabinet(s) inaccessible to residents. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. LPA audited the medications for residents and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no additional or prohibited markings by the facility. The facility administrator meets the qualifications as specified in Title 22 regulations. Administrator has a current RCFE administrators’ certificate with an expiration date of 12/03/2025. There are required postings throughout the facility, including emergency exit plans with necessary telephone numbers. Provider Information Notices are available and able to be presented to Staff, residents, visitors, and accessible to LPA upon request during the inspection process. Exit interview conducted by LPA. Copy of this report provided to the facility.the state’s words, verbatim · CDSS document, Oct 23, 2024

Allegation investigated: Due to neglect, resident sustained injury while in care Staff did not seek timely medical treatment for resident Due to neglect, resident sustained drastic weight loss while in care Staff did not provide adequate assistance to resident in care

Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Phillips met with Executive Director/Administrator Brian McCague and explained the reason for the visit. On the allegation: Due to neglect, resident sustained injury while in care. It is alleged that Resident #1 (R1) was found on their bedroom floor with blood around their head. The allegation states that staff suspect that the resident sustained an unwitnessed fall but were unable to explained what really happened. On 05/25/2023, Licensing Agency received an Unusual Injury/Incident Report from the facility that stated R1’s floor sensor/mat alarm was triggered at 12:25a.m. and R1 was found lying on their right side next to their bed with a bloody gash on their head. Continued on 9099-C Unsubstantiated Staff called 911 immediately while applying pressure to the wound. R1 was diagnosed with a laceration on their head that was cleaned and sutured as well as hematomas on their hips. R1 was discharged back to the facility the same day of this incident at 6:15a.m. as no further head injuries were assessed at the hospital. LPA received a copy of the resident's discharge summary from the hospital on 05/25/2023, due to a fall causing head trauma and a laceration of the scalp requiring scalp sutures. Medical tests conducted were CT of the brain, CT of the cervical spine, ECG, X-Ray of the chest, and X-Ray of the left forearm. The reporting party/complainant corroborated this version of events during an interview with the Licensing Agency on 06/12/2023, and stated R1 needed stitches on their head and sustained multiple bruises on their hips. Based on the information obtained, there was insufficient evidence that due to neglect, resident sustained an injury while in care. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff did not seek timely medical treatment for resident. It is alleged that Resident #1 (R1) had an ingrown toenail on their left toe and that the injury was ignored for two (2) weeks with no treatment being requested for R1. The allegation states that two (2) weeks later R1 sustained a bad infection on their left toe and R1 was seen by an attending physician who cut R1’s toenail and prescribed antibiotics. LPA received signed and dated documentation beginning in December 2022 of a Professional Medical Services Agreement between the facility and a board-certified medical Doctor licensed in the State to provide wound care services to the residents of the facility. This Doctor exclusively provides wound care services referred to by the residents’ primary physicians and does not act in any other capacity. LPA received Physicians Orders/Audits from the primary care physician of the resident dated from 04/28/2023-06/20/2023 on a consistent basis (every day to every other day/occasionally every 3 days). LPA received copies of Medical Services provided to the resident from 06/20/2023, regarding an ingrown toenail infection. There is no evidence through record review that R1 was ignored for two (2) weeks with no treatment on the ingrown toenail. Through interviews with Staff, LPA found no evidence that R1 was ignored for treatment on the ingrown toenail, and all Staff interviewed stated R1’s ingrown toenail was provided treatment appropriately. There is no evidence through either record review or interview any medical treatment needed by R1 was delayed or ignored. Based on the information obtained, there was insufficient evidence that due to neglect, resident sustained an injury while in care. Therefore, the allegation is deemed Unsubstantiated at this time. Continued on 9099-C On the allegation: Due to neglect, resident sustained drastic weight loss while in care. It is alleged that Resident #1 (R1) experienced a drastic weight loss and decline in condition while in care at the facility. The allegation states that the facility explained the weight loss as side effects from physician prescribed antibiotics for R1. Through record review, LPA requested and received a Diet Change Form for Personal Care for R1. This Diet Change form adds a protein/health shake to every meal for R1 to address weight loss caused by the antibiotics. The Diet Change Form is signed and dated 06/15/2023. Through Staff interview, LPA learned that the facility attempted to mitigate the side effects of the physician prescribed antibiotics through meal service changes to R1. LPA requested and received documentation of the antibiotics prescribed to R1 in which a side effect is noted of weight loss/loss of appetite. R1’s weight was being monitored by the facility and actions were made to address the weight loss of R1 through the side effect of the physician prescribed antibiotics. LPA received detailed Doctor's Progress Notes from 05/26/2023, 06/02/2023, 06/05/2023, 06/13/2023, & 06/16/2023. LPA also received documentation of the facility 24 Hour Chart Check for the Resident for the months of May and June 2023. These documents had noted the weight changes in R1 based on the side effects of antibiotics and the responses by the facility. Based on the information obtained, there was insufficient evidence that due to neglect, resident sustained an injury while in care. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff did not provide adequate assistance to resident in care. It is alleged that Resident #2 (R2) needs constant assistance from facility staff due to their medical diagnosis and physical health impairments. The allegation states that staff are not checking up on R2 regularly, and that staff rotate constantly with different staff shifts providing different levels of care to R2. This has allegedly caused R2 to wander into other resident’s rooms as well as defecate in the hallway of the facility. LPA Phillips conducted complaint investigation visits to the facility on 06/21/2023 and 07/01/2023. During these visits, LPA requested and received relevant documents to the allegation for record review. The Physician’s Report for Residential Care Facilities for the Elderly (RCFE) for R2 dated 09/17/2021 indicated that R2 had a physical health status of macular degeneration causing blindness, auditory impairment, and bladder impairment as well as a diagnosis of dementia. Continued on 9099-C On 09/25/2023, Licensing Agency received an Incident Report from the facility stating that R2 was transported to the hospital via 911 for weakness, lethargy, and disorientation with the family members of R2 being notified. The incident report indicated that R2 was discharged the same day with their relative into the facility Skilled Nursing Facility (SNF). On 09/29/2023, Licensing Agency received a telephone call from Long Term Care Ombudsman that indicated R2 is emotionally unstable at times and loses their sense of knowing where they are at times. The Long-Term Care Ombudsman stated that R2 was sent to the hospital via 911 on 09/25/2023 alone with no staff accompanying them for approximately six (6) hours. The Long-Term Care Ombudsman stated the facility staff did not acknowledge or make necessary actions for someone with R2’s medical diagnosis/physical health impairments that has different needs. However, it is standard procedure/protocol at an RCFE when a resident is sent to the hospital for no facility staff to accompany them during the trip. The facility SNF Observation Report of R2 dated 10/04/2023 indicates that the facility noted a history of wandering by R2 and that R2 needs assistance with all Activities of Daily Living (ADL). The Clinical Notes from the visiting Hospice Care agency on 10/04/2023 indicated that facility staff explained that R2 is a fall risk but won’t stay in their chair or seated walker. Staff said R2 gets up to try to walk every few minutes, and that it may be needed to change R2’s Plan of Care at the facility. The Clinical Notes from the visiting Hospice Care agency on 10/14/2023 indicated R2 spends quite a lot of time walking around the facility living room and dining room area. Staff stated to Hospice Agency Representative that R2 needs continued reminders to use a walker or for redirection. The facility SNF Observation Report of R2 dated 10/18/2023 indicates that encouragement is needed for additional caregiver to assist with R2’s needs. The facility implemented a bedroom sensor/floor alarm in R2’s bedroom to alert facility staff anytime R2 leaves their bed. On 04/05/2024, the facility Resident Progress Notes stated that R2 was found sitting on the floor next to their bathroom entrance by Staff. R2’s bedroom sensor mat/floor alarm had not been triggered to alert staff when R2 got out of their bed. However, R2 was frequently checked on by staff who observed this despite the bedroom sensor/floor alarm. R2 denied pain and was assessed with no injuries by R2’s attending physician. Based on the information obtained, there was insufficient evidence that Staff did not provide adequate assistance to resident in care. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of report provided to facility.the state’s words, verbatim · CDSS document, Jul 10, 2024 · control 29-AS-20230614155647

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