Cedar Creek Alzheimer's & Dementia Care Center

Allegation investigated: Staff do not serve residents food of good quality. Staff do not communicate with responsible party regarding resident's care. Staff do not provide responsible party with facility policies and procedures.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Community Outreach (CO) Sabrina Sneper. On 01/09/2026, the Department received a complaint with the above 3 allegations. On 01/15/2026, the Department conducted an initial investigation visit. LPA interviewed ADM, 5 staff, and 3 residents. LPA requested resident R1's care plan, centrally stored medication forms, Medication administration records, and physician reports. Continue on LIC9099-C. Page 1 of 4. Unfounded Staff do not serve residents food of good quality: The allegation is that the facility meal food was not served hot, milk was not hot to serve to residents, and milk was not filled full in the cup/glass to residents. On 01/15/2026, LPA interviewed Administrator (ADM) Michelle White. ADM stated every resident receives plenty of food for the meals. ADM stated the kitchen staff prepare food/meals for resident based on their order/preference. ADM stated meals are placed on the plates, and caregivers deliver to dining table in the dining room for residents. ADM stated some residents have special diets, and the kitchen staff prepare the special diet the for the residents. ADM stated caregivers do not push or hurry residents to finish the meals, and some residents take up to one hour or one and half hours to finish meals. ADM stated the facility has the food temperature log for the meal food when meals are ready to deliver to residents to make sure meals are warm/hot to deliver to residents. ADM provided the meal temperature log. ADM stated milk is served around 40 degree F as around the same as in the refrigerator temperature. ADM stated that is the usual way people drink milk. ADM stated residents can request to heat the milk if they prefer hot milk. ADM stated usually the milk or beverage is not served full of the cup/glass because residents may spill out if not carefully. ADM stated resident can request more milk or beverage if needed. LPA interviewed two kitchen staff (S1, S2). Both stated resident meals are prepared based on residents' order/preference and are placed on plates, and caregivers deliver meals to residents. Both stated residents' meals are put in oven before delivered to residents. Both stated the kitchen staff keep meal temperature log. LPA interviewed 2 caregivers (S3, S4). Both stated milk is not served as hot milk and residents can request to heat the milk. Both stated milk is not served as full glass/cup because resident may spill out. Both stated they deliver meals from kitchen to residents. Based on the review of the meal temperature log, the meals were kept warm/hot and milk and beverage were kept around 40 degree F before delivered to residents. Based on the review of the facility food menu, protein, Carbohydrates, and vegetables are provided everyday to residents. Continue on LIC9099-C. Page 2 of 4. Staff do not communicate with responsible party regarding resident's care: The allegation is that family member (FM) was not aware of resident R1 uses wheelchair due to facility staff did not notify FM.. On 01/15/2026, LPA interviewed Administrator (ADM). ADM stated resident R1 already used walker and wheelchair when the new management team took over the facility. ADM stated R1 prefers to sit because R1 has pain knees. ADM stated the facility encourages R1 to walk with walker for exercise. ADM stated R1 has physical therapy treatment. ADM stated based on R1's plan of care dated 05/22/2025, R1 was able to ambulate with 4-wheeled walker and after 05/16/2025, R1 used a wheelchair all the time and had not been ambulating in the facility. ADM stated R1's family member visits R1 very often and should be aware of R1 used wheelchair before October 2025. LPA interviewed 2 caregivers (S3, S4). Both stated R1 used walker and wheelchair before October 2025 and needs staff assistance. Based on the review of R1's Physical Therapy Plan of Care approval for R1 dated 05/22/2025, R1 used a wheelchair all the time and had not been ambulating in the facility since 05/16/2025. Staff do not provide responsible party with facility policies and procedures: The allegation is that staff did not respond to family member (FM) the request of facility's policies, procedures and plan of operation. On 01/15/2026, LPA interviewed Administrator (ADM). ADM stated he/she did not receive any request for facility policies and procedures from FM but he/she helped Community Outreach (CO) to prepare the document of the facility Plan of Operation, the facility emergency plan, the facility policy and procedures. LPA interviewed Community Outreach (CO). CO stated he/she received a request for application package from FM. CO stated he/she gave a whole package of documents including but not limited to, application procedures, admission agreement, plan of operation. CO stated after he/she provided the whole package of document to FM, FM did not complain and did not request any more document. CO provided a copy of the application package. LPA interviewed a Med Tech (S5). S5 stated FM requested Medication Administration Records (MARs). S5 stated he/she provided the MARs to FM. Continue on LIC9099-C. Page 3 of 4. The Department has investigated the above allegations. Based on the investigation, observation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. Exit interview conducted with CO. This report was provided to review and for signature. A copy of this report was provided to CO. Page 4 of 4. Staff did not distribute resident's medication as prescribed: The allegation is that facility staff did not distribute resident R1's medication M1 on 12/03/2025 for PM shift. On 01/15/2026, LPA interviewed a Med Tech (S5). S5 stated one day in December 2025. R1's family member (FM) took R1 for doctor appointment. FM requested R1's MAR. S5 stated he/she provided R1's MARs to FM and FM found on 12/03/2025, PM shift, the item of R1's medication M1 without staff initial. S5 stated he/she knew R1's M1 was administered for 12/03/2025 PM shift but just the Med Tech (S6) forgot to initiate it. S5 stated he/she explained it to FM. On 01/17/2026, 11:20AM, LPA interviewed Med Tech(S6). S6 stated he/she did administer medication M1 to R1 on 12/03/2025, at bedtime but he/she forgot to initiate it. S6 stated he/she initiated it at another day. Based on the review of R1's December 2025 MARS, on 12/03/2025, the medication M1 PM shift was observed with staff initial. The department has investigated the above allegation. Based on the records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with CO. A copy of this report was provided to CO. Page 2 of 2.the state’s words, verbatim · CDSS document, Apr 8, 2026 · control 26-AS-20260109082544

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Debbie Cota. ADM informed that 45 residents and 20 staff in the facility. LPA reviewed 5 resident files and 5 staff files. LPA toured the facility with ADM. Lobby, common area, activity room, kitchen, dining room, laundry room, salon room, break room, storage room, and restrooms were inspected. 29 shared resident bedrooms were inspected. 2 bedrooms shared with one restroom and 1 single room with restroom, 3 common shower rooms and common restrooms were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. The temperature of refrigerator was observed at 40 degree F and the temperature of the freezer was observed at -5 degree F. Medication room was observed locked. Cleaning product room was observed locked. Room temperature was at 73 degree F, and hot water temperature was at 106 degree F in facility. The fall prevention alarm system was tested and was working. First aid boxes were observed in the facility. Fire extinguisher was serviced on 9/24/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. carbon monoxide detector were tested and were observed working. The courtyard and backyard were toured. The last time the facility conducted the fire drill was on 6/12/2025. ADM stated the facility conducts fire drill every quarter. No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the reports was provided to ADM.the state’s words, verbatim · CDSS document, Sep 16, 2025

Allegation investigated: Facility is unwilling to meet resident’s transferring needs

On August 18, 2025, Licensing Program Analyst (LPA) Kiran Jain conducted this visit to deliver and discuss the findings of a complaint allegation and investigation with Health and Wellness Director(HWD), Teresa Ly. On 07/17/2024, the Department received a complaint allegation that “Facility is unwilling to meet resident’s transferring needs”. On 04/02/2025, LPA conducted an initial complaint inspection and investigation by reviewing and obtaining copies of the facility’s Nurses Progress Notes (NPN) regarding a resident (referred as R1) for June and July 2024 (061024, 070224, 070524, 071124, 071224,071424, 071724, 071924,0724,07224,072324, 072324, and 072424). Continued on LIC9099-C Unsubstantiated Based on the NPNs report noted for 071724, 071924, and 072324, staff assisted R1 with transferring in and out of bed. On 06/10/24, R1’s medical and health condition changed. R1 was noted to have an unsteady gait due to weakness, which resulted in his/her inability to stand and walk. R1 was admitted to a Skilled Nursing Facility (SNF) for rehabilitation, where R1 was evaluated by a Physical Therapist (PT) on 07/02/2024. R1’s DPOA (Duly Power of Attorney) was aware of R1’s change of condition. On 07/05/2024, R1 was admitted back to the facility from SNF but was later sent to the hospital, on 07/05/2025, due to being unresponsive or unarousable to stimuli. After 07/05/2024, R1’s change of health/medical condition, including level of care, became more apparent, such as but not limited to R1’s inability to reposition in bed, including transferring from/to bed/wheelchair, increased body mass, and shortness of breath (SOB). On 07/22/2024, R1 was seen by his/her Occupational Therapist (OT), who documented that R1 was asleep in bed, could not stay awake, was wheezing, was unresponsive, was not following commands, and was completely bedbound. On 07/24/2024, R1 was seen by a physical therapist (PT) who recommended the initiation of hospice services as an option to R1’s DPOA. It was unclear whether R1’s DPOA agreed to the recommendation of the hospice services. Lastly, on 07/25/2024, R1 was sent to the hospital due to staff observing R1 to be less responsive and was cold touch with chest congestion. On 04/02/2025, LPA obtained and reviewed R1's Care Plan for 07/05/24. The goal was to safely transfer R1 t/from bed/wheelchair. The plan was to obtain PT/OT home health for lower extremities strengthening. If R1 requires more than 2 people to transfer, then leave R1 in bed and provide care services to R1 there, including repositioning every 2 hours to avoid pressure injury and maintain skin integrity. Call 911 if R1 appeared in distress during transfers. Based on LPA's overall review of R1’s care plan, R1 had been experiencing physical and cognitive decline, with suspected water weight gain, and had become unresponsive. Staff attempted to assist R1 out of bed daily with 2-person assistance to transfer R1 from bed to wheelchair and leave R1 in bed if 2 staff members were not able to hold R1’s upper extremities and move his/her lower extremities at the same time during the transfer. Continued on LIC9099-C While R1 was in bed, staff repositioned R1 every 2 hours and provided incontinence care and ensured R1’s skin integrity and R1 didn’t develop any pressure injuries. On 06/02/2025, LPA obtained and reviewed the facility’s note that was faxed to R1’s physician, requesting PT/OT services for R1 to help strengthen his/her legs during transfers. R1’s physician referred to PT or OT for R1 wherein he/she was seen, and noted on 07/23/34 physician’s visit, R1 requires to be repositioned every two hours. On 04/02/2025, the LPA obtained R1’s 2024 weight record. Based on the LPA’s review, R1 gained weight from 05/2024 to 07/2024, from 179 to 200 lbs. Based on an interview with S2, S2 stated R1 was getting puffy along with water retention. As a result, transferring R1 became challenging as R1 was dead weight due to weaker upper and lower extremities, and R1 was not supporting his/her weight. On 04/02/2025, the LPA obtained and reviewed R1’s Appraisal needs and services plan dated 06/06/2023, signed by R1’s DPOA on 06/28/2023, which indicated that R1 required assistance with ADLs, dressing, grooming, showering, and incontinence care. Based on an interview with S2, the facility conducted annual Appraisal Needs and Services Plans and conferences but was unable to complete the 2024 plan on time, as R1 had been in and out of the hospital multiple times starting in June 2024. On 04/02/2025, the LPA obtained and reviewed R1’s Functional Capability Assessment for 07/022024, which indicated that for transferring, R1 was unable to move in/out of bed or chair, unable to reposition, needed help moving the wheelchair, and did not walk. On 04/02/2025, the LPA obtained and reviewed R1’s LIC 602 Physician’s Assessment reports for 10/20/2023 and 06/28/2024, which listed diagnoses including dementia, hypothyroidism, hypertension, edema, and a cardiac pacemaker. R1 was determined to be bedridden due to both physical and mental conditions and could transfer only with cooperation. On 04/02/2025, the LPA obtained and reviewed LIC624 Incident Report for 07/25/2024, which stated that R1 was sent to the hospital for a change of status as R1 was observed less responsive, had chest congestion, and low body temperature of 94°F. On 04/02/2025, the LPA obtained and reviewed R1’s shower log from May to July 2024, which showed R1 was scheduled for showers twice a week. In May 2024, R1 received showers as scheduled. In June 2024, R1 received showers as scheduled, except on days when R1 was hospitalized. In July 2024, R1 received sponge baths on days when R1 was not in the hospital. Continued on LIC9099-C On 04/02/2025, LPA interviewed the Administrator (ADM), who stated that on 06/10/2025, R1 was sent to the hospital due to a change in medical/health condition and subsequently transferred to a Skilled Nursing Facility (SNF). ADM stated that R1’s responsible party/durable power of attorney (DPOA) was aware that R1 was dead weight, could take 4 care staff to transfer R1 t/from bed/wheelchair, and required bed repositioning by 2 care staff. ADM added that upon R1’s discharge from SNF on 07/05/2025, an assessment was done for R1. The facility and DPOA had verbally agreed on the plan of care or appraisal, and safety protocols, dated 07/05/2025. The plan was to obtain PT/OT home health for lower extremities strengthening. If R1 requires more than 2 people to transfer, then care services will be provided to R1 on bed, including repositioning every 2 hours to avoid pressure injury. ADM stated that on 07/25/2025, R1 was sent to the hospital as R1’s condition worsened with congestion, wheezing, and decreased responsiveness. On 07/09/2025, the LPA interviewed six staff members (S2, S3, S6, S7, S8 and S9). S2 stated they had scheduled showers for R1 twice a week and always attempted to provide showers in the shower room using a chair as part of the staff’s willingness to get R1 out of bed and provide care. Sometimes, when staff were able to transfer R1 on a chair, R1 would not support his/her body. R1’s flaccid physical state would put R1 in an unsafe position. Sometimes during transfers, R1’s repository condition diminished and R1 would exhibit labored breathing along with wheezing. During these unsafe times for R1 to use the chair, staff bathed R1 in bed. S3 said along with two to three staff members, they tried to get R1 out of bed on most days. They repositioned R1 every two hours in bed when R1 appeared pale and began breathing heavily during transfers. S6 stated that two to three staff members lifted and transferred R1 to a shower chair and rolled the chair to the shower room. S6 described R1 as “dead weight” and reported that there were times when R1’s condition changed mid-transfer, requiring staff to leave R1 in bed. S7 reported that R1 required two to three staff members for transfers, became agitated during transfers, and would breathe heavily. S8 stated that R1’s willingness to get out of bed often depended on R1’s mood and confirmed that R1 was given showers twice a week with the assistance of three to four staff members. S9 reported that at times, R1 appeared sleepy throughout the day and had to remain in bed. When R1 was seated in the dining room but became sleepy, staff would ask the supervisor to transfer R1 to bed. Continued on LIC9099-C Based on interviews and records reviews, the facility has designated a 2-person transfer of R1 to/from bed or wheelchair, however, this also depends on R1’s condition daily, wherein staff may or may not be able to lift or get R1 up to chair and/or in/out of bed due to his/her declining health. In contrast, it is alleged that R1 was observed to be left in bed all day and night. The Department has determined that the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation(s) are UNSUBSTANTIATED. No deficiencies were cited under the California Code of Regulations, Title 22. An exit interview was conducted with the Health and Wellness Director. A copy of this report was discussed and provided to the Health and Wellness Director, Teresa Ly, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 26-AS-20240717125830

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Steve conducted a case management visit to assess resident R1 and R2 for total care exception request. LPA met with Administrator Debbie Cota (ADM) and stated the purpose of today's visit. During today's visit, LPA met resident R1. Resident R1 is dependent on staff to care and supervise R1's activity's of daily living (ADLs). LPA introduced self to R1. LPA asked R1's name but R1 did not reply. ADM asked if R1 wants to eat something and R1 replied yes. ADM gave a spoon of pudding to R1 to eat and asked if R1 likes it. R1 replied yes. ADM asked R1 if R1 needs more pudding and R1 replied yes. ADM gave more spoons of pudding to R1 and asked R1 if R1 likes it. R1 replied yes. ADM asked R1 if R1 is happy and R1 answered yes. ADM asked R1 if R1 needs some water and R1 shook his head no. LPA asked R1 if R1 is happy. R1 smiled and replied yes. Based on the observation, R1 is able to communicate his/her needs/likes by verbal communication and shaking head. Based on the observation, total care exception is not needed at the time for R1. The facility staff shall continue to document R1’s condition and care provided should be kept in R1's files. Any changes in R1’s condition should be reported immediately to R1's primary care physician, responsible party and licensing agency. Facility staff will monitor R1's health care needs and collaborate with R1's primary physician regarding care. Facility staff shall ensure R1's Appraisal Needs and Services Plan is updated annually or as needed if the resident experiences significant physical or mental changes. Facility shall provide ongoing annual staff training specific to the needs of resident and shall be documented in facility records. Continue on LIC809-C, page 1 of 2. Administrator shall notify the Department if there are any changes to R1 wherein R1 is not able to communication his/her needs and Administrator can submit total care exception to retain resident at the facility at that time. LPA met resident R2. Resident R2 is dependent on staff to care and supervise R2's activity's of daily living (ADLs). LPA introduced self to R2 and asked R2 question. R2 had no response. ADM asked R2 if R2 needs anything to eat. R2 had no response. ADM asked if R2 wants to eat pudding and R2 had no response. ADM gave couple spoons of pudding to R2 and R2 ate it. ADM asked if R2 likes it. R2 had no response. A caregiver S1 asked R2 if R2 wants to eat anything. R2 had no response. S1 gave spoons of pudding to R2 and R2 ate it. S1 asked if R2 needs to drink some water. R2 had no response. S1 gave R2 some water to sip. S1 asked if R1 likes it. R1 had no response. Based on the observation, R2 is unable to communicate his/her needs. Based on the observation, total care exception is needed at the time for R2. The Department will proceed to process the total care exception request for R2. ADM will provide documents if needed. No deficiencies were cited per California Code of Regulations, Title 22. Exit interview was conducted with ADM. This report was reviewed with ADM and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 10, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit in regards an incident report, which stated a resident had struck another resident. LPA's met with Administrator Administrator Debbie Cota. LPA's explained the purpose of the visit. On October 23, 2024, the Department received an incident report, regarding resident R1. The incident report stated on October 22, 2024, at approximately 7:15pm, resident R2 was upset at the front desk. R2 was pushing the front desk computer and was aggressive with staff when re-direction was attempted. Resident R1 was nearby and saw what was happening and became upset. R1 got up and slapped R2 in the face. Both residents were separated. No physical harm was note on R2's face. The incident report states that staff S1 and S2 were present during the alleged slap. On October 25, 2024, LPA Manuel Monter interviewed resident R1 and R2. Resident R1 was asleep and could not be interviewed during LPA's visit. Resident R2 stated he/she does not remember the slapping incident that occurred on October 22, 2024. LPA interviewed staff S1. S1 stated he/she was getting ready to clocked out and was at the front desk, while staff S2, was working at the front desk. S1 stated resident R1 was sitting on a grey chair, 5 feet away from the front desk. S1 stated he/she observed resident R2 walk from the dinning room towards the front desk, and was upset. S1 stated R2 began to make a commotion and was pushing the monitors. S1 stated he/she attempted to de-escalate R2. S1 stated R1 then suddenly stood up and slapped R2. S1 stated after being slapped, R2 calmed down and S2 escorted R2 towards his/her bedroom. Staff S1 stated resident R1 and R2 did not have an argument or altercation earlier that day. Haven't seen any physical altercations between them in the past. Page 1 Out of 2. LPA interviewed ADM. ADM stated R1 and R2 do not have a history of fighting with each other. ADM stated R1 likes to sit in the front desk area, away from the other residents. ADM stated R1 does not enjoy R2's company due to being intrusive, such as trying to helpful. ADM stated she submitted updated care plans for both residents to CCL. Based on record review, Residents R1 and R2 have Neurocognitive disorder. LPA determined that the above incident does not require further investigation. This report was reviewed with Administrator Debbie Cota and a copy of the report was provided. Page 2 Out of 2. END OF REPORT.the state’s words, verbatim · CDSS document, Oct 25, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Director of Community relations Diana (DCR) Jane Gutierrez. DCR informed that 50 residents and 29 staff in the facility. LPA reviewed 5 resident files and 5 staff files. LPA toured the facility with DCR. Lobby, common area, activity room, kitchen, dining room, laundry room, Salon room, break room, storage room, and restrooms were inspected. 28 shared resident bedrooms were inspected. 2 bedrooms shared with one restrooms and 1 single room with restroom, 3 common shower rooms and common restrooms were observed. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. The temperature of refrigerator was observed at 40 degree F and the temperature of the freezer was observed at -10 degree F. Medication room was observed locked. Cleaning product room was observed locked. Room temperature was at 70 degree F, and hot water temperature was at 106 degree F in facility. The emergency call in the resident room was tested and staff came within 1 minute. First aid boxes were observed in the facility. Fire extinguisher was found expired. The bought new Fire extinguishers and installed them before LPA finished the annual inspection. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested and were observed working. The courtyard and backyard were toured. The last time the facility conducted the fire drill was on 6/18/2024. No citation were noted today. Exit interview was conducted with DCR. This report was provided to DCR for signature. A copy of the reports was provided to DCR.the state’s words, verbatim · CDSS document, Sep 20, 2024