Citrus Heights Terrace

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Magda Luis, Interim Administrator. LPA stated the reason for today's inspection was to follow up on (3) incident reports (SIR) submitted to the Department on September 15, 2026, for resident (R1). The following was discussed: Resident (R1) was being assisted with incontinence care by a Med-Tech staff and a caregiver staff on September 8, 2026 (7:25 pm), and staff observed a "significant amount of blood" was observed coming from resident's private area. Staff immediately contacted an emergency medical transport who took (R1) to the emergency room for further evaluation. (R1) returned to the community the next day (2:00 am) and with a temporarily placed Foley catheter for urinary retention. Lab results were taken but had not returned during the brief hospital stay. (R1) was placed on 4-hour status checks. On September 9, 2026 (7:30 am), staff observed blood in (R1's) catheter/urine. (R1) complained of pain and discomfort, and the catheter was noted to not be draining at this time. (R1) was sent out again for emergency medical attention after a nurse was contacted. (R1) returned the same day with a Foley catheter and referral for Home Health. (R1) was also placed on 4- hour status checks. On September 10, 2026 (7:30 am), R1 was sent to the emergency room again due to an observed change in condition. (R1) was observed to attempt to get out of bed to use the bathroom, on two occasions, and displayed an unsteady gait. (R1) was hospitalized until September 13, 2026, when they returned with antibiotics for a Urinary Tract Infection (UTI). The Administrator stated (R1) completed their antibiotic course and is doing well. LPA and the Administrator observed (R1) to be enjoying the patio during today's inspection and to get up and ambulate independently. (R1) has a follow up appointment with their primary care doctor on September 17, 2026. *cont on 809C-1. 809C-1. LPA reviewed the hospital discharge paperwork for the (3) day stay. The paperwork notes the medications, Ciprofloxacin, Tamsoulsin and Saccharomyces Boulardii were ordered on September 14, 2026 for the UTI and urinary retention treated. (R1) has a follow up video appointment with their physician on Thursday, September 17, 2026, for any additional related concerns. LPA and the Administrator toured the interior of the facility and observed many residents to be participating in a Bingo activity. LPA also observed new couches and chairs in the common area hallways, as well as new flooring. There were no odors noted either. LPA did not observe any health and safety risk, or personal rights violation, to residents in care. It appears the facility took appropriate and timely action in sending (R1) out for medical attention. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 16, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and initially met with Arionna Neal, Shift Manager. LPA met with Rachael Robert, Resident Care Coordinator (RCC) at 2:30 pm. LPA stated the reason for today's inspection was to follow up on an incident report (SIR) submitted to the Department on August 29, 2026, for resident (R1). LPA observed a staff sitting at the front desk, monitoring the exit door and cameras. The RCC stated staff will be monitoring the front exit door from 5:00 pm to 9:00 pm. Additionally, the front door alarm is being tested every (15) minutes. LPA discussed the incident with the shift manager and RCC. Both stated she was present at the community on Sunday, August 24, 2026 (2:15 pm) when (R1) became agitated and refused care. The manager stated (R1) exited the door, near room #132, and stayed outside in the enclosed patio, pointing to the live video camera monitor in the RCC's office. Because (R1) became increasingly combative with staff when staff tried to redirect and provide care, the Med-Tech contacted 9-1-1 to send (R1) out for a medical evaluation. (R1) returned back to the community two days later, on August 26, 2026 (12:30 pm) with new medication orders which staff implemented immediately, and was placed on Alert Charting for staff to closely observe for any behaviors, safety and response to medications given. The RCC both confirmed (R1) did not exit through the parking lot gate at any time and stayed within the enclosed patio. The manager and RCC stated (R1) is doing much better on the new medications. LPA observed (R1) sitting outside on the patio, enjoying fresh air, and observed multiple residents playing Bingo with the Activities Coordinator. LPA did not observe any health and safety risks or personal rights violations. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 2, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with the Interim Administrator, Magda Luis. LPA stated the reason for the inspection was to follow up on an incident report (LIC624) submitted to the Department on August 24, 2026. There are currently (5) residents under hospice care. LPA and the Interim Administrator discussed the following: Resident (R1) had an unwitnessed fall on Wednesday, August 19, 2026 (6:40 pm), in their room. Staff responded immediately and observed (R1) sitting on the floor with a small tear on their right arm, discoloration on the face, and underneath the right foot. (R1's) family member was contacted and asked that non-emergency services be contacted due to resident taking blood thinner medication. The incident report states that a facility Med-Tech was notified by a hospital nurse that (R1) would remain hospitalized due to having a broken spine. The administrator stated that the facility has not received any documentation confirming (R1) sustained a broken spine. The administrator explained that (R1) moved in to the community on August 12, 2026 and was able to transfer independently, but slowly, and a bed alarm was provided by (R1's) health care group upon move-in due to sometimes getting up at night to use the toilet. The care plan notes (R1) needs minimum assistance with mobility. LPA obtained basic paperwork from resident's file. The administrator stated that (R1) attended a medical appointment, with their spouse, earlier on August 19, 2026, and received an injection to treat neck pain. Staff put (R1) to bed earlier that evening due to (R1) looking more tired than usual. (R1) did eat dinner, or have an Ensure drink. The administrator stated she found out from the family member on August 23, 2026 that (R1) passed at the hospital. The administrator will submit an LIC624A to the Department by August 30, 2026 and request a county death certificate. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 25, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Rachael Robert, Resident Care Coordinator (RCC) and then the Interim Administrator, Magda Luis. LPA stated the reason for the inspection was to follow up on an incident report (LIC624) submitted to the Department on August 11, 2026. There are currently (5) residents under hospice care. LPA observed new flooring being installed in the north wing during today's inspection. LPA and RCC discussed the following: Resident (R1) walked out of the community, unassisted, through the front door, on Monday, August 10, 2026 (at 5:09 pm). The concierge had just left their shift at 5:00 pm and there was no staff present in the lobby at the time of the incident. The RCC explained that staff were conducting a mandatory head count of residents shortly after dinner was finished and realized (R1) was not in the building. A mandatory head count was completed during dinner and (R1) was present in the dining room. Staff contacted the Administrator, RCC, responsible person and 9-1-1 at approximately 5:40 pm. At 6:40 pm, local police brought (R1) back to the community after locating them walking in the nearby area. Staff did not observe any visible injuries to (R1) upon returning to the community, and (R1) will follow up with their primary care physician. The family member indicated that (R1) used to try and elope when living at home with them and is very active. The RCC indicated that the alarm on the front exit door did not sound when the door was opened at 5:09 pm, and it was determined to be a "temporary malfunction". The facility confirmed that the door alarm was working correctly just prior to (R1) leaving, based on staff interview/s and camera footage. Maintenance staff tested and ensured the door alarm was working correctly the next morning, on August 11, 2026. *cont on 809C-1.. 809C-1.. The RCC indicated that (R1) had been wearing a bracelet (Wanderguard) since moving in in May 2026 and provided paperwork showing that staff were monitoring twice daily that (R1) was wearing it. The RCC explained that the "am" shift had confirmed (R1) was wearing the bracelet during their shift and the "pm" also completes mandatory two hour checks, but when they went to check prior to (R1) leaving, (R1) was not found. The RCC stated (R1) has taken off their bracelet at various times prior to the incident, has not previously tried to exit from the facility, and must have removed the bracelet on August 10, 2026, between 3:00 pm and 5:00 pm, prior to the exiting from the building. The RCC added that (R1) was not wearing the bracelet as the Wanderguard alarm did not sound at the time of exiting the building. Initially, (R1) wore a necklace (Wanderguard) but then switched to wearing a bracelet for a brief period. (R1) has been wearing an anklet device following the incident and has not tried to take it off. Following the incident, the facility completed an Elopement Risk Evaluation, a Resident Re-Appraisal, and updated (R1's) care plan. The RCC added that (R1) tends to walk around the community and also be near the lobby area on a regular basis. The facility is looking into obtaining a second staff to sit at the concierge area into the early evening, while visiting hours occur. Currently, (30) seconds are required to hold the exit door handle before the alarm sounds, which was an increase from (15) seconds previously. The RCC stated that staff are testing the exit door alarm at least once during each shift and when staff are using the door to enter/leave the community. Staff will continue to complete "End of Shift Reports" and Narrative Charting when observing residents. LPA observed (R1) participating in an activity with other residents in the dining room and to be wearing an anklet device. LPA observed the RCC to test the front egress door and staff to respond timely, within (30) seconds. The RCC and Interim Administrator stated there are discussions about adding a gate inside the lobby for additional security measures. Per California Code of Regulations, Title 22, Division 8, Chapter 6, the following (1) deficiency is being cited related on the 809-D page. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 13, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.699(5) · Plan of correction due date: Aug 13, 2026

§1569.699 Exit doors; egress-control devices of time-delay type; fences (a) When approved by the person responsible for enforcement, as described in Section 13146, exit doors in facilities classified as Group R, Division 2 facilities under the California Building Standards Code, licensed as residential care facilities for the elderly, and housing clients with Alzheimer’s disease or major neurocognitive disorder, may be equipped with approved listed special egress-control devices of the time-delay type, provided the building is protected throughout by an approved automatic sprinkler system and an approved automatic smoke-detection system. The devices shall conform to all of the following requirements: (5) Actuation of the panic bar or other door-latching hardware shall activate an audible signal at the door. This requirement is not met as evidenced by: Based on interview with the Interim Administrator and Resident Care Coordinator, the Licensee did not ensure that the egress door alarm sounded on Monday, August 10, 2026 (5:09 pm) when (R1) was able to exit from the community, unassisted, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: Licensee/Administrator already conducted staff training with the "pm" shift on the August 10, 2026. Training to be scheduled for the "am" and "NOC" shifts - will conduct training at their cross-over within a week, or by 8/20/2026. Maintenance already increased the time from (15) seconds to (30) seconds until the egress door opens after the alarm is sounded. Additionally, maintenance will possibly change a part in the magnetic box if it's determined to be related to the alarm not sounding. The facility has started the process of placing a staff person at the concierge from 5-8 pm. Lastly, the facility is in discussions about adding an interior security door that clients would have to go through before they are able to reach the egress door. The facility agrees to provide any updates/documentation related to these follow up actions, to the Department, by August 27, 2026.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Rachael Robert, Resident Care Coordinator (RCC) and Administrator Designee. LPA stated the reason for the inspection was to follow up on several incident reports (LIC624) submitted to the Department in June, 2026. There are currently (4) residents under hospice care. LPA and the RCC discussed the following: Resident (R1) had an unwitnessed fall on 6/26/2026 ( 5:00 pm), was evaluated by emergency personnel and sent out for further medical attention. (R1) indicated to care staff that they hit their head but did not complain of pain. (R1) returned the same day with no injuries and with new orders to use a walker and start Home Health (Physical Therapy). (R1's) care plan was updated to note the use of a walker. (R1) is making progress with using their walker and PT visits 2x/week. Resident (R2) complained of chest pain on 5/30/26 (11:50 am) and on 6/10/26 (5:20 pm). R2 was evaluated by emergency personnel and sent out for further medical attention. (R2) returned to the community following each hospital visit and test results noted there were no signs of a heart attack, blood clot or pneumonia. (R2) was advised to follow up with their primary care physician. Staff has continued to monitor (R2) for any changes in condition. No changes were made to resident's medications after each visit. Resident (R3) had an unwitnesed fall on 6/8/26 (5:20 pm), after becoming dizzy following dinner. (R3) fell on their left side, and reported pain on their left wrist, left hip and stated they hit their head. (R3) returned to the community on 6/9/26 (12:45 am) and is using a wheelchair currently due to their hip fracture. Home Health (Physical therapy) was started two weeks ago and resident is doing better. (R3's) care plan was updated to reflect resident needing stand-by assists with ADL's and transfers and increased safety checks. *cont on 809C-1.. 809C-1.. Resident (R4) was discussed since (R4) previously eloped from the facility on 5/26/2026 and on 4/19/2026. Case management inspections were conducted following each incident. LPA and the RCC observed (R4) to be ambulating in the hallway during the inspection. The RCC stated that (R4) has been "doing good" and recently begun having a 1:1 staff with them during part of the day. The 1:1 goes on walks with (R4), and (R4) has been wearing their WanderGuard band all of the time. RCC confirmed that (R4) enjoys the company of staff. The RCC stated staff have participated in several recent training sessions on fall prevent and management. Specifically, a non-emergency ambulance provider led training in May 2026, and the monthly facility clinical meeting, in June 2026, addressed falls. LPA and the RCC toured the interior of the facility and observed residents to be resting and participating in activities with staff. LPA and the RCC observed (R4) to be walking in the hallway with a 1:1 staff. LPA was advised there were currently (5) caregiver and (2) Med-Tech staff, and (1) concierge present during the inspection. LPA did not observe any health/safety risk or personal rights violation present when touring. It appears the facility responded to each above incident timely and sent the resident out for further medical attention. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 1, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Rachael Robert, Resident Care Coordinator (RCC) and Administrator Designee. The Interim-Administrator, Magda Luis, was not available due to attending an outside event during the time of the inspection. LPA stated the reason for the inspection was to follow up on resident (R1) who eloped from the facility on May 26, 2026, and previously on April 19, 2026. The RCC stated that (R1) threw away their WanderGuard necklace device earlier today and staff temporarily placed an anklet on them. At the end of the inspection, LPA observed (R1) to be sleeping in their room and wearing the necklace device that had been located. The RCC stated that staff continue to take (R1) for walks and confirmed that (R1) has not tried to exit from the facility following the incident on May 26, 2026. The RCC stated that (R1) enjoys being with staff and always has a staff nearby them when in the common area. Also discussed was the facility's Corrective Action Plan, submitted to the Department following a meeting on May 1, 2025. LPA discussed each of the ten points addressed in the plan with the RCC and confirmed the processes are currently in place and being followed. Also discussed was due to a change in staffing in 2025, there is still some legal review in process. LPA toured the interior of the facility with the RCC and observed staff and residents to be engaged in activities and lunch preparations. LPA was advised there were currently (7 ) caregiver and Med-Tech staff, and (1) concierge present during the inspection. LPA did not observe any health/safety risk or personal rights violation present when touring. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 2, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met Rachael Robert, Resident Care Coordinator (RCC). LPA stated the reason for the inspection was to follow up on an incident report recently submitted to the Department involving resident (R1) who eloped from the community on May 26, 2026 (10:53 am). The RCC explained that (R1) was able to exit the facility through the front entrance without being observed by staff because the concierge staff had to cover for a care staff who had called out for work around 7:20 am after the morning shift began. At the time (R1) exited the building, the concierge staff was attending to residents at the other end of Hall #1, which is away from the front entrance. The RCC added that (R1) began pushing on the front door and then walked away from the door when the alarm was triggered; however, when the alarm stopped, (R1) walked back to the front entrance, exiting to the parking lot. The RCC stated she and staff immediately searched within the facility but were unable to locate (R1), who wasn't able to be seen on the cameras. At 11:00 am, the RCC and a Med-Tech drove in separate cars to search for (R1) in the nearby area, but were not able to locate them. Around 11:15 am, the local police were contacted and at 12:14 pm, (R1) was returned to the community after being found in a nearby neighborhood. The incident report notes (R1) returned without any "injuries, pain, distress or change in condition." The RCC stated that following the incident, maintenance staff checked the front door to ensure the door doesn't unlock before 15-20 seconds of the alarm sounding. The RCC indicated that staff will be instructed today (3:15 pm) on how the timing works on the egress door unlocking after the alarm sounds. *cont on 812C-1.. 809C-1.. The RCC stated that a Wander Guard anklet was previously placed on (R1); however, (R1) would regularly tear it off, and staff would find it in (R1's) room in the trash can. Before (R1) exited from the community, staff ensured that (R1) was wearing the anklet earlier that morning, but it was found in the trash can when searching for (R1). LPA and RCC spoke with (R1) during today's inspection in their room. LPA observed (R1) to be wearing a necklace with a monitoring device. (R1) admitted to throwing away anklets that were previously placed on them. LPA stated to (R1) that for their safety, they need to have a buddy with them when leaving the facility. (R1) appeared to understand. The RCC stated that (R1) left the facility due to wanting to walk, and staff will continue to take (R1) on walks. The incident report notes that updates were made to (R1's) Elopement Risk Evaluation, Assessment and Service Plan following the incident. Additionally, the report notes staff will be retrained on elopement response as well as door safety and monitoring procedures. Additionally, the RCC stated (R1's) primary care physician is looking into possibly modifying medications (R1) is currently taking. The RCC stated she will look into offering a different kind of monitoring device, if needed, that is compatible with the current Wander Guard system. Per California Code of Regulations, Title 22, Division 8, Chapter 6, the following (1) deficiency is being cited related to resident (R1), on the 809-D page. There is a civil penalty also being issued due to a repeat violation. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, May 28, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(6) · Plan of correction due date: May 29, 2026

87705 Care of Persons with Dementia (f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (6) Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This requirement is not met as evidenced by: Based on documentation reviewed and an interview conducted, the Licensee did not ensure that resident (R1) was unable to exit the facility, unassisted, on May 26, 2026 (10:53 am), which posed an immediate health and safety risk to residents in care. (R1) was returned to the facility around 12:14 pm, with no injuries noted.the state’s words, verbatim · CDSS document, May 28, 2026

Plan of correction: Licensee/Administrator agree to conduct training on the timing of the egress door, specific to when the alarm sounds and when the door unlocks. The Administrator will hold an elopement drill today (pm shift) to note which caregivers attended to the alarms with urgency and who did not, and note the reason they did not and follow up with disciplinary action. (R1's) care plan was updated with more details of care needed to address the elopement risk. The facilitly will consider obtaining another type of bracelet/anklet that (R1) cannot remove easily. The facility will continue to communicate (R1's) primary care physician. Documentation of training due to CCLD by tomorrow, 5/29/26 (COB).

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Magda Luis, Interim Administrator. LPA stated the reason for the inspection was to follow up on (2) incident reports recently submitted to the Department. LPA discussed the incident reports in the Administrator's new office space that was in the process of being converted from the salon. Resident (R1) fell in the lobby area on May 8, 2026 (2:50 pm). The receptionist observed (R1) to be lying on the floor with their elbow and upper right arm bleeding due to sustaining a skin tear after the fall. Emergency medical services were contacted, arrived at 3:10 pm, and assessed (R1), who was sent out for further medical evaluation due to a possible head injury. Hospital discharge paperwork notes that (R1) returned to the facility the same day with a discharge diagnosis of Closed Head Injury and Skin Tear of upper extremity. The administrator stated (R1) tends to ambulate too quickly with their wheelchair, and staff needs to continue providing reminders to walk slower. LPA and the administrator observed (R1) to be ambulating with their wheelchair throughout the corridors during today's inspection. Resident (R2) complained of chest pain and dizziness on May 9 ,2026 (2:00 pm). A Med-Tech staff attempted to contacted Home Health at 2:00 pm and then called emergency medical services who arrived at 3:05 pm. The Administrator, primary care physician and responsible person were also notified. (R2) returned the same day with no changes and will follow up with their primary care physician. The facility placed (R2) on (4) status checks each shift and will contact the primary care physician with any changes in condition. LPA and the Administrator observed (R2) resting comfortably in their room during the inspection. The administrator stated (R2's) symptoms were attributable to a secondary diagnosis of anxiety. It appears the facility took timely action in seeking medical attention for each resident. There are no deficiencies issued in this report. Exit interview. Report provided.the state’s words, verbatim · CDSS document, May 14, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Magda Luis, Interim Administrator and Rachael Robert, Resident Care Coordinator (RCC). LPA stated the reason for the inspection. LPA, the Administrator and the RCC discussed the following (2) recent incident reports recently submitted to the Department. Resident (R1) had an unwitnessed fall in their room on 5/1/26 (4:00 pm) and fell face down on their face. Emergency Services were called due to the observed injury and (R1) was admitted to the hospital with a diagnosis of a nasal fracture. (R1) returned to the community on 5/4/2026 and went to a follow up medical appointment where there were some medication changes, including for pain medication. LPA observed (R1) resting in their bed at the start of today's inspection. LPA observed bruising on (R1's) nose and mouth/chin area. (R1's) family member arrived to take resident to a scheduled medical appointment. LPA reminded (R1) to ask for assistance when trying to get up and ambulate and to use their walker, which was in the room. The Interim Administrator stated (R1) probably fell when trying to get up from bed quickly, confirming (R1) is eating well and will let staff know if they are experiencing pain. The RCC stated a bed alarm has been placed near (R1's) bed and (R1) is also using a walker more. The Administrator confirmed this is the first fall for (R1) since moving to the community in January 2026. LPA discussed the recent hospice death of resident (R2) on 5/2/2026. The Administrator stated (R2) passed peacefully and had not exhibited any behaviors recently since being admitted to hospice in August 2025. The facility took appropriate and timely action in seeking medical care for (R1) after their fall. There are no citations issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, May 7, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Rachael Robert, Resident Care Coordinator (RCC). LPA stated the reason of the inspection. LPA and RCC discussed the following (2) recent incident reports submitted to the Department. Resident (R1) left the facility unassisted on April 19, 2026 (5:05 pm) by exiting through the back gate. (R1) was brought back by a nearby neighbor approximately (20) minutes later. The RCC stated staff present during the incident have been held accountable due to not following all protocols when an alarm is activated. The RCC stated the protocols are that staff is to look at the monitor which shows interior/exterior camera footage, communicate with other staff by radio, and allow the alarm to run until the resident is located. The RCC explained that a staff was leaving at the time the alarm was activated, but the alarm was immediately shut off which caused some staff to think (R1) had already been located. A follow up in-service staff training was held on April 21, 2026 to address the miscommunication error and not following proper protocols. In addition, (1) staff received a disciplinary action on April 20, 2026. LPA and the RCC toured the building and observed/tested multiple exit doors. The RCC demonstrated how to properly ensure the egress door is locked, after being activated, including waiting a few seconds for the door to close/lock and staff possibly needing to enter a code before walking away from the exit door. The RCC stated daily radio checks are completed and proper protocols are discussed in daily Stand-up meetings with staff. LPA reviewed (R1's) physician's report which notes (R1) is not able to leave the facility unsupervised due to their primary diagnosis. The RCC stated (R1) likes to walk around inside the community and outside as well, and the new staff was not familiar with (R1's) behavior due to being off work for an extended period due to personal reasons. *cont on 809C-1.. 809C-1. LPA and the RCC discussed resident (R2) who had an unwitnessed fall on April 12, 2026 (4:00 pm) after slipping on the floor in their resident bathroom. (R2) requested to go to the Emergency Room due to complaints of back pain and a leaking colostomy bag. (R2) returned the same day with a new colostomy bag and continued to receive Home Health services, which include Physical Therapy. (R2) continues to receive checks (4x/shift) and staff will promptly report any changes in condition to the primary care physician. The RCC stated (R2) was sent out to the hospital on April 19, 2026, due to an issue related to the colostomy bag and is scheduled to return to the community later today, possibly with a bed alarm. The facility promptly sent (R2) out for further medical treatment after communicating with Home Health. Per California Code of Regulations Title 22, Division 6, Chapter 8, the following (1) deficiency is being cited related to resident (R1), on the 809-D page. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 22, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(6) · Plan of correction due date: Apr 22, 2026

87705 Care of Persons with Dementia (f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (6) Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This requirement is not met as evidenced by: Based on documentation reviewed and an interview conducted, the Licensee did not ensure that resident (R1) was not able to exit the facility, unassisted, on 4/19/2026 (5:05 pm approximatey), which posed an immediate health and safety risk to residents in care. Resident was returned to the facility, uninjured, 20 minutes later, at approximately 5:25 pm.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Staff training on Delayed Egress Doors and the Wander Guard System was conducted by the RCC on April 21, 2026. LPA obtained a copy of the training agenda/attendees. Additionally, daily radio checks are completed as well as reminders during stand-up (9:15 am) and at cross over meetings (3:00 pm). The facility will obtain an updated Physician's Report to accurately reflect (R1) being at risk for elopement and unsafe wandering. (R1) initially wore a Wander Guard bracelet on their wrist until/around February 17, 2026, when it was replaced with a Wander Guard anklet. (Consent form on file- signed by (R1) and their responsible person). *THERE IS NO FURTHER ACTION NEEDED- POC CLEARED ON APRIL 22, 2026. *

Type of visit: POC

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Rachael Roberts, Resident Care Coordinator and Allison Lopez, LVN. LPA stated the reason for today's inspection was to clear (2) Plan of Corrections. LPA discussed the Plan of Correction due on/around February 2025 which included documentation of scheduled carpet cleanings. LPA obtained documentation during today's inspection that spot cleaning was done, as needed, prior to carpet cleaning machines being rented to clean the entire community on August 26, 2025 and on September 16, 2025. In October 2025, a brand new commercial carpet machine was purchased and cleaning began to be scheduled on a monthly basis. LPA toured the interior of the facility and observed the carpet flooring. LPA observed the carpet to be clean with no noticeable stains and to have no tears or tripping hazards. The facility did not have any odors present throughout. LPA observed staff to be gathering residents in the dining room before dinner. LPA discussed the Plan of Correction due on/around December 3, 2025 involving in-service training with all staff to discuss following protocols when there is change of condition, including contacting the resident's primary care provider for direction. LPA was provided with documentation of the material covered and attendees for a training conducted on December 1, 2025. A Letter of Deficiency Citations Cleared was provided for each Plan of Correction (2) cleared, along with this report. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 26, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly, and 4 department trainers, arrived at the facility unannounced on 3/24/26 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator , Magda Luis, arrived to assist LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. During the inspection a janitor closet was left unlocked and unattended by house cleaning staff, leaving hazardous chemicals accessible. LPA reviewed 5 resident and 6 staff files. Files were complete. LPA was provided the following documents to update the facility file: Copy of current resident roster and certificate of liability insurance. As a result of this investigation, a deficiency was noted. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Exit interview conducted with the Director and copy of report and appeal rights emailed to the facility.the state’s words, verbatim · CDSS document, Mar 24, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Jennifer Duenas, Sales Operations Support. LPA stated the reason for today's inspection was to discuss (1) incident report recently submitted to the Department involving resident (R1). LPA and RCC discussed the incident when (R1) had an unwitnessed fall in their room on January 24, 2026. (R1) complained of pain in their mid-back and neck and was went out for further medical attention. (R1) was admitted to the hospital with a diagnosis of a pelvic fracture with possible surgery. The next day the hospital advised the facility surgery would be performed. At this time, the facility is waiting for an update on (R1's) recovery status and when they will return to the community. The Sales Operations Support manager stated that (R1) is continuously walking throughout the day when not sleeping and refuses to use a walker. The facility will request an updated physician's report since the resident has been out of the community for more than (3) days and will update the care plan as needed. LPA obtained a copy of (R1's) current physician's report and care plan during today's inspection. Also discussed today was the recent hospice passing of resident (R2). The Department received a completed LIC624A yesterday falling resident's passing. The facility will submit an amended death report as the date of death was incorrectly reported as December 14, 2025. LPA conducted a brief health and safety inspection to observe residents in care. LPA observed many residents attending a communal birthday celebration. There are no citations in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 29, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Rachael Robert, Resident Care Coordinator (RCC). LPA stated the reason for today's inspection was to discuss (1) incident report recently submitted to the Department involving resident (R1). LPA also completed an interview related to a collateral visit. LPA and RCC discussed the incident when (R1) fell on January 21, 2026 (3:30 am). After falling (R1) yelled for staff assistance and staff promptly found (R1) on the floor in their room, complaining of severe pain on their right hip. Hospice staff was immediately contacted and recommended (R1) be given PRN medication for pain and/or anxiety. A non-emergency medical transport company arrived and assessed (R1) and determined with the hospice company to take (R1) out for further medical evaluation. The facility was contacted by the hospital physician on 1/21/26 (5:48 am) to confirm (R1) had a fracture on their right side hip. The RCC indicated (R1) had a partial hip surgery also on 1/21/26 and hospice has been coordinating with the hospital since then regarding (R1) transferring to a skilled nursing facility. The RCC stated (R1) regularly uses a walker and staff will always monitor them. The RCC confirmed with care staff that (R1) does get up at night, regularly, on their own to use the toilet, and has not fallen before, in over a year. It is not clear how (R1) fell, but when (R1) returns, they will be placed on 48 hour alert charting and have the NOC staff proactively assist with toileting breaks. It appears this was an isolated incident and staff responded in contacting hospice and outside medical attention. There are no deficiencies issued in this report. Exit interview. Copy of report provided to RCC.the state’s words, verbatim · CDSS document, Jan 23, 2026

Allegation investigated: Staff does not provide adequate supervision resulting in resident falling and sustaining bruising.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on October 14, 2025 and initially met with Resident Care Coordinator (RCC), Rachael Robert. LPA stated the reason for today's inspection. LPA met with Jennifer Duenas, Sales Operations Support. During the investigation, LPA interviewed the Administrator (in October 2025), (1) Med-Tech staff and (3) caregiver staff. LPA attempted to interview (R1) on October 15, 2025, but was unable to due to their diagnosis of Dementia and limited verbal ability. (R1's) family member was contacted for information also. Documentation was reviwed related to (R1), including their physician's report, care plan, charting notes, hospital discharge paperwork, email correspondence and other documentation. The results of the investigation are as follows: *cont on 9099C-1.. Unsubstantiated 9099C-1. Resident (R1) moved to the community in September 2023 with diagnosis of Dementia. (R1). The physician's report (LIC602) (completed on 7/22/2024) states that (R1's) primary diagnosis of Dementia is "longstanding, gradually worsening over time" and (R1) is needing some assistance with most ADL's. (R1) "has been on Memantine for some time" and "now with worsening behaviors has been throwing things at memory care, yelling, no clear triggers" but staff at the memory care state (R1) has "worse behaviors after (the family member) visits". The LIC602 notes (R1) has multiple secondary diagnoses, including Behavioral Change, Cataracts Bilateral, decreased vision in both eyes, and falls. The LIC602 also notes (R1) has aggressive and wandering behavior. Allegation: Staff does not provide adequate supervision resulting in resident falling and sustaining bruising. The allegation states that on 10/6/2025, resident (R1) was observed to have dark purple bruising on their neck and face which was sustained when (R1) fell while trying to rise from their seat at a table in the facility's dining room. (R1) was observed on 10/07/2025 and noted to have a swollen area above their left eye (on their eyebrow area) that was purplish in color with bruising running down the left side of their face to the middle of her neck and photos were provided to the Department. The facility states that (R1) rose from their seat, tripped, fell and hit their face on the floor, but there was no explanation provided for the bruising to their neck. (R1’s) family member stated in October 2025 that they are at the facility regularly and for the past month, has been trying to tell the staff that (R1) is a fall risk. This family member stated they believe (R1) sustained bruises to the face and neck because staff, (S1), who works on the "pm" shift, did not provide supervision as she leaves the dining area and cannot be found. The administrator stated on 10/15/25 that (R1) "cries, yells and tries to hit staff" and confirmed an incident report was submitted was submitted to the Department on 10/2/2025 for a "witnessed fall" on 10/1/2025. The Administrator added that she was recently made aware that (R1’s) family member has been regularly visiting (R1) late, up until around midnight, and the visit will usually take place in the halls or TV area. The administrator stated these late visits have been "disrupting (R1’s) sleep pattern" and (R1) is "very tired" when woken up at 7:00 am for breakfast, stating that (R1) is only getting a maximum of (7) hours of sleep each day. The administrator explained that (R1) "wanders, cries and hits their head on the wall” as they miss their family member after the visit ends. *cont on 9099C-2.. 9099C-2.. LPA and the Administrator discussed (R1) falling in the dining room on 10/1/2025 (11:47 am). The facility stated that there are a minimum of (3) staff who assist with serving residents all meals. On 10/14/25, (R1's) health care group advised that staff must assist (R1) with ambulating and the service plan has been updated accordingly. The administrator stated that on the lunch shift, a manager helps the kitchen staff serve meals and caregivers will rotate on who passes the food to residents. The administrator added that after the residents in the dining room are served, (1) staff will serve trays to residents in the rooms, and commented "not that many residents get lunch trays in their room- there are (7) total and stated it takes about (15) minutes. LPA asked the Administrator about what caused the bruising on (R1's) neck, and she stated she thinks it was "caused from the fall", commenting "it depends on (R1's) mood if they allows staff to assist". On 11/4/2025, the administrator stated that (R1s) family member is no longer visiting after 9 pm, when visiting hours end; however, (R1) "continues to fall" and was sent out on 11/3/2025, after having an unwitnessed ground level fall, returning the same day with diagnosis of hematuria. The administrator indicated that (R1) will be assessed 4x/shift and any change is to be reported to Primary Care Physician. Follow up appointment was on 11/4/25 - Seroquel 50 mg was discontinued but Seroquel 25 mg remained unchanged. Also discussed on 11/4/2025 was a prior unwitnessed fall on 10/29/25 (10:26 am)- Resident was crying extensively and exhibiting a behavioral expression, and was sent out for further medical evaluation due to complaining of neck pain. Discharge papers state the discharge diagnosis was a "fall and contusion of face" but does not mention neck pain. LPA reviewed the LIC624 submitted on 10/2/2025 for the fall on 10/1/2025. The LIC624 states that (R1) was "ambulating in the dining room, had a fall and landed on the floor hitting their face. (R1) was sent out for further medical evaluation and returned the same day with a diagnosis of "head trauma and periorbital hematoma of the left eye". Discharge papers confirm this discharge diagnosis. Charting notes document that on 10/1/2025 (11:47 am),(R1) fell while ambulating in the dining room, landing on the floor and hitting their face. (R1) was taken to a local hospital, and an injury was noted of a knot on the left eyebrow/forehead. Notes made on later on 10/1/2025 (3:13 pm) indicated (R1) would be returning to the facility later that day and there is “significant swelling by the left eye”; however, there was no internal bleeding, or new med changes and the CT scan is clear. *cont on 9099C-3... 9099C-3.. Notes made on subsequent days reflect that the “swelling is going down”; however, resident is still wandering around the facility with her eyes closed at times, and (R1) has been falling asleep during meals during the shift. Notes from 10/6/2025, document that (R1) became agitated and emotional on the NOC shift when their family member was trying to leave, and (R1) “kept getting up and wandering around” the community. Staff (S1) stated she began working at the community in May 2025, works on the "pm" shift from 3:00 pm- 11:00, and assists residents with supervision in the dining room. (S1) indicated she "never witnessed (R1) fall". Another staff stated (R1) has had a lot of falls and bruising as a result, and (R1) wanders around the community. This staff confirmed he has "never seen (R1) fall- but only after they fell", commenting (R1) is "very wobbly". This staff added that he tries to calm her down as she "cries a lot". LPA asked how (R1) may have injured their neck as well as their face/nose when falling in early October 2025. This staff replied "I’m not sure how (R1) injured their neck- residents fall in different ways- we can't restrain them". LPA observed (R1) sitting in the dining room on 10/15/2025 (1:15 pm) and observed the left side of their face, above and below their eye, to be yellowish purple. LPA attempted to engage in conversation about how the bruising occurred, but (R1) could not explain it, and only commented “I think it hurts”. LPA observed (R1’s) eyes to be closed but then (R1) to slightly open them when LPA asked if they could open their eyes. On 10/15/2025, LPA spoke to a Med-Tech staff and caregiver staff who were also in the dining room at that time. The Med-Tech staff commented that she recently spoke to a representative at (R1’s) health care plan about the new Gabapentin prescription, which was prescribed as it "calms their nerves in pain and on their head". The Med-Tech stated (R1) is "not eating breakfast as (R1) is tired" in the morning and has "walked with their eyes closed and bumped into walls" on some mornings. The Med-Tech confirmed that (R1) has been "crying a lot, which has been normal lately". A care giver staff, stated that (R1) has been "screaming and walking into the walls" a lot lately. LPA reviewed an email sent on 10/11/2025 from the administrator to a representative at (R1's) health care group. The email states that (R1) has had a "change in condition- getting aggressive, crying yelling and swearing" two to three times daily, and staff need to stay with (R1) for at least an hour. *cont on 9099C-4. 9099C4. The email states that the facility will reach out to the health care group each time this issue occurs, medication changes have been made but the behaviors still continue. Finally, the email states that the facility thinks (R1) needs a higher level of care and to advise. The health care group responds by including the assigned representative to the email thread. On 11/5/2025, the facility administrator requests via email that a conference be scheduled with the family member also to discuss how to prevent any more falls, safety of resident, resident care and other topics. LPA was advised on 12/4/2025 by a hospice nurse that (R1) was placed on hospice services on 11/19/2025. The nurse indicated that Lorazapem and blood pressure medications have been stopped as they were making (R1) dizzy, contributing to falls. The nurse also stated that pain medications have increased and (R1) hasn't fallen since these medication changes. The facility reported (R1) to have passed later in December 2025. On 11/18/2025, the facility was cited for not ensuring facility staff provided the necessary interventions on 8/5/2025 when (R1) was running in the facility and later fell, sustaining a nasal bone fracture and laceration on the nose and lips, requiring stitches in the emergency room. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid- there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 13, 2026 · control 59-AS-20251014152318

Allegation investigated: Staff hit resident. Staff do not provide adequate food service. Staff cannot communicate with residents due to language barrier.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on October 14, 2025 and initially met with concierge staff. LPA met with Jennifer Duenas,Sales Operations Support, shortly after arriving, and stated the reason for today's inspection. During the investigation, LPA interviewed the Administrator (in October 2025), the Resident Care Coordinator (RCC), the Activity Director, (1) Med-Tech staff and (4) caregiver staff. LPA observed the dining room on (2) separate occasions and reviewed documentation as appropriate. The results of the investigation are as follows: *cont on 9099C-1.. Unsubstantiated 9099C-1. Allegation: Staff hit resident. The allegation states that staff (S1) was observed to hit resident (R1) on/around mid-September 2025 while staff was pushing resident back to their room. The allegation states that when (R1) became agitated, staff (S1) became frustrated and hit (R1) in the shoulder. The facility submitted a Report of Suspected Dependent Adult/Elder Abuse (SOC341) to the Department on September 12, 2025. The SOC341 states that on September 6, 2025 (approximately 5:00 pm), a family member observed (R1) to be having an aggressive behavior during dinner time and hit staff (S1). The report states that (R1) was hit on the back on the left shoulder by (S1), who then took (R1) back to their room, stating to (R1) they had to go back to their room. The report notes the Ombudsman's office was also notified of the alleged incident by fax. The administrator stated on October 15, 2025 that (S1) was suspended accordingly and following their internal investigation, it was determined that the alleged incident did not occur and (S1) was allowed to return to work. LPA interviewed (S1) who was adamant they did not hit (R1) and this is a "false claim". (S1) explained (R1) started to get angry when they were sitting in their wheelchair in the dining room because one of the caregivers stated (R1) is "not supposed to be in the dining room due to being infected" with something contagious. (S1) stated when they tried to take (R1) in their wheelchair back to their room (R1) then " tried to hit" them, and a Med-Tech arrived to assist and was able to calm (R1) down. (S1) stated he and staff, (S2)were the only staff present when (R1) became agitated, prior to the Med-Tech arriving and confirmed they "did not hit the resident (R1) back" explaining they "can't do that" and fully is aware of that. (S1) described (R1) to be "shaking in his wheelchair, with uncontrolled movements". (S1) stated they had the next two days off from work, but when returning, they "had to be reassigned to the other side" of the facility where (R1) does not reside. (S2) stated to LPA she did recall being in the dining room on September 6, 2025, around dinner time, and did not observe either (R1) hit (S1) or (S1) hit (R1). Charting notes for (R1) do not document anything information about the alleged incident; however, the notes reflect that (R1) was "very agitated" with staff on the following day around 11:30 pm. (R1) moved to a higher level of care on October 20, 2025 and was not able to be interviewed. *cont on 9099C-2.. 9099C-2... Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid- there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff do not provide adequate food service. The allegation states residents will complain about being hungry, but staff will not provide any snacks in between breakfast and lunch and lunch and dinner. The administrator stated the facility serves snacks, between meals and there is a snack cart, with fruit and sandwiches, that is wheeled around during activities. She explained that snacks are left in the kitchen and staff will get them if a resident asks and that some family members will bring snacks in that are kept in the Medication Room. LPA spoke to a Med-Tech and observed snacks for (2) residents to be stored in the medication room on December 22, 2025. The RCC stated on December 4, 2025 that some residents go to bed after dinner and some residents request snacks, explaining the caregivers make sure the Med-Techs are also nearby to assist residents with snacks. The RCC stated snacks are offered such as crackers, yogurt, Ensure drinks, and a "lot of fruit" and expressed she has "not ever seen snacks run out", and "many families will send snacks" for residents which are kept in boxes in the medication room. The RCC confirmed care staff are familiar with which residents have snacks stored on site. (4) care staff were interviewed. One staff stated snacks offered at the "pm" time are "small snacks"- and consist of "cookies, fruit, bananas, strawberries, mango" and confirmed staff will serve snacks to residents "wherever they are"- in their rooms or in the dining room or common area. This staff commented, "We never run out of snacks". A second staff stated she feels there are enough snacks offered to the residents on the "am" shift and provided examples of snacks as: Oreos, Graham crackers with peanut butter, fruit cups and sometimes bananas, but was not aware if there are sufficient snacks on the "pm" shift, of if they have ever run out. A third staff confirmed snacks are offered after lunch, and staff will serve snacks after lunch and during Bingo also, residents like snacks and are "always wanting food". *cont on 9099C-3.. 9099C-3..A fourth staff stated snacks are offered, at 4:00 pm, during activities, and around 7:00-7:30 pm, after dinner. This staff indicated that after dinner snacks consist of cookies, crackers, sandwiches, PB&J and ham and cheese, and bananas, and asserted "They need better quality snacks and more sandwiches and fruits" and also "more choices with beverages", including sugar free drinks , such as lemonade." This staff explained that a snack cart is left by the kitchen after dinner and by 7-7:30 pm, there is "nothing left" on it. This staff commented that some residents are "always asking for snacks", especially around 8:00 pm- 9:00 pm, stating "sometimes they don't have enough snacks, staff want to see consistent snacks, and staff should have access to the kitchen". LPA observed morning snack just served on December 4, 2025 (10:20 am) and (2) two residents eating a fruit cup (cut up pears) in one dining room. While walking to the other dining room, LPA observed a resident sitting in the common area in the hallway eating a fruit cup. LPA spoke with Activity Director who confirmed snacks are served during morning and afternoon activities at 2:00 pm, pointing to a tray of covered fruit cups near the punch container. This director confirmed she will offer snack to residents in the dining room and also to those sitting in the common areas/hallways. On December 22, 2025 (3:45 pm), LPA observed a partial plate of cookies in each dining room that was served for afternoon snack. A Med-Tech confirmed residents were served peanut butter and jelly sandwiches for morning snack today and that there are a few specific residents who will let staff know when they want a snack in the evening. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid- there is not a preponderance of the evidence to prove that the alleged violation occurred. *cont on 9099C-4.. 9099C-4.. Allegation: Staff cannot communicate with residents due to language barrier. The allegation states staff cannot communicate with residents because staff cannot speak English, and staff will have to speak on a walkie-talkie and have it translated. The administrator stated on October 15, 2025 that there are typically (4) staff on a shift, and staff know enough English to communicate with the residents. (4) caregiver staff were interviewed. Both "am" staff indicated that there are no issues with staff not being able to communicate with residents, and stated "on the "am', we have good walkie-talkie etiquette". One "pm" staff interviewed stated "everyone knows how to speak in English" and there is no translation needed. A second "pm" staff stated some staff speak Spanish at the facility and do use a walkie-talkie to interpret for each other, and there were (2) staff who previously worked at the community who "could not speak English very well", but there are currently no staff who need other staff to assist. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid- there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit inter view. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 22, 2025 · control 59-AS-20251014152318

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Rachael Robert, Resident Care Coordinator (RCC). LPA stated the reason for today's inspection was to discuss (2) incident reports recently submitted to the Department. LPA met with Interim Administrator, Magda Luis, at 11:35 am. LPA and RCC discussed resident (R1) who fell in their room on November 21, 2025 (8:35 am). Staff found (R1) sitting on their bed and bleeding from a wound on the upper right side of their forehead that was sustained from a previous fall on October 29, 2025. A Med-Tech contacted (R1's) health care provider around 9:00 am to inform of the bleeding and was advised to apply pressure to control the bleeding. At 9:33 am, the Med-Tech called the health care provider back to advise that the bleeding from the wound was not able to be controlled, and (R1) stated they were feeling light-headed. The facility was advised to send (R1) to the Emergency Room and a medical transport arrived at 10:05 am. (R1) returned to the community later the same day and with no new orders. The RCC stated (R1) has the habit of picking their wound and since this incident, staff have placed a wrap around (R1's) head to deter resident from picking the wound. Staff will also try and redirect (R1) if they are observed to be picking at the wound and they will continue to provide first aid care. The administrator stated (R1's) wound is healing well. LPA and RCC discussed a recent fall for resident (R2) with the hospice nurse who was present. (R2) fell on November 22, 2025 (12:50 pm) out of bed onto the floor and was bleeding from their nose and mouth. Staff immediately contacted the hospice company and was not able to speak to a nurse until 1:30 pm, at which time hospice staff advised that (R2) be sent to the emergency room. Discharge papers show (R2) was treated for a fall and a "comminuted fracture of nasal bone". cont on 809C-1.. 809C-1.. The RCC stated that (R2) has been very active lately and staff are monitoring them more. RCC added that (R2) has not been eating lately and hospice is making daily visits. The hospice nurse joined the conversation and confirmed (R2) began receiving hospice services on November 19, 2025 and last ate solids on November 23, 2025, following their last fall. The nurse explained that (R2) is not able to swallow at this time and their medications, Lorazepam and blood pressure have been stopped since they may have been contributing to the falls. The nurse explained that medications for pain have increased and the medication changes seem to be effective as (R2) has not fallen since, and (R2's) vitals remain good. The nurse and RCC confirmed that (R2) is taking sips of liquid only at this time, and is sometimes is able to take them with a straw. The nurse added that the facility care givers have been providing extra care and more frequent checks to (R2) and staff has also been continually contacting hospice with any questions. The nurse stated that a nurse has visited daily to ensure all medication orders/changes were made effectively. LPA reminded the RCC and Interim Adminisrator to be sure to submit all incident reports to the department within (7) calendar days of the incident occurring. It appears the facility took appropriate and timely action in sending each resident out for further medical evaluation. There are no deficiencies issued in this report. Exit interview. Copy of report provided to the facility.the state’s words, verbatim · CDSS document, Dec 4, 2025

Allegation investigated: Staff do not provide adequate care and supervision to the residents.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on August 18, 2025 and met with Interim Administrator, Magda Luis, and stated the reason for the inspection. Also present was Resident Care Coordinator, Rachael Robert. During the investigation, LPA interviewed multiple facility staff, including the Administrator at the time, Interim Resident Care Coordinator, (1) Med-Tech, and (1) family member of resident (R1). (R1) was not able to be interviewed due to their diagnosis of Dementia and limited verbal ability. Additional staff who had knowledge of the incident were not available for an interview. LPA reviewed documentation related to (R1) including, but not limited to, the Physician’s Report, Assessment, Service Plan, Charting Notes, Incident report (LIC624) and Medication Administration Record (MAR) for August 2025. The results of the investigation are as follows: *cont on 9099C-1.. Substantiated 9099C-1.. Allegation: Staff do not provide adequate care and supervision to the residents. The allegation states that on Tuesday (08/05/2025) around dinner time, resident (R1) was escorted to the dining table but managed to wander out of the dining room and into the hall, where (R1) fell and broke their nose in two places, requiring stitches on their lips. The family member stated in August 2025 they are concerned that the residents at the facility aren't getting proper supervision, and staff are not "hands-on enough" to prevent things like this from happening. This family member stated they also have had to lend a hand for (R1) and for other residents when visiting. Two (2) staff interviews conducted on August 19, 2025 revealed that (R1) was running in the hallway earlier in the day on August 5,2025, around 11:00 am, which was unusual behavior for (R1), and this was the first time (R1) was observed to run. The re-assessment (dated July 21, 2025) notes (R1) "will walk around the community very slowly". The administrator explained, on August 19, 2025, that a third staff, who "was not assigned to care for (R1)" let a Med-Tech (S1), working on the "am" shift, know that (R1) was "acting very off" that day, and explained how (R1) was "leaning forward when walking and was very agitated". The administrator indicated that (R1) was "not listening" to staff earlier that day before falling around 4:45 pm. (R1's) re-assessment (July 21, 2025) notes “Staff will observe resident expressions due to UTI’s, will tend to peri care area for cleanliness and report any changes”. The assessment also notes (R1) needs Full assistance with feeding and mealtime support- Staff need to pay attention as some days may need extra help/cueing. The reappraisal also states that (R1) needs "maximum assistance with ongoing strategies to maintain safe and appropriate interactions" and for staff to "provide enhanced interventions and care coordination to de-escalate negative behaviors". The incident report (LIC624) submitted to the Department on August 6, 2025 describes the conditions leading up to (R1) experiencing a fall face down in the hallway on August 5, 2025 (4:45 pm). The LIC624 notes that prior to the fall, (R1) was "observed to be walking at a fast paced around the hallway" and that "care staff approached (R1), but (R1) declined assistance". The report also states that "later during the dining period, the resident was in and out of the north dining room when (R1) accidentally bumped into the door frame of resident room (#), causing (R1) to lose balance and fall face first on the carpeted floor". (R1) sustained a nasal laceration and nasal bone fracture and returned with stitches on their nose". *cont on 9099C-2.. 9099C-2.. Charting notes entered by a Med-Tech staff (S2) who witnessed the fall document that "Resident was seen walking fast paced around the facility- multiple care staff and both Med-Techs tried to get (R1) to have a seat but (R1) got agitated and refused assistance. (R1) walked in and out of north dining room, bumped into the door frame (nearby room), lost balance and fell face first into the carpet". Charting notes entered by the Interim Resident Care Coordinator on August 7, 2025, describe how "prior to the incident, (R1) was observed to be walking at a fast pace around the hallway"; care staff approached (R1) to suggest a seat, but (R1) declined assistance". The notes describe (R1's) agitation just prior to the fall and how (R1) was "in and out of the north dining room when accidentally bumped into the door frame" of a nearby room. The notes also state (R1's) family member was present to take a photo and video of (R1) when the ambulance provider arrived. The administrator stated staff observed a "lot of blood" after (R1) fell, and (R1's) "whole eye area and cheek area were purple", confirming (R1) returned later that day around 9:00 pm with a Urinary Tract Infection (UTI) and 5-day antibiotic". The MAR shows that Amoxicillin 875-125 mg was prescribed to start on August 6, 2025, one tablet every (12) hours for (5) days, until August 10, 2025 and Naproxen 500 mg was prescribed to be given twice per day, on August 7, 2025, as needed for mild pain for (14) days. Additionally, the MAR reflects Aspirin 81 mg was held from August 6, 2025 through August 11, 2025. The Administrator stated on August 19, 2025 that maintenance staff, tried to access the video footage from 8/5/25 (4:45 pm) but was not able to and commented that the video "may not be available after a week". LPA spoke to maintenance staff on this same day who confirmed he was unable to access the video. (R1's) family member stated they will "hold (R1's) hand as (R1) can't see that well" and confirmed they visit (R1) regularly. The physician's report notes (R1) has a visual impairment and does not like to wear their glasses. The care plan notes (R1) needs full assistance with vision care, staff are to assist as individuals living with Dementia may not see from the sides, resident refuses to wear glasses and (R1) "needs to be escorted to meals, hand held and guided". Although the allegation states (R1) was escorted to the dining room prior to the fall on August 5, 2025 (4:45 pm), charting notes made by (2) different staff indicate that (R1) "was in and out of the north dining room, and accidentally bumped into the door frame, causing her to lose balance and fall face first". *cont on 9099C-3. 9099C-3..Based on information obtained, the allegation is found to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 59-AS-20250818132224

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Nov 19, 2025

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that staff provided the necessary interventions on August 5, 2025, starting at around 11:00 am, when (R1) was observed to be running throughout the facility, until 4:45 pm, when (R1) fell near the dining room and sustained a nasal bone fracture and laceration on the nose and lips,, requiring stitches in the emergency room, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: The Licensee/Administrator agree to conduct in-service training with all staff to discuss following protocols when there is change of condition, including contacting the resident's primary care provider for direction, requesting a UTI analysis. Training agenda/date due by tomorrow, November 19, 2025- additional time can be allowed for the training itself (2 weeks).

Allegation investigated: Staff did not provide adequate supervision, resulting in resident sustaining bruises. Staff do not ensure that resident is hydrated. Staff do not maintain facility free from odor.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on September 30, 2025 and met with Editha McCullough, Resident Care Coordinator, and stated the reason for the inspection. Administrator, Veronica Morales, Administrator, returned from lunch shortly. During the investigation, LPA interviewed multiple facility staff, including the Administrator, Med-Techs, Caregivers, a Housekeeper, a Psychiatric and Mental Health Nurse Practitioner, and (2) family members of (R1). LPA reviewed documentation related to (R1) including, but not limited to, the Physician’s Report, Assessment/Service Plans, Charting Notes, Mental Health notes and (2) communications to the facility, Medication Administration Records (MAR), and (2) photos provided to the Department. The results of the investigation are as follows: *cont on 9099C-1.. Unsubstantiated 9099C-1.. Resident (R1) moved to the community on April 19, 2021 with a primary diagnosis of Dementia and a secondary diagnosis of hypertension, anxiety and depression. (R1) remained ambulatory during their entire stay through October 21,2025 and needed moderate assistance with bathing, dressing, and grooming. The care plan (6/17/2025) additionally notes that (R1) needed maximum assistance with toileting, cognitive tasks such as orientation and redirection, and with staff interventions and care coordination to de-escalate negative behaviors. Allegation: Staff did not provide adequate supervision, resulting in resident sustaining bruises. The allegation states that staff did not provide adequate supervision, resulting in (R1) sustaining bruises on their arms. The assessment (6/17/2025) notes that (R1) is independent and doesn’t need any assistance due to not presenting a risk of wandering/elopement but does need moderate ongoing support for disruptive sleep patterns. A family member stated that neither staff nor (R1) are able to state how the bruises occurred. The Administrator stated she was not aware of any bruises and never saw them. When showed the photo, the small circles appeared to be at different stages of healing. The administrator stated (R1) talked to themself a lot and could have bumped into things in their room. Additionally, they could be a side effect of the medication. On October 2, 2025, a caregiver stated (R1) has "spots on both arms and has had bruises for at least a month", commenting she sees them when (R1) reaches for a cup but didn’t know how the bruises occurred but can "see the decline in (R1’s) face". This care staff stated she has never seen (R1) get physically aggressive with anyone and is "really outgoing with residents, giving them a "high fives", verbally, or fist bumps"; however, (R1) will bump into things in their room. A second caregiver indicated she "does not know about any bruises as (R1) won't let staff shower them, and (R1) has "refused the medication for showers to calm them". The photos provided to the department showed three small bruises on each fore-arm. The family members stated they think the bruising aligns with fingers. The resident's charting notes reviewed from August 2025 through September 3, 2025 did not document any bruising on (R1's) arms. With showers not being permitted by (R1), staff was not able to do any skin checks. Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. *cont on 9099C-2. 9099C-2.. Allegation: Staff do not ensure that resident is hydrated. The allegation states staff may not be hydrating (R1) because when visiting (R1) for two hours, staff did not offer resident water, they did not have a water bottle in their room and their urine smelled strong. The care plan (dated 6/17/2025) indicates that moderate assistance is needed from staff with (R1's) eating and drinking, including encouraging hydration. An subsequent assessment (dated 7/25/2025) notes that (R1) needs encouragement with hydration. A housekeeper stated (R1) always fills up their 49'ers cup and has 2-3 cups total and thinks (R1) "drinks enough". A Med-Tech staff stated "(R1) always gets juice in the dining room and always has 2 cups to fill". This staff stated she hasn't seen the 49er cup and hasn't seen (R1) get water but confirmed that staff "regularly offer water to other residents but residents prefer juice". The administrator showed LPA where the juice dispenser is located in each dining room and stated the "punch" is sugar free and only lightly flavors the water so residents will drink it more. The administrator stated (R1's) family member provided a second 49er cup following the meeting on October 10, 2025, and she observed (R1) to be drinking from it. Another caregiver confirmed (R1) can get water without assistance from staff and he is "very good at getting the juice/punch that is available in the dining room". This staff commented that (R1) "eats a lot and does not refuse meals" and confirmed that staff offer liquids to residents in both dining rooms and there is also a dispenser with flavored water which residents know as "punch". A second caregiver stated she will offer water with the medications, and residents are offered water in the dining room. This staff confirmed (R1) will also ask for water and can fill up water by themselves as they are totally ambulatory. This staff indicated that during meals and activities, staff will offer hydration to residents, and there is a punch cart. Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. 9099C-3.. Allegation: Staff do not maintain facility free from odor. The allegation states (R1’s) room smells really bad. Both the care plan and assessment indicate that (R1) needs full assistance with all aspects of bathroom activities and hygiene, and staff need to monitor and check on (R1) periodically to confirm that “toileting has gone successful”. LPA and a Licensing Program Manager observed a strong odor to be in the hallway area near (R1’s) closed door on September 18, 2025. LPA observed a pervasive odor again coming from/near (R1’s) open door on October 15, 2025. LPA did not observe incontinent odors to be present in other areas of the facility during this inspection or subsequent ones. Both the family member and administrator stated that the family had an air purifier delivered to the facility. The administrator stated the purifier was on and working, but it didn't make a significant difference in the odor in the room. Staff interviews indicated that overall housekeeping does an effective job in maintaining odor control throughout the building. A housekeeper confirmed the caregivers will change resident's sheets and clean the bathroom as there is "urine in the floor", and commented that (R1) "peed one time in the shower" and she has not tried to open the window, as (R1) won't allow it "even for a little fresh air". Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid- there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided. 9099A-C-1.. The administrator stated to LPA and a Licensing Program Manager (LPM) on September 18, 2025 that she and staff have "tried everything", including telling (R1), "let's shower and get pizza before the 49'ers game starts", and (R1) will "slam doors" and scream. The administrator stated she has talked with (R1’s) newly assigned psychiatrist who wants to change (R1’s) medications but doesn't want (R1) to be lethargic. During this meeting, it was also discussed how issuing a (30)-day eviction notice may be the appropriate step to take as (R1) has refused to take a shower, or allow staff to help provide essential hygiene care, or change their clothes. The administrator confirmed (R1’s) care plan was updated in July 2025 to reflect (R1’s) continual refusal of showers. On August 1,2025, a virtual meeting was held with (R1’s) mental health provider, (R1), their family and the facility due to (R1) continuing to refuse showers, having soiled bedding, and becoming agitated when prompted by staff and poor hygiene; however, (R1) remains compliant with taking medications. Plan includes “initiating Memantine and Brexplprazole, discontinuing Buspirone and gradually tapering Lorazepam next visit”. (R1’s) family member stated that there was a virtual meeting held on August 28, 2025 with (R1’s) psychiatrist at the time and it was discussed how (R1) continues to refuse to take showers on a regular/daily basis, and that the psychiatrist said to change (R1’s) meds and see how (R1) does. The administrator confirmed the purpose of the meeting was to discuss (R1) continuing to refuse showers, and the doctor dropping (R1) who was changed to a local doctor through a different health care provider on August 30, 205. The mental health meeting notes document the reason for the meeting was due to (R1) “experiencing behavioral issues such as aggression and lack of compliance with hygiene” and that (R1) had not showered in over a month and remains combative with hygiene care”. The notes state that Rexulti 2mg was recently started, with minimal behavioral change and PRN Lorazepam 1 mg #8/month was added for acute agitation prior to giving a shower; (2x/week) Memantine was increased to 10 mg; continue Donepezil; support hygiene compliance, staff to monitor/report consistently. The administrator stated she discussed the family participating through FaceTime in encouraging (R1) to take a shower, but the family felt it was solely the facility’s job to encourage (R1) to do so. *cont on 9090A-C-2.. 9099A-C-2.. The department reviewed a letter, dated August 29, 2025, sent from the psychiatrist to the facility regarding their communications the prior day of “resident’s refusal of showering and clothing changes, and subsequent agitation with staff. Please proceed with administration of PRN medication as clinically appropriate to help calm the patient”. Also decided during the meeting was that (R1) will “transition to a different psychiatric provider who will be able to see the patient in person and provide a more appropriate level of care needed’. LPA reviewed a letter, dated September 25, 2025, sent from (R1’s) current Psychiatric and Mental health Nurse Practitioner to the facility. The letter states it was written to provide a “psychiatric evaluation of (R1) who is currently facing potential eviction due to hygiene -related concerns”. The letter documents that (R1) has not reportedly engaged in bathing or showering for the past two months; however, the resident indicated they have been showering when asked. This medical professional expressed that it is her “clinical opinion that (R1) is presently incapacitated in self-care, specifically regarding personal hygiene”, and there have been several conversations with (R1’s) responsible person on their “disease progression and manifestations, their cognitive capabilities and goals of care and treatment”. The MAR reflects these multiple medication changes. The facility charting notes from June 2025- September 2025 document multiple times when (R1) refused showers or to change their clothes when staff offered to assist and was screaming and slamming doors. The notes also document that multiple attempts were made by staff, at different times of the day, on many days and (R1) still refused. Staff interviews conducted on October 2, 2025, indicated that (R1) will refuse a shower saying they already took one or would take one “tomorrow”. Interviews also concluded that (R1) has shown a decline in condition over the last few months, since around June/July 2025. A Med-Tech staff stated she has seen a decline with (R1) and they have "refused increasingly more over the last 3 or 4 months" and will "slam the door and yell at staff". A housekeeping staff stated (R1) will allow her to enter their room to clean it, and she will ask (R1) "daily about taking a shower and they always tell me they will tomorrow". This staff stated (R1) can be aggressive and thinks staff have tried everything to get them to shower. Additionally, the administrator confirmed that (R1) would not use moist towels provided by the facility or the wipes the family brought in. *cont on 9099A-C-3.. 9099A-C-4.. All staff stated that (R1) will willingly take their medications, on a daily basis, except for the Lorazepam pill to help calm them prior to offering/giving a shower. LPA reviewed documentation written by the facility's Regional Nurse, Allison Lopez, LVN, on September 29, 2025 following her appraisal of (R1) that day. The documentation states that "(R1) requires assistance with dressing, incontinence care and showers but continues to refuse this assistance from staff. (R1) will yell, scream and slam their door when offered assistance, despite the need". The documentation additionally reads that due to the facility being "unable to provide necessary assistance with ADL needs, we have determined that we are unable to meet (R1's) care needs" at the facility and "(R1) is no longer appropriate for residency at the facility and requires a level of care beyond what the the facility can provide". The administrator stated on October 2, 2025 that the facility had not issued an eviction notice and confirmed that to still be the case on a subsequent inspection on October 15 and November 4, 2025. On October 10, 2025, a care conference meeting was held at the facility with the administrator, (R1's) family members and the Regional Nurse. The pending eviction was discussed due to (R1) continuing to not allow staff to provide essential care, specifically with showers and changing clothing. When the family went to tell (R1) that would happen, (R1) threatened to hit one of the family members. One family member indicated that a notice had not been received as of October 2, 2025, and the second family confirmed that a notice had not yet been issued as of November 4, 2025. The administrator indicated that (R1) moved from the facility on October 21, 2025, and a notice was never issued. Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 7, 2025 · control 59-AS-20250930083209

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Veronica Morales, Administrator. LPA stated that the reason for today's inspection was to follow up on an incident report submitted to the Department on October 30, 2025. The incident report relates to resident (R1)who was had an unwitnessed fall on October 29, 2025 (6:20 AM). The caregiver found (R1) lying down on the floor next to her bed. The shift manager was notified and checked (R1) who was found with blood dripping from their forehead. (R1) was sent out for further medical evaluation and returned the same day with no new orders but with a diagnosis of: ground level fall, laceration of forehead, and blunt head trauma. (R1) is not currently taking blood thinners but takes Depakote which can cause minor bleeding or bruises. (R1) has had multiple falls since moving in on/around June 2025. (R1) had a follow up appointment on October 30, 2025 (10:00 am). (R1) has a history of falling and has a walker but forgets to use it, so staff provides cuing. The care plan was updated October 30, 2025 to reflect additional assistance needed with transferring and cuing. On November 4, 2025, (R1) was evaluated given a Post Fall Assessment and evaluated using the Morse Fall Scale on November 4, 2025, which determined (R1) to be a "high fall risk". (R1) was moved to another resident room near better camera coverage and was monitored 4x per shift. LPA observed the prior room to have a night stand next to (R1's) bed and to have less natural lighting. LPA observed the new room to have a taller dresser and more natural lighting. LPA observed (R1) sitting in the dining area earlier today and to have extensive bruising in the process of healing from their forehead to their neck area. The facility will continue to monitor (R1), who will also go to medical appointments as needed. There are no deficiencies issued in this report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Nov 7, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Veronica Morales, Administrator. LPA stated that the reason for today's inspection is to issue an amended report for complaint findings delivered on January 29, 2025 (complaint # 59-AS-20241014152140). Also discussed during today's inspection was how resident (R1) continues to fall and was last sent out yesterday, November 3, 2025, for a medical evaluation. LPA was provided with an incident report (LIC624) from when (R1) fell on October 29, 2025 (10:26 am) in the hallway. Resident was crying extensively and exhibiting a behavioral expression. Resident was sent out for further medical evaluation due to complaining of neck pain. LPA reviewed a second incident report from when (R1) fell on November 3, 2025 (11:40 am). Resident had an unwitnessed fall in the hallway near the South Dining room and was sent out for further medical evaluation. (R1) returned the same day with a diagnosis of a ground level fall and hamaturia. Staff will continue to be closely monitored for (48) hours. A new medication, Keflex 500, was prescribed to be taken every 6 hours for 5 days. (R1) had a follow up appointment scheduled today, November 4, 2025. Seroquel 50mg was discontinued but the scheduled dosage of Seroquel 25mg was not changed. Also discontinued was Gabapentin 100 mg. Facility staff will continue to monitor (R1) 4x/shift and report any changes in condition to the primary care physician and plan to schedule a care meeting with them. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 4, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada and Licensing Program Manager (LPM) Maribeth Senty arrived unannounced to conduct a case management inspection and met with Veronica Morales, Administrator, stating the reason for today's inspection. LPA, LPM and the Administrator discussed the following residents/reports submitted to the Department: Resident (R1's) change in condition that occurred on/around 7/25/25 was discussed. Resident's care plan was updated then to reflect (R1's) refusal of care. During today's inspection, (R1's) medical professional was contacted by phone and explained recent steps taken due to (R1) starting with them, including medication management and changes. It was agreed that the facility will issue a 30-day notice to (R1) and responsible person/s since (R1) continues to refuse essential care. The Administrator agreed to provide a copy of the 30-day notice to the Department for review within (5) days of its issuance. Resident (R2) passed on September 9, 2025 at the facility and was under Palliative/end of life care. (R2) had several falls starting in August 2025 and was sent to the hospital on 8/13/2025 after suffering a stroke while attending their health care center. (R2) returned on August 14,2025 and palliative care was started. The Administrator contacted the Med-Tech staff who observed (R2) who had fallen out of bed on 9/9/25. This staff explained what position (R2) was found in and provided a photograph during the discussion. (R2's) head was between a pillow and the mattress and was not stuck in the bed rails as the facility earlier reported. The facility will submit an incident report for the incident on 9/8/25 since non-emergency medical technicians responded after the fall and assisted (R2) back into bed. *cont 809C-1.. 809C-1.. Resident (R3) was allegedly hit by staff (S1) on 9/6/25 (5:00 pm) when in the dining room. This event was reported to the Administrator by a non-staff person who described (R3) as having an aggressive behavior prior to (S1) hitting (R2) back on the left shoulder. An internal investigation was conducted and it was determined that (S1) was not observed by other staff to strike (R3). Additionally, the Ombudsman investigated the alleged abuse and spoke with (R3) who stated they were not struck, which was consistent with what the facility determined. LPA was provided with a copy of the SOC341 during today's inspection that showed the report was faxed successfully on 9/15/25 (11:32 am). LPA reminded the Administrator that incident reports are due within (7) days of the incident to the Department. It was agreed that due to not having sufficient evidence, (S1) would be able to return to work. Additionally, (S1) has worked at the community for a couple of years and there have been no prior concerns/complaints. (S1) will be assigned to another side of the building upon return. Additionally, cameras may be placed in the dining rooms. The facility appears to have followed facility protocols for working with the resident in trying to provide care, seeking timely medical assistance and placing a staff on administrative leave when an internal investigation is warranted. A tour was also conducted of the interior. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 18, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Veronica Morales, Administrator, stating the reason for today's inspection. LPA and Administrator discussed the following residents/reports submitted to the Department: On 8/26/25, resident (R2) was found holding resident (R1) by the top of their shirt and yelling that (R1) had entered their room and taken a personal item. The Administrator stated (R1/R2) used to be roommates and (R1) was confused and went in the room and took a sweater. Staff immediately intervened and neither resident was observed to have any injuries. (R1) recalled the incident and stated this was the only incident with (R2) and staff assisted promptly. (R2) was not able to recall any part of the incident. LPA observed (R2) to be sitting with a 1:1 care staff, who confirmed she has been providing 1:1 supervision to (R2) who has shown no aggression since this first incident. The Administrator confirmed (R2) started taking newly prescribed medications following the incident and the 1:1 will continue for two weeks approximately. LPA and Administrator discussed resident (R3) who was evaluated for a leg wound and rash on 8/26/25 while attending a day program. (R3) was prescribed a creme to treat scabies and received the first treatment on 8/26/25 and will receive the second treatment on 9/2/25. LPA observed a stocked PPE cart outside (R3's) room during today's inspection and also a staff who was cleaning in the room to be wearing PPE (N95 mask, gloves and shoe coverings). The Administrator stated no other residents or staff currently have signs of a rash, and (R3) is being quarantined in their room. LPA and the Administrator discussed resident (R4) who had (2) falls at the facility, on 7/27/25 and on 8/1/25. (R4's) family and hospice refused to send (R4) to the emergency room except for on 8/13/25, when (R4) was complaining of abdominal pain. *cont on 809C-1.. 809C-1.... The Administrator stated (R4) would always yell/scream for assistance and would sleep a lot also. The Administrator stated (R4) would not have been able to snap/unsnap a belt to keep them upright in the wheelchair. After the fall on 8/1/25 (1:00 pm), hospice staff recommended that (R4) be up in their wheelchair for an hour after meals to assist with digestion. Additionally, hospice nurses would visit 2 times weekly and (R4) would receive bed baths twice weekly also from an assistant. The Administrator stated that hospice never indicated that (R4) had sustained any rib fractures. It appears the facility took appropriate actions following each incident in seeking medical care and reporting to the department. There are no citations issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 29, 2025

Allegation investigated: Facility staff failed to provide adquate supervision which resulted in one resident assaulting another resident, who required hospitalization and surgery.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on April 8, 2025 and met with Veronica Morales, Administrator, stating the reason for the inspection. The facility is licensed for (49) residents, all of whom have a diagnosis of Dementia. During the investigation, the Department conducted interviews with multiple facility staff, residents, hospital personnel, and reviewed multiple pages of documentation for both residents (R1) and (R2), including facility documents and hospital documents. The results of the investigation are as follows: Resident (R1) was found on the floor in their room on 4/7/25 (12:40 am) and stated to facility staff they had been pushed by their roommate, (R2), when walking out of the bathroom of their room. Both (R1) and (R2) were sent to the emergency room for further medical evaluation. (R1) was diagnosed with a right femoral neck fracture and admitted at that time. Surgery was performed on 4/7/25 and (R1) was discharged to a skilled nursing facility on 4/10/25. *cont on 9099C-1.. Substantiated 9099C-1.. (R2) was sent to the emergency room on 4/7/25 following the altercation with (R1) for further medical evaluation. Facility charting notes document (R2) returned to the facility on 4/7/25 (4:56 pm) with medication changes and indicate that (R2) had 1:1 care/supervision for the NOC shift of 4/7/25 to 4/8/25, and staff will be doing alert charting and behavioral charting on (R2). Notes further document at 4/9/25 (2:36 pm) that "(R2) took all medications and 1 on 1 care has been with resident all shift", and on 4/9/25 (9:47 pm) that resident has "had no issues out of baseline; med compliant and eaten all meals". Notes state on 4/10/25 (2:28 pm) that "(R2) will continued to be monitored with a 1:1 and resident's behavior/location to continued to be monitored every 30 minutes round the clock". Staff interviews concluded that (R2) has a history of aggression with staff in the past and has pushed another resident prior to this incident. (R2) also consistently wanders throughout the community and shows exit seeking behaviors. Several staff conveyed in interviews that (R2) should not have been admitted to the facility based on their care needs, as they need specialized care that Citrus Heights Terrace cannot provide. The Department was told by three different staff that (R2) should have been placed in a higher level of care such as a skilled nursing facility. The facility had to implement 1:1 care for (R2), which is not a service the facility provides and was hiring an outside agency to fulfill the 1:1 care role. Based on this investigation, the allegation is substantiated that the facility failed to provide adequate care and supervision. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. (R2), who has a known history of aggression towards residents and staff, was not placed on one-on-one (1:1) supervision until following the latest unprovoked assault which resulted in (R1) sustaining a right hip fracture. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page along with a civil penalty for a repeat violation. An immediate civil penalty in the amount of $500.00 is assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted. *cont on 9099C-2.. 9099C-2.. At the time of the complaint inspection on August, 4, 2025, an immediate civil penalty of $500 was issued. Due to the fact that this was a repeated violation, an additional $500 was levied. The Licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49. Exit interview with Administrator. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 4, 2025 · control 59-AS-20250408122042

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 5, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that adequate supervision was provided to (R2), prior to April 7, 2025 (12:40 am) when (R2) pushed (R1) in their room), causing (R1) to sustain a right femur neck fracture, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 4, 2025

Plan of correction: LIcensee/Administrator agree to provide in-staff training on 8/8/2025 relating to 1:1 care/supervision for residents when needed. Documentation of training due by 8/9/25. Administrator previously conducted staff trainings on 4/29/25; 6/11/25 and 7/11/25 aggressive behaviors; 7/25/25 aggressive behaviors and dementia. A civil penalty in the amount of $500.00 is being assesed- due to this being a repeated violation, an additional $500.00, for a total of $1,000.00, is being assessed in this report.

Allegation investigated: Facility staff failed to properly supervise residents resulting in resident being attacked and hospitalized for injuries.

**This report was amended on August 4, 2025, to reflect additional language being added related to the penalty that was assessed in the original report (dated 7/29/25) and for a possible additional penalty to be assessed following a review to be conducted under Health and Safety Code §1569.49. ** Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on April 1, 2025 and met with Veronica Morales, Administrator, stating the reason for the inspection. The facility is licensed for (49) residents, all of whom have a diagnosis of Dementia. During the course of the investigation, the Department (CDSS) conducted multiple staff/resident interviews and reviewed pertinent documentation related to resident (R1) and residents (R2/R3) who were involved in several recent alterations with (R1). Documentation included resident charting notes, physician's reports, care plans, and incident reports (LIC624) and other documentation. The results of the investigation are as as follows: *cont on 9099C-1.. Substantiated 9099C-1. Allegation: Facility staff failed to properly supervise residents resulting in resident being attacked and hospitalized for injuries. The allegation states on Sunday, March 30, 2025, a resident walked into the resident's (R1's) room while (R1) was sleeping and attacked (R1) who sustained a fractured vertebra and a dislocated joint in the hand. Staff interviews conducted and documentation reviewed confirmed that on March 30, 2025, resident (R2) entered (R1's) room, at approximately 9:30 am, and physically attacked (R1) while (R1) was sleeping. Staff who was present and observed (R2) enter (R1's) room stated they followed (R2) into the room one to two minutes later and observed (R2) to be standing over and hitting (R1) who was resting in bed. Staff called for a second staff to assist with separating the residents from each other. Both residents were sent out for further medical evaluation following this incident. Medical records note that (R1) was sent out to the emergency room at one hospital and diagnosed with “Scapholunate dissociation, unspecified laterality (primary encounter diagnosis), Closed compression fracture of L3 lumbar vertebrae, initial encounter, Rib pain. (R1's) family member confirmed that (R1) was diagnosed with a fractured hand/wrist and fractured lower back. Documentation reviewed confirmed that (R2) was sent to a different hospital and diagnosed with a "behavioral problem". Interviews and documentation concluded that (R2) has a known history of aggression towards residents and staff and had previously attacked (R1) on at least two separate occasions. The Department was told by (3) facility staff during interviews that (R2) should have been placed in a higher level of care facility, such as a skilled nursing facility. Further, interviews and documentation revealed that although (R2's) initial placement was appropriate, (R2) had several changes in condition, including increased aggression, wandering and sundowning and should have been removed from the facility. After the third unprovoked altercation between (R1) and (R2) the facility began to implement 1:1 care/supervision with (R2), which is not a service the facility provides, and began hiring a staff to provide the this care/supervision through an outside agency. The facility failed to implement reasonable and timely interventions to mitigate known risks, leading to neglect. Based on information obtained during the investigation, the Department finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. *cont on 9099C-2.. *9099C-2.. **This report page was amended on August 4, 2025, to include additional language and a corrected penalty amount that was assessed in the original report on 7/29/25.** Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) citations are issued on the 9099-D page along with a civil penalty for a repeat violation. An immediate civil penalty in the amount of $500.00 is being assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted. At the time of the complaint inspection on July 29, 2025, an immediate civil penalty of $500 was issued. Due to the fact that this was a repeated violation, an additional $500 was levied. The Licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49. Exit interview with Administrator. Copy of report and appeal rights provided. 9099A-C-1.. LPA reviewed one report completed by (S1) and submitted to the Department following the incident on March 25, 2025 which states (R1) stepped in when (R3) was yelling at (S1) and "while the exchange of words escalated quickly and before the Med-Tech could step in, the punch was thrown". The report continues "Med-Tech intervention separated the two and I believe only one punch was thrown by (R3). (R1) did not throw any punches". (S1) commented in an interview to LPA that (R3) "was sweet but then could get really agitated" and explained "(R3) had a 1:1 the whole last month they were here, in June, due to their behaviors". A second staff who was interviewed stated in July 2025 that she recalls (R1) and resident (R3) but doesn't recall an altercation between these two residents. This staff commented (R3) moved out recently and confirmed (R3) had a 1:1 prior to moving out earlier this month. This staff was asked if she feels the facility has sufficient supervision for residents and responded "it depends on the resident's mood as much as the supervision". This staff added, "we get a lot of staff from a temporary staffing agency" and indicated she feels these staff "are doing a good job". A third staff stated in July 2025 that she was not at the facility when (R3) had the fight with resident, (R1) but she "heard about the altercation" between these residents. This staff confirmed she provided prior resident, (R3) with 1:1 care/supervision but was "not aware of the reason why (R3) had 1:1", commenting, "I followed (R3) everywhere". The Administrator stated that (R3) was given 1:1 care/supervision following an incident on June 25, 2025, when (R3) hit another resident with a fork. LPA was shown documentation of the 1:1 following the incident. It appears the incident occurred so quickly on March 25, 2025 that (S1), who was present during the entire incident, was unable to prevent (R3) from punching (R1). Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Due to lack of supervision, multiple residents are assaulting other residents. The allegation states a couple of months ago, a female resident pulled a chunk of hair out of (R1')s head. For the past 3 weeks there have been multiple residents assaulting other residents. *cont on 9099C-2.. 9099A-C-2.. A review of charting notes for (R1) documents that (R2) went into (R1's) room on October 25, 2024 (11:00 pm) where there was a verbal altercation, resulting in (R2) puling (R1's) hair out. The notes say (R1) was okay and just "shocked' and (R3) was helped back into their room. LPA conducted a review of incidents occurring in the month of March 2025. Resident charting notes and incident reports documents the following incidents: The Administrator confirmed that on March 25, 2025 (7:00 pm), (R3) became agitated in the TV/Lobby room and got into a physical altercation with (R1), and punched them in the face, hitting them in the eye and then kicked staff who tried to separate the altercation. Following the incident, the shift lead contacted 9-1-1 to transport (R3) to the hospital for further medical evaluation. (R3) returned from the hospital on March 26, 2025 (1:08 pm), groggy from the medication given at the hospital. The facility submitted a report for suspected abuse on March 26, 2025, following an incident occurring on March 26, 2025 (7:45 am). The incident involved( (R2) entering (R1's) room and scratching their arm. The report notes that a Med-Tech was called to (R1's) room after (R2) went in (R1's) room and scratched them. The report notes the event was unwitnessed. (R1) indicated the event was an unprovoked event. (R2) was sent out for further medical attention due to showing agitation and aggression. When a non-emergency ambulance provider arrived to evaluate (R1), (R1) requested to be sent to the hospital. Charting notes document that on March 28, 2025 (3:00 pm), (R3) got into an altercation with resident (R4) in the dining room. (R3) stated to staff that another resident (R4) hit her first. The Administrator referenced a report that (R3) was observed to have red marks in the face but didn't need to be sent out. Charting notes cite other instances where residents (R2 and R3) were aggressive with staff members. The facility conducted staff training related to abuse/aggressive behaviors on April 10, 2025, June 10, 2025, June 17, 2025 and on July 25, 2025. Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 59-AS-20250401083039

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 30, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on interviews conducted and documenation reviewed, the Licensee did not ensure that adequate supervision was provided to (R2) and (R1), prior to March 30, 2025 (9:30 am) when (R2) entered (R1's) room and attacked (R1) while (R1) was resting, which poses an immediate health and safety risk to residents in care. (R2's) care plan, (dated 7/1/2024), notes that resident requires "maximum assist" with staff monitoring behavioral expressions and resident has had "some expressions that Admin is monitoring closely".the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Licensee/Administrator began 1:1 supervision with (R2) following the incident on 3/30/2025 but (R2) moved out on 3/31/25. The Administrator created a policy (on 4/8/2025) addresing when 1:1 staff should be implemented for a resident with behaviors or for other reasons. Training to be conducted in August for all staff, including newer staff, on August 10, 2025. A CIVIL PENALTY IS BEING ISSUED IN THE AMOUNT OF $1,000.00 ALSO.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a)(1)(C) · Plan of correction due date: Aug 12, 2025

87463 Reappraisals (a)The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. (1) Significant changes in condition, as defined in Section 87101, Definitions, include, but are not limited, to: (C) Behavioral expression, as defined in Section 87101, Definitions, that may result in harm to self or others, such as unsafe wandering, elopement, hallucinations, lacking in hazard awareness, or lacking in impulse control. This requirement is not met as evidenced by: Based on documentation reviewed, the Licensee did not ensure that resident (R2's) care plan was updated following resident showing a change in condition with behaviors/behavioral expressions documented back to October 2024 through March 2025, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Licensee/Administrator agree to continue to review each resident's care plan after a behavioral expression, or fall, and update the "Behavioral Expresssion Appraisal and Plan" or "Post Fall Assesment Plan" as needed. A Post-Fall Assessment is completed when the LIC624 is completed. (R3) moved out of the community on/around March 31, 2025. Currently there are no residents with aggressive behaviors.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Veronica Morales, Administrator, stating the reason for today's inspection. LPA and Administrator discussed the following incident reports submitted to the Department, from June 20, 2025 to July 1, 2025. Resident (R1) was observed to have a rash on their back during ADL's on June 24, 2025 (2:00 pm). Resident was sent to the Emergency Room and returned the same day with a prescription for Triamcinolone 0.1% cream. Resident was placed on alert charting to include checks (4) times daily. Two treatments were administered. Resident is currently doing fine, and the rash has disappeared. This is the only case of suspected scabies in the building, and (R1) did not have a roommate. On June 24, 2025 (6:45 pm) resident (R2) was observed to be very agitated and physical with (2) staff, barricading them in their room and not allowing the Med-Tech to administer medication. Resident was sent to the hospital for further evaluation and returned in June 26, 2025 with a new medication, Risperidone 5 mg. LPA received a copy of the completed Behavioral Expression Assessment and updated resident's care plan upon their return. Resident went back on hospice following their return. On June 25, 2025 (12:00 pm), resident (R3) hit resident (R4) with a fork. Neither resident was injured and the residents were immediately separated. The facility completed a SOC341 following the incident and the Ombudsman also investigated. (R3'x) Seroquel dosage was increased and a 1:1 care staff was implemented immediately following the incident. *cont on 809-C.1 809C-1.. Resident (R5), who is a known fall risk, was observed to be walking out of their room without a walker or wheelchair, on June 27, 2025 (8:15 am). While staff was redirecting resident back to their bed or chair, (R5) pulled away and fell on the floor, hitting their side of their body. Resident was sent to the emergency room, and diagnosed with a broken rib. Resident was prescribed pain medications and placed on more frequent checks (4x/day). Resident's family member visits regularly. Resident is recovering well with minimal pain medications and is cooperating with using the wheelchair now. A fall mat has been requested and resident's bed has been lowered. It appears the facility promptly sent residents out for further medical attention in each of the (4) above incidents. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 10, 2025

Allegation investigated: Staff had an inappropriate interaction with resident. Staff did not safeguard resident's personal items.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on March 24, 2025 and met with Veronica Morales, Administrator, stating the reason for the inspection. The facility is licensed for (49) residents, all of whom have a diagnosis of Dementia. During the course of the investigation, LPA interviewed the Administrator, the Resident Care Coordinator at the time, (4) residents, resident (R1), who is the subject of the investigation, and a family member of (R1). LPA reviewed pertinent documentation for (R1) including the physician's report, care plan, and charting notes. The results of the investigation are as follows: Resident (R1) moved to the facility on December 29, 2024 with a diagnosis of Dementia, Diabetes Mellitus Type 2, Depression, incontinence, fall risk and uses a walker or wheelchair. The care plan states (R1) needs moderate assistance with bathing, dressing, grooming,toileting and mobility, cognitive functioning and maximum assistance with medications. The results of the investigation are as follows: *Cont on 9099C-1.. Unsubstantiated 9099C-1.. Allegation: Staff had an inappropriate interaction with resident. The allegation states that staff (S1) had an inappropriate interaction with resident (R1). NOTE: The Department conducted the investigation for the above allegation and separate interviews were conducted for this allegation from the interviews the LPA conducted for the other (3) allegations. Resident (R1) stated that staff (S1) would "rub up against" them and explained when (S1) assisted (R1) from getting up from bed, (S1) would rub up against their back. (R1) stated (S1) would have their clothes on while rubbing up against them and then pull open their "stretchy pants" and lean forward, exposing their private parts to (R1). (R1) stated that (S1) exposed themselves "twice" but would rub up against them "a lot", adding that when they asked (S1) to stop this type of interaction, (S1) would not, so (R1) reported it to the Administrator. (R1) stated Administrator, Veronica, spoke to (S1) about this and now (S1) is not allowed to take care of (R1) anymore. (R1) stated no other staff has exposed themselves to (R1) and has never seen (S1) expose themselves to another resident, commenting they "feel safe" at the facility. Administrator, Veronica Morales, stated she does not believe staff, (S1) exposed themselves to (R1), explaining she has never had any complaints about (S1) before or an issue with (S1) spending too much time in a resident's room. The administrator stated that in the beginning of April 2025, (R1) reported that (S1) was "exposing" himself to (R1) and asking if they could shower (R1). The Administrator stated that (R1's) family members informed her that (R1) has made similar comments while living at other care homes. The Administrator stated she spoke to (S1) in her office about these allegations and (S1) stated it "never happened" although (S1) acknowledged permitting (R1) to use their cell phone to make a call. The administrator explained that she initially decided to reassign (S1) to another section of the facility so they do not provide any care (R1). Additionally, (S1) is not allowed to be close to (R1) or be in their room. The administrator stated that (S1) is "very respectful and a hard worker" and (R1) has not mentioned this incident in subsequent conversations. The administrator stated that (S1) has relocated to a "sister facility" as of 6/11/25, as there was an opening in that related facility. Multiple (3) residents stated in interviews that no staff has ever made them feel uncomfortable or made them do anything they didn't want to do. These residents denied ever hearing about a staff exposing themselves to them or any other resident. *cont on 9099C-2.. 9099C-2.. (S1) denied ever touching (R1) with their private parts, exposing their private parts to (R1), or ever having any interaction with (R1) that could have been mistaken for (S1) exposing or touching (R1) in this way. The family member stated that (R1) "can be confused and have hallucinations" stating "I think (R1) had a lot of dreams they thinks are true and also sexualizes a lot of things- lots of weird stuff", which may be common for "baby boomers". Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff did not safeguard resident's personal items. The allegation states that resident’s (R1) belongings and money have been stolen from their room. On 4/2/25, the Department received additional information that staff are not safeguarding resident (R2's) personal items. The Administrator, Veronica, stated on 3/27/25 she is not aware of any of (R1's) belongings that are missing, including money and confirmed (R1) has a cell phone and has also used the facility phone too. The administrator commented that (R1) "gets confused and then forgets" and has a diagnosis of Dementia and Diabetes. On 5/20/25, the Resident Care Coordinator (RCC) stated that (R1) has not had any items go missing, including a cell phone, and that (R1) lives in a shared room and has called 9-1-1, Community Care Licensing, Adult Protective Services, and the Ombudsman "many times". The RCC stated (R1) is "pretty high functioning and got mad because their daughter won't let them leave to go to church". (R1) stated to LPA on 5/20/25 that the RCC has the list of missing items and "right now I am missing a cane, 4 white towels/washcloths and 27 pairs of white garment bottoms"- (R1) stated she is also missing deodorant and facial scrub and thinks it's "another resident taking her things". (R1) added that her family member took her cell phone because of calls made to Adult Protective Services and the police. On 5/27/25, (R1's) family member stated that (R1) does not have anything of value, including cash, and there is "nothing she is concerned with". The family member indicated she does not recall (R1) having a cane and their needs are being met. When LPA stated (R1) has claimed their laundry has disappeared, the family member stated all of (R1's) items are labeled and she visits (R1) twice weekly and she feels "staff is doing a good job". The family member commented that (R1) is "very paranoid" and it's "been magnified" since (R1) has been diagnosed with Dementia. The family member added that (R1) "can be confused and have hallucinations", which may be common for "baby boomers". *cont on 9099C-3. 9099C-3.. On 5/20/25, the RCC stated that resident (R2) had a prior conservator before a public conservator was appointed. The RCC stated the family member would bring new clothes and remove torn or stained clothing from (R2's) closet every time he visited, every 2 months. The RCC stated the socks (R2) moved in with were "not compression stockings" but were just tall socks, and the Ombudsman came out to investigate the lost socks. LPA was unable to contact this family member, after two attempts. LPA was provided with a list of missing items on 4/10/25 and attempted to contact the prior conservator for (R2) regarding the missing belongings on 4/10/25 but was unable to. The complaint alleges that a list of missing items was provided to the facility on 3/20/25, and the facility was going to look for them, but nothing had been found as of April 1, 2025, and all items were labeled with resident's name. The list includes pants, blouses, laundry basket, blanket, diabetic compression socks, a wallet, and false teeth. LPA discussed the missing items with the administrator more in detail on 6/13/25. The administrator stated she checked (R2's) room in early April 2025 with the RCC after the Ombudsman came out to investigate, and the items were not found in (R2's) room. Additionally, the RCC discussed these missing items at a staff meeting. All that was found was a wallet with identification belonging to another resident (R3), who had since moved out. The family was contacted for (R3). Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided. 9099A-C-1... The administrator stated that all mail is received at the front desk, residents are informed by staff, and then residents will pick up their mail at the front reception desk. The administrator explained that the families receive most of the important mail, but some residents do receive mail. The administrator confirmed that all monthly bills have been paid by (R1's) family members, and there is no balance currently owed to the facility. This information is still correct as of June 13, 2025. On 5/20/25, the administrator stated that (R1) does receive some mail, but staff will hold it and give it to her two family members who visit regularly. The RCC stated on 5/20/25 that (R1) receives mail from two agencies related to their finances, and that she has asked (R1's) daughters to change the address so this mail will not continue to be received by the facility. The RCC stated (R1) has dementia and so this type of mail should go to the family member who holds Financial Power of Attorney. Resident (R1) stated on 5/20/25 that they have not received any mail while staying at the facility, and confirmed the name of their family member who holds Financial Power of Attorney. LPA contacted this family member who confirmed, on 5/27/25, that (R1's) mail is still being sent to the facility address and (R1) wasn't giving (R1's) their important, financial mail to her when it was received at the facility. This family member added that the facility is doing a good job of collecting (R1's) mail and holding it for her when she visits two times weekly and that (R1) has not received any personal mail, such as greeting cards, while living at the facility, but "(R1's) church members have brought them gifts" in person. This family member stated on 5/27/25 that (R1's) bills are current (with no balance) and last month, she provided an outside agency with copies of bank statements showing (R1's) deposits and expenses. The family member confirmed that she stopped paying (R1's) credit card balances, in August 2024, per advise from a financial advisor, and there was a balance owed, as stated in the complaint allegation. LPA was unable to contact the representative from the outside agency for any additional information. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. *cont on 9099C-2... 9099A-2.. Allegation: Staff do not assist resident with obtaining medical care. The allegation says staff is complicit with (R1's) family members who are restricting (R1’s) access to medical care. (R1) stated to LPA on 5/20/25 that their daughters have access to their medical account and that their unpaid bills are affecting their access to medical care. The administrator stated that "there are no issues with medical" services for (R1) and that (R1) is receiving all medical benefits and services she is entitled to. Charting notes document that when resident moved in on December 9, 2024, the RCC was working with (R1's) family member to start home health services. There are no issues noted that (R1) did not receive any medical care but many entries where (R1) was questioning and/or refusing medications ordered for them to take. On 5/27/25, the family member who has Power of Attorney authorization stated (R1) is off insulin and is a "lot healthier" since moving to the facility; however, she is not happy; commenting, (R1)"can be confused and have hallucinations" and stated "I think she had a lot of dreams she thinks are true and also sexualizes a lot of things- lots of weird stuff", which may be common for "baby boomers". This family member stated (R1) had "18 falls since May 2024", including when living on their own, and uses a walker, as recommended, and commented after (R1) had 3 falls in a week and was on the floor for (8) hours, while living on their own, so she and her sister realized (R1) needed assistance. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit provided. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 13, 2025 · control 59-AS-20250324155628

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Veronica Morales, Administrator, and Robert Godfrey, Regional Manager. While at the facility for another inspection, LPA and Administrator discussed an incident report submitted on 6/11/25 for resident (R1), who attempted to elope from the facility. LPA and Administrator discussed the incident that occurred on 6/10/25 (7:30 am). At breakfast time, (R1) was not found in their room and staff heard the back exit door alarm sound. Staff immediately responded and went out the back door towards the right side to look for (R1), who had exited towards the left side of the patio. When (R1) reached the egress gate, they were able to read the sign that said the door would open in 15 seconds. Staff immediately responded to the second alarm sounding and found (R1) just outside the gate, in the parking lot. Staff redirected resident back inside who sustained no injuries. The Administrator stated (R1) had not previously attempted to elope from the facility but may have tried to do so after her roommate moved out on 5/30/25, causing some stress and anxiety. (R1's) family was contacted regarding placing a Wanderguard bracelet on resident for added security following the incident. The Regional Director stated that a new Wanderguard system was recently installed on 6/4/25. Currently there are (5) residents using the bracelet and additional residents can be offered one, if needed. The new system is an update and there are sensors on all (5) exits and Med-Techs receive an alert on their pages when the sensors are activated. The Administrator provided staff training on 6/11/25 to staff that are regularly scheduled and will look into adding some additional cameras on the side of the building also. The facility staff promptly responded to the first alarm and then to the second alarm when (R1) tried to exit. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 13, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Veronica Morales, Administrator, and Ashley Stahl, Resident Care Coordinator. LPA stated the reason for the inspection was to follow up on several incident reports and death reports. The following was discussed: Resident (R1) was verbally aggressive on 5/13/25 to staff, refusing ADL's, and provoking other residents. Resident was sent out and returned the same day with a diagnosis of UTI and antibiotics. Resident is doing better a week later. Resident (R2) had an incident involving feces on 4/23/25 and was sent out that day. Resident's labs returned normal. This was a first incident of this kind for this resident.. Resident's care plan was updated to reflect this behavior. Recently, the Administrator recommended placing resident under hospice care to family due to a noticeable decline. . Additional monitoring with more frequent checks has been implemented and specific undergarment/clothing zip ups have also been suggested. Resident (R3) moved out of the facility recently, on 5/7/25, due to past aggressive behaviors. Resident (R4) was sent to the emergency room on 12/28/24, for an altered level of consciousness. Resident passed on 12/29/24 at the hospital. LPA obtained documentation previously by email but did not conduct a case management inspection. Resident (R5) fell on 1/22/25, was sent to the hospital and diagnosed with a fractured hip. Resident returned the next day with a referral for hospice. Resident passed on 2/6/25. LPA re- requested care plan in effect prior to the fall - due by 5/22/25. LPA had previously received a copy of the updated care plan following the fall. There are no deficiencies issued in this report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, May 20, 2025

Type of visit: Office

On May 1, 2025, at 2:00 PM, a virtual Non-Compliance Conference meeting was held with Sacramento North Regional Office via Microsoft Teams Meeting. Present in the meeting was Licensee, Mark Cimino, mutiple Ciminocare representatives, Regional Manager (RM) Alycia Berryman, Licensing Program Manager (LPM) Maribeth Senty, and Licensing Program Analyst (LPA) Sabrina Calzada. Topics discussed during this meeting were: Current staffing levels, vacancy rate and recent additions Systematic checks in place, options in each resident care plan Falls and post fall assessments. Number of substantiated complaint allegations in the last year. Enhanced resident care planning and interventions. Assessment for alternate placement of residents with aggressive behaviors. Behavioral Expression Assessment before resident is admitted. Staff training on understanding and responding to resident behavior expressions. The licensee was in agreement with the drafted non-compliance plan as outlined in LIC 9111. An exit interview was conducted and a copy of this report will be provided to the facility Administrator via email. A copy will be signed and returned to CCLD.the state’s words, verbatim · CDSS document, May 1, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete a required annual inspection and met with Veronica Morales, Administrator. LPA stated the reason for today's inspection. The facility is licensed for (49) residents, (34) of whom may be non-ambulatory and (15) may be bedridden. There is an approved for hospice wavier for (17) residents and delayed egress exit doors. There are currently (6) residents on hospice. LPA and the Administrator toured the interior and exterior of the facility including the common areas, (5) resident rooms, medication room, (2) dining rooms, activity room, salon, kitchen and staff lounge. LPA observed the facility to be clean, in good repair, and odor-free. Fire extinguishers observed throughout and were last serviced on 7/23/24 There are (3) exit doors, including the front entrance door, equipped with an egress door alarm. Alarms on door alerts and gates are checked daily. There is an enclosed courtyard with seating for residents. The inside temperature measured 73*F. Hot water was checked in (3) resident rooms and measured 116/117*F in each room and is checked weekly. Each resident room has a pull cord in the bathroom and one for each resident near their bed. There is sufficient 2+ day perishable, including fresh produce, and 7+day non-perishable supply of food in the kitchen. Refrigerator/freezer temperatures are recorded daily. Residents do not have access to the kitchen area where sharps are kept. There are (2) activity calendars posted for the month and activity staff will document resident's daily participation in each activity. Laundry machines were all working today, and scheduled monthly maintenance has been implemented. LPA reviewed (5) resident files. Files were organized and contained current physician's reports and care plans. Medications were reviewed for (1) resident. Orders match medications being given and electronic documentation is maintained. Pharmacy to provide Med-Techs with training on all aspects of medications in April 2025. *cont on 809C-2.. 809C-2.. The medication room and medication carts were organized and there are (2) Med-Techs on the 'am" and "pm" shifts. Each medication cart has a complete First Aid kit. LPA reviewed (5) staff files and found them to be organized and contain all the required documentation. Staff are in the process of completing the initial and/or continuing required training through an approved vendor. Documentation was on file. All staff is cleared and associated. All staff will be completing a two-year First Aid/CPR certification. Administrator RCFE #6069635740- exp 5/5/26. All required postings and non-audio cameras are in the common area. Discussed regulation changes made effective January 1, 2025. The Dementia Care Plan has been updated to include these changes. The Admission Agreement was reviewed also and observed to contain additional updated changes. Discussed Guardian roster and how to update staff information. LPA requested, current copy of liability insurance, LIC308 and updated staffing schedule (or LIC500)- due 4/7/25. There were no deficiencies observed during today's inspection. Exit interview. Copy of report left.the state’s words, verbatim · CDSS document, Mar 27, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada and Ombudsman arrived unannounced to conduct a case management inspection and met with Veronica Morales, Administrator, and stated the reason for today's inspection. Also present was Robert Godfrey, Regional Director, and Resident Care Coordinator, Ashley Stahl. The facility submitted an incident report (SOC341) to the Department and the Ombudsman's office on March 18, 2025 regarding resident (R1) who was found on the floor in their room on March 16, 2025 (8:00 am). The report states that resident (R2), who was exit-seeking, walked into (R1's) room and pushed (R1) to the ground, causing them to hit their face and sustain a large bruise and bump on the right side of the face. Both residents were taken to the emergency room for evaluation. The (RCC) was asked to provide additional information on the incident and explained that (R1) told her that (R2) pushed (R1) who fell. The RCC stated the fall was unwitnessed and (R1) could have tried to get (R2) out of their room and fell doing so, as they are "very unsteady on their feet". (R2) returned the same day with a diagnosis of a Urinary Tract Infection (UTI) and new medication to take for (7) days. (R1) returned a few hours later with no new orders and is doing fine. Also discussed was how (R1) told their family member March 11, 2025, when picked up for a doctor's appointment, that they had a rash. The family member reported seeing red marks all up (R1's) arms, thighs and back, and a Med-Tech determined the rash to be scabies. (R1) was given a prescribed creme treatment on March 11, 2025 and a second treatment on March 15, 2025. There was not a scraping done to definitively diagnose the skin condition, however, the rash has improved. Staff will complete a skin check later today when (R1) receives a shower. The facility followed proper reporting and procedural protocols in sending both residents out. An outside nurse will be evaluating (R2) soon again regarding their wandering tendencies. There are no deficiencies cited in this report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 20, 2025

Allegation investigated: Licensee does not ensure facility floors are maintained in clean condition.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on 10/17/24. LPA met with Ashley Stahl, Resident Care Coordinator, and stated the reason for today's inspection. LPA was advised that the Interim Administrator, Magda Luis, would arrive later, around 3:00 pm. During the investigation, LPA interviewed the Administrator, Resident Care Coordinator (RCC), the Maintenance Supervisor, and a family member of resident (R1). LPA also reviewed documentation relating to carpet cleaning schedules. The results of the investigation are as follows: *cont on 9099C-1.. Substantiated 9099C-1.. Allegation: Licensee does not ensure facility floors are maintained in clean condition. The allegation states that carpets in the facility have not been cleaned and have large stains. On 10/21/24, the LPA and Ombudsman toured the interior of the facility to observe the condition and cleanliness of the carpet. The carpet near the hallway area by room #107 appeared to be heavily stained. In the hallway, near room #135, a large puddle was observed as well as an incontinent urine smell and heavily soiled carpet by the door. The Ombudsman reported that a follow up inspection was conducted on 11/1/24, and the carpet was observed to have been recently cleaned in both of these areas after bringing it to the facility's attention . On 1/29/25, LPA observed a large carpet stain near room #133 and in the hallway near the laundry room by room #110. In other areas of the community, the carpet appeared to look clean; however, the solid carpet piece at the corners of the hallways had some marks, which the Maintenance Supervisor indicated wheelchairs can cause. A family member stated the carpet was visibly very soiled with stains on/around September thru October 2024, and there was an odor present also in the hallway. The family member stated the carpet was much better starting in late October as it had been cleaned recently. Carpet cleaning schedules confirmed the carpet was cleaned on 10/23/24, and again on 11/7/24, by a new company. LPA observed both dining rooms to be clean and free from food or beverage spills on the floors on 10/21/24 and on 1/29/25. The maintenance supervisor stated on 2/6/25 that facility carpets, including in resident rooms, are professionally cleaned every 2.5 months, and he will clean any new spots, as needed, with the facility shampooer. Additionally, housekeeping will vacuum carpets daily. The maintenance supervisor stated that the facility started using another outside professional carpet cleaning company in October 2024, and the next cleaning is scheduled for around the end of February 2025. Based on information obtained during the investigation, the Department find the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview with the Administrator. Copy of report and appeal rights provided *cont on 9099C-2... 9099A-C-1...Allegation: Licensee does not ensure sufficient staffing to meet residents’ care needs. The allegation states the facility is very short staffed so the staff are unable to properly assist the residents with their care needs. LPA reviewed staffing schedules for all shifts in October 2024. All shifts showed (4) caregivers minimum and (2) Med-Techs during the "am'" and "pm" shifts and (2) care staff and (1) Med-Tech staff during the NOC shift. LPA also reviewed (40) resident shower schedules for the month of October 2024, from 10/1/24 through 10/21/24. LPA observed schedules to be consistently initialed by facility staff as completed or refused by resident. Most schedules showed residents were receiving a shower for an average of two times per week and some schedules noted when hospice staff gave the shower. LPA reviewed charting notes for (R1) from March 2024 through January 2025. LPA observed that it is documented many times that (R1) refused all ADL care, and could be agitated and combative at times, even when (2) staff attempted to assist resident. The Resident Care Coordinator stated staffing levels are sufficient and (R1) would/will regularly refuse care, food and medications. The Administrator stated (R1's) falls have nothing to do with staffing levels. Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. *cont on 9099AC-2... 9099AC-2..Allegation: Staff neglect resulted in resident sustaining multiple unwitnessed falls. The allegation states (R1)has had multiple unwitnessed falls and staff are not adequately supervising (R1) because of the short staffing. (R1) did not require any medical care after the falls but did have bruising on the face as a result. LPA reviewed charting notes for (R1) and incident reports and noted the following (4) falls: On 3/27/24 (7:30 pm), (R1) was observed on the floor in hallway after an unwitnessed fall. (R1) was sent to the Emergency Room. On, 4/5/24 (12:50 pm), (R1) walked to the front reception area and informed staff she had fallen and was observed to have a knot and bleeding on their head. (R1) was sent to the emergency room following this incident also. On, 9/1/24 (10:10 pm), (R1) sustained an unwitnessed fall and was observed to have scrapes and a bloody nose. (R1) was sent to hospital and returned to the community on 9/2/24 (3:00 am). Notes say Med-Tech confirmed that (R1) did not suffer any other injuries than the facial ones and was given creme. On 9/9/24 (10:30 pm), (R1) was observed following an unwitnessed fall. Notes say resident hit their head. LPA was provided with a photo showing (R1) had sustained (2) black eyes, in September 2024. LPA was provided with another photo, taken on/around 10/10/24, showing bruising on both of (R1's) upper cheeks. (R1) was sent to the hospital and returned 10/11/24 (10:31 pm) with no changes in medications. Staff (S1) was interviewed and indicated they are not aware of any falls and/or bruising (R1) has sustained and they are able to successfully provide care and administer medications to (R1), without (R1) being combative. (S1) stated he has observed bruises on other residents and it's usually from "two residents trying to squeeze through a hallway", commenting he have been bruised before. (S1) and the Resident Care Coordinator stated they have never seen (R1) use a walker. Notes for (R1) document multiple times when resident was wandering throughout the building at night and during most of the day. (S1) suggested that (R1) may have fallen as their "knees were tired" from walking a lot during the day and at night, causing them to fall. (S1) confirmed on 2/6/25 that (R1) had a recent medication change to medications, Losartan and Trazadone, and (R1) now sleeps much better through the night. *cont on 9099A-C-3.. 9099A-C-3..(R1's) care plan was updated on 12/5/24 to reflect an increase in care needs in the areas of bathing, dressing, grooming, dental, toileting, transfer and mobility. The Administrator stated (R1) is a fall risk with the diagnosis of Dementia and their care plan has a minimum assistance with "mobility" since they walk. The family member stated (R1) walks independently and quickly throughout the building and their falls have recently stopped. The family member was not aware of a recent medication change, helping (R1) to sleep better during the night. LPA observed (R1) to ambulate, on 2/6/25, without any assistance. Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Licensee does not provide residents with quality food service. The allegation states the food is not tasty or desirable, and the facility serves mostly junk food that looks cheap and is unhealthy. LPA toured the kitchen and observed the food being prepared as well as the food in the refrigerator and freezer on 10/21/24 (11:25 am). LPA observed a large pot of zucchini/spaghetti and bell pepper added to the ground beef. LPA observe many loaves of multi grain bread, and abundant fresh produce, including salad mixes and bell peppers in the refrigerator and also many bags/boxes of frozen vegetables. Copy of menu was posted in the kitchen. On 1/29/25 (11:45 am): LPA observed the kitchen at 11:45 am. Both culinary staff were present (seasoned staff). LPA observed the refrigerator to be full with milk, eggs, cheese and produce and the freezer to contain meat and vegetables, in the original container/box. On 10/21/24 (12:25 pm). Observed staff to have recently served lunch and residents to be eating their lunches at the tables. (2) residents had pureed food. All other resident plates had spaghetti, zucchini and garlic bread and appeared to be balanced. Good sized portions were observed also. On 1/29/25, LPA observed residents seated for lunch in each of (2) dining rooms. Food was being served around 12:15 pm in the north dining room and at 12:20 pm in the south dining room. Lunch consisted of baked chicken, rice, zucchini and a roll. LPA observed residents to be eating the food and one resident stated it was ''tasty". Residents’ were given portions to fill most of a standard size plate. *cont on 9099A-C-4.. 9099A-C-4... Allegation: Licensee does not provide residents with quality food service. The allegation states the food is not tasty or desirable, and the facility serves mostly junk food that looks cheap and is unhealthy. LPA toured the kitchen and observed the food being prepared as well as the food in the refrigerator and freezer on 10/21/24 (11:25 am). LPA observed a large pot of zucchini/spaghetti and bell pepper added to the ground beef. LPA observe many loaves of multi grain bread, and abundant fresh produce, including salad mixes and bell peppers in the refrigerator and also many bags/boxes of frozen vegetables. Copy of menu was posted in the kitchen. On 1/29/25 (11:45 am), both culinary staff were present. LPA observed the refrigerator to be full with milk, eggs, cheese and produce and the freezer to contain meat and vegetables, in the original container/box. Another delivery would be made on Saturday, 2/1/25. On 10/21/24 (12:25 pm) Observed staff to have recently served lunch and residents to be eating their lunches at the tables. (2) residents had pureed food. All other resident plates had spaghetti, zucchini and garlic bread. Good sized portions were observed also. On 1/29/25, LPA observed residents seated for lunch in each of (2) dining rooms. Food was being served around 12:15 pm in the north dining room and at 12:20 pm in the south dining room. Lunch consisted of baked chicken, rice, zucchini and a roll. LPA observed residents to be eating the food and one resident stated it was ''tasty". Residents’ were given portions to fill most of a standard size plate. LPA reviewed multiple pages of food orders from an outside food service company for orders delivered on 10/5/24 and on 10/19/24. LPA observed a variety of foods ordered that were seen in the refrigerator and listed on the menu. Weekly menus were also reviewed for weeks of 9/30/24- 11/3/24. Each meal reflected a balanced diet, with a fruit and/or vegetable, included. A family member stated in January 2025 that the food had improved lately and is better tasting. Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Feb 6, 2025 · control 59-AS-20241017133934

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Feb 20, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on observations and interviews conducted, the Licensee did not ensure that carpet areas were maintained in a clean, sanitary and odorless condition, on/around September 2024- October 2024, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 6, 2025

Plan of correction: Licensee/Administrator are planning to schedule professional carpet cleaning every 2.5 month or sooner, if needed, and to spot clean frequently. The facility recently changed to a diffrerent company which appears to be cleaning the carpet more throughly. Documentation of scheduled cleanings to be provided to the Department by 2/20/25. Also, any carpet tears will be repaired soon.

Allegation investigated: Staff do not provide adequate laundry services.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to (4) additional allegations of a complaint received on 10/14/24. LPA met with Ashley Stahl, Resident Care Coordinator, and stated the reason for today's inspection. LPA was advised that the Interim Administrator, Magda Luis, was currently out of the building. During the investigation, LPA interviewed the Administrator, Maintenance Director, (3) staff, and a resident's family member. LPA observed the laundry room on 10/21/24, on 1/29/25. The results of the invesitigation are as follows: The allegation states that laundry is not getting completed and delivered back to residents' rooms timely, due to not having enough staff to assist with laundry. *cont on 9099C-1.. Substantiated 9099C-1.. The Administrator stated the "am shift does laundry and the "pm" shift puts the laundry back". confirmed that the NOC shift washes "linens only", and housekeepers will "help start the laundry". The Administrator added that it's "challenging when clothing is not labeled" and confirmed that "laundry is included" in the basic services the facility provides. The Administrator explained that on 10/10/24 the dryer company came out and cleaned all ducts and machines and soon afterwards, one of the dryers did not work properly. The Administrator confirmed that staff has "not used the dryer since Friday", 10/18/24 and that maintenance staff called the repair company on Friday, 10/18/24, to request they fix it. The Maintenance Director confirmed, on 10/21/24, the facility dryer is not currently working, the repair was called in on 10/18/24, and on 10/22/24 or 10/23/24, the repair company would come out and repair the machine. One staff stated that laundry "can pile up" and explained how she recently "found a pile of dirty clothes that were left on the shower bench in a resident bathroom". This staff stated she is not sure if it was a hospice staff or a facility staff that left the laundry in the bathroom, but she took the laundry to the laundry room to be washed. This staff indicated that "all shifts do laundry" and the person who starts the load may not be the person who finishes the load, adding there is a "lot of laundry done" but was not sure if it is being completed timely. A second staff stated she is "not sure if there is a time" when it's not done timely, asserting "the "am" shift is much busier- we have no down time", explaining all caregivers assist with laundry and when they go in the laundry room, they "rotate the clothing between the washer and dryer" to ensure it keeps moving through the laundry cycles. This staff stated "laundry will be rotating throughout the day" and "we (staff) try to maintain laundry going in and out, on both the "am" and "pm" shifts, in between showers". This staff added the "pm" shift has "down time" and caregivers will go back regularly to check on the laundry to ensure it's being completed, commenting, "everyone is accountable for getting laundry going". A third staff confirmed there was a dryer issue a few months ago, in October 2024, relating to the bottom dryer "overheating", adding the top dryer has also had issues. This staff stated that staff are told to "go back and check on laundry during their downtime" and that she "tries to do all the linens first so there are towels for showers". This staff indicated that residents often wear clothes that don't belong to them, and she has seen residents wearing two different shoes before. This staff added "most resident's don't have pajama set so they wear a pajamas top and brief", and "socks seem to be a problem as there are (2) boxes now that are clean and not delivered". LPA observed (1) box of clean socks in the laundry room on 1/29/25 in the afternoon . *cont on 9099C-2.. 9099C-2.. A family member stated that the laundry has not been processed timely for months and clothing and linens are not being returned to the correct resident, explaining they have observed many residents wearing "mismatched and ill fitting clothing" and shoes that also don't match. Currently, this family member's resident is missing a pair of pajamas, their roommate is using their bottom sheet, and staff are putting their roommate to bed wearing jeans instead of pajamas. On 10/21/24, LPA observed one dryer to have a sign posted that it was not working as of 10/18/24. On 1/29/25, LPA observed both dryers to be working in the laundry room and residents in the dining rooms to be wearing correctly matched shoes when they were eating lunch around 12:30 pm. Interviews with staff and a family indicated there are regular issues with one of the dryers working correctly, "there are not enough people to keep the laundry going" and it would be helpful to have one designated staff overseeing the laundry processes to ensure laundry is being washed and returned timely and correctly to each resident. Based on information obtained during the investigation, the Department find the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview with Resident Care Coordinator Copy of report and appeal rights provided. 9099A(C)-1... Allegation: Staff yell at residents. There was no additional information provided. The Administrator stated "sometimes caregivers speak loudly due to hearing issues with residents or because staff is so excited to see the residents" and commented "many residents have hearing loss and it's more staff's tone than their volume". The Administrator clarified, "I hear louder voices but not yelling". One staff stated she does not recall staff yelling, "but yes, staff can talk loudly if there are hearing issues with the residents or be more firm and raise their voice to redirect a resident's behavior". This staff gave the example of a resident being aggressive with another resident and a staff needing to raise their voice to redirect the resident. A second staff stated that staff do "not yell purposely" but staff do raise their voice so a resident can hear and confirmed that both caregiver and Med-Tech staff sometimes raise their voices. A family member stated she has not heard any staff yell at residents and staff are "really sweet and very nice". Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff are not meeting residents' showering needs. The allegation states residents are not being showered as scheduled. The Administrator stated staff will record when the residents refuse a shower and the documentation is kept for a month. A family member stated she was told she could check the shower roster if she has concerns her family member is not being bathed. Two staff stated showers are given throughout the day, on the "am" and "pm" shifts and showers are scheduled twice weekly, or as needed. LPA reviewed approximately (40) resident shower schedules for the month of October 2024, from 10/1/24 through 10/21/24. LPA observed schedules to be consistently initialed by facility staff as completed or refused by resident. Most schedules showed residents were receiving a shower for an average of two times per week and some schedules noted when hospice staff gave the shower. Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 31, 2025 · control 59-AS-20241014152140

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 14, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews conducted and observations made, the Licensee did not ensure that laundry services meet each resident's needs, including sufficient and trained staff to complete the laundry processes, and delivering clean laundry timely to each resident, which poses a potential personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Jan 31, 2025

Plan of correction: Resident Care Coordinator and Administrator are working on creating a new laundry schedule for each resident in the building, based on where their room is located. Training to be conducted to explain the new procedures- to be submitted to the Department by email/fax by 2/14/25.

Allegation investigated: Staff do not safeguard residents' personal property.

**This report was amended on November 4,2 2025 due to a citation being dismissed on October 28, 2025. The citation was issued under Regulation 87218(a)(1)- Theft and Loss. The 9099D page is also being amended on November 4, 2025 to show this citation was dismissed. ** Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete a complaint investigation and deliver findings to a partial complaint received on 10/14/24. LPA met with Ashley Stahl, Resident Care Coordinator, and stated the reason for today's inspection. LPA was advised that the Interim Administrator, Magda Luis, was currently out of the building. During the course of the investigation, LPA interviewed the Interim Administrator, Resident Care Coordinator, (3) facility staff and a resident's family member. LPA also toured the facility on 10/21/24 and 1/29/25 and reviewed (7) resident files. The results of the investigation are as follows: The allegation states that resident laundry often goes missing and is not returned to the correct resident's room. *cont on 9099C-1.. Substantiated 9099C-1.. A resident's family member stated that not all laundry is returned to their resident's room, even after labeling the clothes. This family member stated that resident was missing a pair of pants and is currently missing a pair of pajamas. Additionally, this family member stated that the roommate of her family member was using their sheets and blankets were also missing. This family member stated they have observed residents wearing clothes, and shoes, that don't match or are ill-fitting. The Department received a complaint about another resident missing a raincoat, socks and a pair of dentures for a year. The Resident Care Coordinator stated that this resident has numerous jackets in their closet and never had the specific type of sock that was reported to be missing by the conservator. The RCC stated that this resident moved in with dentures in 2022 but has not seen them lately but believes the Conservator may have taken them from the facility. The RCC stated the Conservator is difficult to get in contact with and recently had medical surgery. LPA reviewed (7) resident files including for both residents referred to in the above paragraphs. In all (7) files reviewed, there was either not a completed LIC621/Client /Resident Personal Property and Valuables on file, or the form was signed by the resident's family member and facility representative as "declining to track personal property" when it was completed at admission. In the common area near the front entrance is posted the "Resident Personal Property Policies" which states "At the time of admission, the resident is required to complete the form "Client Personal Property and Valuables" (LIC621) and it is signed by the resident, or their representative and the Administrator. Based on information obtained, the LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview with Resident Care Coordinator. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 59-AS-20241014152140

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility Staff's Neglect/Lack of Care and Supervision resulted in resident sustaining an unexplained injury while in care.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings for a complaint received on July 1, 2024. LPA met with Magda Luis, Interim Administrator, and stated the reason for today's inspection. During the investigation, the Department interviewed several facility staff members, hospital staff, and reviewed documentation related to resident (R1), including, but not limited to, 9-1-1 and hospital medical records. (R1) moved to the facility on/around January 2024. The results of the investigation as follows: On 6/28/24, at 1000 hours approximately, resident (R1) was complaining of pain in their breast, ribs, neck and knee areas. (R1) was transported to a nearby medical center on the same day and diagnosed with a "cervical vertebral fracture, a right single rib fracture, and a right chest wall contusion". *cont on 9099C-1... Unsubstantiated *9099C-1...Facility staff were interviewed and unable to explain how (R1) sustained these injuries and residents were not able to provide any information on (R1's) injuries or the incident on 6/28/24. (R1) was attempted to be interviewed, but they were not able to provide any information on the incident or how they sustained the injuries. The emergency room physician who attended to (R1) on 6/28/24 explained that a typical way an individual could sustain a neck injury would be if he/she fell face down or ran into a wall, causing the individual's head to be pushed back. This same physician noted that it wouldn't be unusual for an individual to go to the emergency room complaining of neck pain and discover they had a neck fracture. The physician confirmed that based on (R1's) medical records from November 2023, (R1) did not have a documented neck fracture, so it's reasonable to believe the neck fracture occurred between November 2023 and June 2024. Additionally, the physician confirmed that the neck fracture did not appear to be new in June 2024 and appeared to be approximately four to eight weeks old, if not older. The physician further indicated that he could not imagine a C2 (neck) injury happening to (R1) since they were bed-bound or wheel-chair-bound; however it would not be unexpected, and there would have had to have been some kind of force. Also, if (R1) had fallen, there would likely have been facial bruising, which was not observed on (R1) when going to the Emergency Room on 6/28/24. Finally, the physician confirmed that (R1) did have a previous fall, in February 2024, and indicated that it's possible this previous fall could have been related to the C2 fracture, but it could not be confirmed without knowing the circumstances of the fall in February. Medical transport records from 6/28/24 note that one staff was not aware of (R1) complaining of neck pain, but was concerned about them having a hematoma, or bruising to the right chest wall. Records state that this facility staff first noticed the bruising earlier that morning when assisting (R1) with dressing, and there was no injury or trauma noted to have caused the hematoma. One facility staff stated she was off work on 6/28/24 and was not aware of any bruising (R1) had. A second staff could not recall if he was not assigned to work, or work with (R1), on 6/27/24. This staff stated (R1) spent most of their time in bed, needed assistance with feeding and transfers, and would be "combative" with staff when staff tried to change them. This staff also reported that (R1) was not a fall risk as *cont on 9099C-2.. 9099C-2... they would not try and get out of bed unless staff was there to assist, and it was rumored that (R1) may have been "mishandled" by staff during a transfer; however, this was staff talking in the break room. A third facility staff indicated that she recalls when (R1) was found in bed with a bruise on their side, around 6/28/24, but did not know how the bruising was sustained. This staff indicated that staff were not talking about or seemed to know how the bruising occurred, which she found strange. This staff stated that the bruising could have possibly happened on the night shift, as she did not observe any bruising on the morning of 6/26/24 or 6/27/24, and added that (R1) was not a resident who would try and get out of bed on their own. This staff added that she has never seen a facility staff being aggressive with (R1) or (R1) to be aggressive with another resident. A fourth facility staff indicated that she was first made aware of bruising on (R1) from an "agency staff" on the morning of 6/28/24, when she was called to (R1's) room, and observed she had already been transferred to their wheelchair. The facility staff indicated she asked facility staff who had worked the prior afternoon about the bruising, and no staff could provide any information on how (R1) sustained their injuries. This facility staff stated she was not able to communicate with any staff who worked on the night shift from 6/27/24 -6/28/24, and also could not confirm which staff actually worked as the schedule may have changed and an "agency staff" could have filled in. On 7/4/24, (R1) was discharged to a skilled nursing facility with orders to wear an Aspen collar for three months. (R1) did not return to the facility following her stay in skilled nursing. Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 59-AS-20240701085917

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada and the assigned Ombudsman arrived unannounced to conduct a case management inspection related to (3) current residents and met with Magda Luis, Interim Administrator. LPA stated the reason for today's inspection. The following items were discussed: Resident (R1) who reported having a missing rain coat, dentures and other belongings. Discussed how residents need to complete a Personal Inventory Record upon move-in, staff duties with returning clean laundry to residents. Resident (R2) who reportedly had a recent case of scabies. The Administrator confirmed that (R2) was sent to the Emergency Room in December 2024 and was diagnosed with scabies at the hospital. The Administrator also confirmed that there have not been any other recent scabies cases. Resident (R2) - also discussed was how often caregivers provide shaving/beard care to (R2). The Administrator stated that one of the caregivers recently tried to shave (R2) but they refused. The Administrator agreed to follow up and speak with hospice about shaving during bathing. Also discussed was how there were several other male residents (observed today) who appeared to not receive regular beard care. The Administrator stated there is currently one male caregiver (on the pm shift) and often the male residents prefer a male caregiver to shave/trim their beard. The facility will purchase an electric shaver this week to assist in providing regular beard care. Residents can use the salon by appointment only. Resident (R3) who was observed to have several scabs on their face at the start of today's inspection. The Administrator indicated that (R3) is "always picking" themselves and how (R3) needs a Behavioral Specialist. The Administrator spoke with the Wellness Coordinator, who was on site today, who agreed to discuss with the Nurse Practitioner soon. There are no deficiencies being cited in this report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Jan 15, 2025

Allegation investigated: Staff neglect resulted in resident being hospitalized.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings for a complaint received on September 23, 2024. LPA met with Ashley Stahl, Resident Care Coordinator, and stated the reason for today's inspection. LPA spoke with Magda Luis, Interim Administrator, at the start and end of today's inspection. During the investigation, the Department interviewed several facility staff members and reviewed documentation related to resident (R1), including 9-1-1 and hospital medical records. The results of the investigation as follows: Documentation reviewed indicates resident (R1) requires four safety checks per shift, "ongoing assistance with care due to advanced Dementia, and has "poor safety awareness, poor judgment, disoriented to person/time/place and repeats information". *cont on 9099C-1.. Substantiated 9099C-1.. The fire department's report from 9/22/24 notes they were dispatched to the facility, at 1545 hours, for the reason "unknown problem/person down", arrived at 1551 hours and found (R1) "slouched in a wheelchair". The chief complaint noted on the report was "altered level of consciousness, possible heat stroke". Also documented is that facility staff reported there was a recent shift change and staff found (R1) who was left outside in the sun and with a blanket. Upon discovering (R1) outside, facility staff brought (R1) into the facility and called 9-1-1. Facility staff reported they believe (R1) may have been outside for a maximum of (3) hours and were not certain due to a recent shift change. Hospital medical records indicate that (R1's) initial temperature was elevated and cooling protocols were implemented. A Computed Tomography (CT) was determined to be negative for intracranial hemorrhage or large brain mass. Staff interviews indicated that (R1) was able to slowly ambulate themself in the wheelchair and would ask other residents for assistance, including to take them outside. One staff stated they believe (R1) asked another resident for assistance and that's how they got outside on the patio and staff didn't know where (R1) was. Shortly after shift change, (R1) was noticed outside on the patio but was not brought inside until about (40) minutes later, by the "pm" staff. A second staff confirmed residents are allowed to go outside on the patio but staff try to re-direct residents from going outside, if it's a hot day. If staff are not able to redirect the resident, staff are to check on the resident who is outside every 10-15 minutes, offer water and keep trying to redirect the resident inside. This staff stated another staff informed them around 1530-1600 hours that (R1) was outside and needed to be checked on. This staff stated they observed (R1) to be wearing layers of clothing, was not responsive, their eyes were flickering and their skin was hot to the touch. Neither the morning or afternoon staff assigned to care for (R1), or other staff, could confirm how long (R1) had been outside on the patio before being sent out for emergency services on 9/22/24, around 1530 hours, and being diagnosed with heat stroke. There is no camera coverage in the seating area where (R1) was. *cont on 9099C-2... 9099C-2.. Based on information obtained during the investigation, the Department find the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview with Resident Care Coordinator and Administrator (by phone). Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 59-AS-20240923141420

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 24, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that staff frequently monitored resident (R1)'s condition while outside on the patio, on the afternoon of 9/22/24, to prevent (R1) from suffering a heat stroke, when temperatures reached 91*F, which posed an immediate health and safety risk to residents in care. Resident was sent to the emergency room at 1545 approximately and diagnosed with an altered state of consciousness and heat stroke.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Licensee/Administrator conducted staff training on 9/24/24, with the "am" shift regarding checking on residents at least every hour and offering beverages to prevent dehydration. Documentation was reviewed showing staff provided 30 minute checks on (R1) the following day, on 9/23/24. New staff will receive training on outside monitoring of residents. The Administrator stated on 9/24/24 the camera monitor from her office will be moved to the front desk area and a bigger camera monitor will be installed in her office and in the dining rooms. Also staff will be asked to check residents outside, every 10 minutes. *On 12/23/24, LPA observed the camera in the Administrator's office showed certain areas of the patio but not the seating area at this time.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Magda Luis, Administrator, and stated the reason for today's inspection. The purpose of today's inspection is to issue an updated license to reflect the recently approved increase in capacity from (45) to (49) residents. Currently, there are (43) residents with (5) residents receiving hospice care. LPA discussed the increase in (4) residents with Administrator and how (34) residents may be non-ambulatory and (15) residents may be bedridden. There are no specific designated rooms for additional (4) residents; however, most rooms are approved for double occupancy. LPA and Administrator conducted a tour to observe the (4) delayed egress doors and the facility for the health and safety of the residents. One outside exit gate was tested and staff were observed to have responded promptly and the strobe lights were activated. No health or safety risks were observed. LPA was provided with a copy of an inspection report from an outside company showing that all delayed egress doors passed the inspection on 11/25/24. LPA printed an updated copy of the license. There are no deficiencies issued in this report. Exit interview. Copy of report provided to Administrator.,the state’s words, verbatim · CDSS document, Nov 26, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a follow up case management inspection and met with Magda Luis, Administrator. LPA stated the reason for today's inspection relates to resident (R1) who had an unwitnessed fall on 8/28/24, in the morning, and was sent out for emergency medical services later that day. The facility submitted an incident report to the Department on 8/30/24. The report for the emergency ambulance provider notes the facility contacted them on 8/28/24 (19:28 hours) for a fall, they arrived at the facility at 19:48 hours, and observed the resident to be resting in her bed. The report further states that resident had a fall earlier that morning (around 8:00 am), and had been sitting in a chair all day, as staff was unable to get resident to stand, contrary to resident's normal baseline of regularly walking around the facility. The report also states that facility staff reported to the ambulance provider they were told by morning staff that resident had a witnessed fall, did not hit her head, but were not given any additional details. Documentation reviewed shows resident arrived at the Emergency Room at 20:16, was diagnosed with a fractured left hip and remained hospitalized until 8/31/24 when she was discharged to skilled nursing for rehabilitation. Several staff interviews were conducted, concluding resident (R1) had fallen and was found on the ground in the courtyard, on 8/28/24, after breakfast and before lunch was served, between approximately 10:00 - 11:00 hours. Staff interviews confirmed that after resident had fallen, (R1) was given assistance to stand up and was brought inside and seated in the dining room. Interviews revealed (R1) remained seated in the dining room until around 17:30 hours, when the facility nurse arrived to perform skin check on multiple residents. When the nurse observed (R1), she didn't want to stand up and complained of pain in her leg area. The nurse was advised resident fell earlier in the day and determined (R1) likely had a fractured hip, instructing that resident be sent out for a further medical evaluation. **cont on 809C-1.. 809C-1.. A "pm" staff stated he was made aware of resident experiencing pain around 17:00 hours, on 8/28/24, and stated if (R1) had been moving around during the "pm" shift, staff would have noticed her walking with difficulty. Additionally, staff interviews provided conflicting accounts if resident ate her lunch and dinner on 8/28/24, while seated in the dining room. The incident report (R1) notes resident around on 8/28/24, around 11:30 am-12:00 pm, and was sent out to the hospital for a possible injury. The family member reported to the facility that resident had a hip fracture and had surgery on 8/29/24. Based on information obtained, the facility did not ensure resident received timely medical attention following her fall on the morning of 8/28/24, as the ambulance provider was not called until 19:28 hours. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency and civil penalty are being issued. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 21, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Oct 22, 2024

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) received timely medical attention, on 8/28/24, after having an unwitnessed fall that morning, as (R1) was not sent out to the hospital until 19:28 hours, and had displayed a change in baseline behavior with her mobility, which posed an immediate health and safety risk to residents in care. (R1) was diagnosed with a left hip fracture after being sent to the hospital on the evening of 8/28/24.the state’s words, verbatim · CDSS document, Oct 21, 2024

Plan of correction: Licensee/Administrator agree to provide staff with training on fall protcols and when to send a resident out for medical attention. Staff training to be completed and documentation provided to the Department by 11/4/24. Admin to advise LPA by 10/22/24 of the training agenda. An immediate civil penalty is being assessed today for $500.00.

Allegation investigated: Staff do not ensure that a resident's incontinence needs are met. Staff do not ensure that a resident's personal care needs are met.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings for a complaint received on June 5, 2024. LPA met with Magda Luis, Interim Administrator. LPA stated the reason for today's inspection. During the course of the investigation, LPA interviewed the Administrator, Resident Care Coordinator (RCC), (5) care staff, and a family member of resident (R1). LPA reviewed multiple documents relating to (R1), including, the Pre-Appraisal, Physician’s Report, care plan, charting notes, the Medication Administration Record (MAR), email correspondences between the Administrator and (R1's) family member, and photos provided to the Department. The results of the investigation are as follows: Resident (R1) moved to the community in January 2023. Resident's physician's report (dated 3/26/24) notes resident has a primary diagnosis of Dementia and a secondary diagnosis of Eczema with “Itchy, red rashes” and “onychomycosis”, and also has poor vision due to bilateral glaucoma, cataracts and farsightedness. The physician's report also notes that (R1) is incontinent with bowel and bladder. **cont on 9099C-1.. Substantiated 9099C-1.. Allegation: Staff do not ensure that a resident's incontinence needs are met. Allegation states that for more than one year, staff have not ensured that resident’s (R1) Depends Diapers are changed regularly as resident has been observed to be wearing soiled diapers and soiled pants on several occasions when she is visited. LPA reviewed multiple e-mails exchangeed between resident's family member and the Administrator where the family expressed concerns that (R1) wasn’t regularly checked and provided with incontinent care. On 12/30/23, the family member described when she was visiting and found resident to be “wearing a shirt as underwear, no Depends and a used piece of toilet paper in her sock”, which made the family member think maybe (R1) hadn't been checked on in a while, had an accident, and tried to change herself. A photo was provided to the Department matching this description. A follow-up email was sent to the Administrator 2/3/24 and included a photo of resident wearing an incontinent pad, taped around her, instead of a “diaper”, and the pad "was undone and very bulky under her pants", which were reported to be too large as they belonged to another resident. The Administrator stated that staff will use the “tape kind” of diaper because (R1) won’t let staff take their pants or shoes off. Resident's family member sent another email, on 3/30/24, to report she immediately noticed a soiled diaper on resident when visiting earlier that evening, and the resident’s pants were soiled also. The family member stated that, during another recent visit, resident was wearing a soiled diaper that also needed immediate changing and inquired what procedures are in place to ensure residents don’t go extended periods with soiled Depends. The Administrator responded that staff are to be “making their rounds every 2 hours”. On 5/11/24, the family member emailed the Administrator, asking her to call her to discuss multiple concerns, and provided the Department with a summary of the concerns, which included, finding (R1) in "wet Depends" when she visited earlier that day. On 6/3/24, the family member emailed the Administrator requesting staff check resident (R1) “more often than she currently is” being checked, stating, “More often than not when we visit her, she's in a soiled Depends and we have to request help for it”, referencing the prior day's visit when resident needed changing right away when they arrived. The family member stated that based on her conversation with resident’s day program, the facility is sending (R1) to their program in the morning in soaked depends and provided a photo of resident’s sweat pants being wet from a soaked diaper, only after being at the program for (2) hours. The Administrator responded, by email the same day, that the day program will often return residents to the community in soaked depends. *cont on 9099C-2 9099C-2.. (R1's) charting notes, on 6/3/24, state the Administrator and Resident Care Coordinator will begin documenting each resident has been provided with incontinent checks before leaving to, and after returning from program. On 6/6/24, the Administrator noted that resident returned from day program with a “soaking wet” diaper. Resident's Pre-Appraisal completed on 12/30/22 indicates that (R1) needs assistance with toileting, including after using the toilet and changing her Depends. The care plan that was completed on 6/15/24 and notes resident needs maximum assistance with toileting, “resident to be checked more frequently for incontinence” and to check after returning from her health care day program. Additionally, the care plan states the Administrator is making Incontinence care a "special care need" due to resident not cooperating much with changing- may take 2-3 caregivers to help with resident to provide distraction to get done and to provide checks when resident is in her room and common area. The care plan indicates that safety checks are to be done (4) times in a shift. (R1's) family member provided additional instances when resident was found in a soiled diaper when she was visiting. Specifically, on Friday, 6/28/24, and on the weekend of 7/27/24 and 7/28/24, around 3:00- 3:30 pm, each day. LPA also reviewed a text message sent by the family member to the Administrator, on 8/27/24, to report that (R1) was found in soiled Depends. The text says the family member had one staff call on the walkie for assistance, but there was no response for (10) minutes, so the family member changed the resident herself. Also on 8/27/24, a second resident (R2) was observed to be wearing “pants that were completed soaked” and a “puddle beneath her” in the dining room, and a photo was provided to the Department. The Administrator stated on 6/13/24 that "(R1) is very difficult and it sometimes takes lot of tries" to change her. One "am" care staff stated on 7/3/24, that resident's family member visits usually on Saturday, during the "pm" shift and it "may be an issue" then with (R1) not being changed timely. This staff commented "one time (R1) was wet" at the start of her shift and "sometimes she is soaked and two times, (R1) went bowel movement on me". Another staff stated (R1's) Depends can become very wet "sometimes when she is sleeping", and when (R1) is awake, she "always takes her to the bathroom", but "sometimes she (R1) doesn't want to move, so I will change her Depend on her bed, commenting "(R1) cooperates with encouragement and reminders". *cont on 9099C-3... *9099C-3.. (R1's) family member stated she usually visits in the evenings, after dinner, around 7:00 pm, and also on the weekends, around 3:00 pm, and when she checks (R1) her "Depends are soiled". The family member indicated that the facility is "maybe understaffed" during the times she visits and that she never visits before noon, asserting that 50% of the time she checks, (R1) is soiled and her pants (clothing) are also wet. Based on information obtained, LPA finds allegation to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff do not ensure that a resident's personal care needs are met. Allegation states 1)since September 2023, staff have not applied resident (R1's) eczema lotion to her body, and 2)Dentures are also not cleaned daily. 1) Resident's family member stated (R1) has had issues with eczema since September 2023 and facility staff have applied the prescription creme "off and on" only, stating she is "not sure how often they are putting the lotion on". Resident's (R1's) Charting Notes entered on 10/31/23 document that caregivers showered resident and noticed a rash all over her body and called a Med-Tech staff and the Resident Care Coordinator. The notes state that the rash covers all of (R1's) left side and on right side thigh, and that her medical group was contacted to send cream, and the facility is waiting on an order. Notes say the family was contacted. The Department reviewed an email sent form (R1's) family member to the Administrator, on 2/3/24, to inform of a rash on (R1’s) left thigh that the family member has observed for the last several visits and asks that the rash be attended to. The Administrator responded the same day that she will reach out to resident's health care group for advice. A follow-up e-mail was sent to the Administrator, on 2/28/24, to advise that (R1) was scratching the rash on her thigh and it looks “bad again” and to request it be attended to. The Administrator responded promptly that she will ask a Med-Tech to follow up with (R1's) health care provider regarding a possible change in the order for the cream/ointment being used. Another follow-up e-mail was sent to the Administrator, on 3/7/24, advising (R1's) rash is “worse”- as it has spread to the backside of her thigh and on her right arm too. *cont on 9099C-4... 9099C-4.. Another follow-up e-mail, with photos, was sent on 3/24/24, to the Administrator to advise that (R1) needs medicated lotion for her rash due to break outs on her right arm, right thigh and now on her chest, explaining that (R1) was scratching her thigh and chest while visiting this evening. The Administrator responded she would reach out to get medication lotion and to schedule an appointment. Another e-mail was sent, with photos, on 3/30/24, to advise the Administrator that the resident’s skin is “not getting better”, has spread more, and resident was scratching herself again when the family member visited tonight. The family member asks if resident's health care provider should be involved. Resident's charting notes made on 4/1/24 document the Administrator had reached out to the health care provider due to skin issues. MAR documentation shows (R1) had an order for Eucerin Eczema Creme (1%) effective 9/20/23 through 5/9/24. Resident charting and MAR combined show that resident refused Eucerin cream on 4/22, 4/24, 4/27, 4/28 and 4/30 but on 4/29/24 (11:00 am), the Med-Tech was able to apply Triamcinolone crème and partially apply Eucerin since she had just applied the other treatment. Notes from 4/29/24 (8:22 pm) document cream was applied from chest to legs, and on 4/30/24 (9:17 pm) notes state "Resident did well today- no refusals and cream was applied. Also on 5/1/24, the resident allowed Med-Tech to put cream on. Administrator documented in Charting notes on 5/10/24 and 5/11/24 that she observed resident to have received a shower with tea tree oil body wash and lotion due to eczema. Family member sent photo taken on 6/8/24 showing eczema breakout had spread to (R1's) stomach/thighs. Doctors later determined the rash on resident's stomach only may have been a reaction to Bactrim. Resident's family member provided a photo taken on 7/1/24, after resident was admitted to the hospital and commented in an e-mail how "dry (R1's) skin was when she got to the Emergency Room". LPA was provided with a subsequent photo taken only one day later, on 7/2/24, where (R1's) ankle looked much better and not nearly as red and irritated. Resident's family member stated she put lotion on her while visiting (R1) in the hospital. On 7/3/24, the RCC stated (R1) has been using (2) different creams for months, and currently (R1) is taking Eucerin and Triamcinolone (.5%), a 14- day prescription, and "only Med-Techs will apply the prescription cream, on shower days (am), and caregivers can apply non-prescription cream/lotion. June MAR shows Triamcinolone cream was administered twice daily from 5/28/24- 6/4/24 only; the order was to apply the cream up to (14) days- there are no notes as to why the cream was stopped on 6/4/24.. *cont on 9099C-5.. 9099C-5...MAR documentation shows another creme, Triadime, was ordered to start on 6/27/24, and this cream was only administered in the morning, on 6/27/24, by the Administrator. There are no additional days initialed in June documenting that the cream was administered. On 7/3/24, a caregiver stated that both caregivers and Med-Techs put cream on (R1's) legs, arms, stomach and back and "sometimes (R1) refuses", as she has observed her do with other caregivers. Resident had returned back to the community from the hospital on 7/4/24. The family member stated that on 7/6/24- (6:57 pm), she was "visiting with (R1) and her arms are already broken out again" commenting, "it looks awful again". Two photos were provided showing how resident's lower arms were broken out. Resident's family member stated another family member was visiting with (R1) on the evening of Wednesday, 7/10/24, and observed (R1's) arms, chest, and neck to be red, and she was scratching. The family member applied CeraVe healing ointment on her arms. A photo was provided on 7/11/24 showing resident's lower left arm to be red and broken out. Resident's family member stated she found (R1's) skin "dry and irritated" on both days on the weekend of 7/27/24 and 7/28/24, and she put lotion on herself. Based on information obtained, LPA finds this portion of the allegation to be SUBSTANTIATED - 2)- Resident's charting notes, created on 10/20/23, document that the Ombudsman visited with the Administrator today regarding oral hygiene care not being provided regularly to (R1). The notes further document that on 9/22/23, the Administrator and resident's family member discussed these concerns and that the Administrator has been checking in with staff to make sure this care was being provided. The notes further state that on 10/20/23, the Ombudsman observed them to be clean with the comment added “it’s a hit or miss that resident will let staff take out her dentures to clean them” and to try a change of face if resident refuses. Resident's family member e-mailed the Administrator on 2/14/24 to request an update on oral hygiene care for (R1), stating it doesn’t look like (R1) is receiving regular care as every time she visits, she sees “a lot of plaque and gunk built up on her dentures”. The Administrator promptly replied she would follow up with staff again to ensure (R1’s) teeth are brushed and set up a system where staff let her know when it’s been completed. A photo was provided that was taken on the evening of 2/13/24, showing significant build-up on (R1's) dentures. *cont on 9099C-6... 9099C-6... A care staff who stated she sometimes works on both the "am" and "pm" shift, explained she will place the dentures to be cleaned around 8:00 pm when (R1) goes to sleep and will place them back in (R1's) mouth when she wakes up for breakfast, which is sometimes around 9:00 am. This staff explained that (R1) has a container where her dentures are cleaned/soaked over night. LPA asked if other "pm" staff will clean (R1's) dentures. This staff stated "yes, "pm" staff will always ask for help as sometimes (R1) wants another staff to clean her dentures", and commented "(R1) is always comfortable with me, but sometimes other "pm" staff will ask me to help since (R1) is comfortable with me" adding she has "never seen (R1's) dentures dirty". Another staff stated "every morning, before breakfast, I rinse her dentures and after lunch too". Resident's family member stated when she visited (R1) on 5/11/24, she observed "lots of gunk on dentures" and she spoke to the Administrator about the her concerns following the visit. Photo documentation was provided showing (R1) had a lot of gunk built up on her dentures on 6-19-23, 9-21-23, 2-13-24, and on 5-11-24. LPA was not able to observe resident's dentures on 6/13/24 (11:00 am) as she was asleep in her room. On 7/3/24, resident was not present at the facility during LPA's inspection, and on 7/11/24, resident was not in her room at the time of LPA's inspection in the morning, and LPA was only able to observe resident leaving around noon for an appointment with her health care provider. Resident's Pre-Appraisal notes resident "depends fully on others for personal hygiene". Resident's care plan, dated 6/15/24, indicates resident is "full assistance with oral care" in the morning and bedtime, and also "needs assistance with setting up oral care for dentures, and assistance with cleaning dentures". Text messages were reviewed from 6/15/24 (8:36 pm) where the Administrator stated (R1) was refusing to allow staff to take her dentures our or brush her teeth. Based on information obtained, LPA finds this portion of the allegation to also be SUBSTANTIATED A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) citations are issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided. 9099A-C-1... Resident's family member stated on 6/10/24 that all of (R1's) clothes are clearly labeled, but she has seen other residents wearing her clothes. Resident stated that a bag of (R1's) clothes were also thrown away due to the scabies outbreak a few months ago; however, reimbursement was given to the family for the clothes that were thrown out. Resident's family member stated that she has been told by the Administrator that other residents are taking (R1's) clothes; however, she visits the community three to four times per week and has "never seen any residents entering mom's room to take clothes". One laundry staff indicated on 6/13/24 that "all clothes are labeled with the resident's room # or name", and if there is no room # or name, staff will hang it up and place it on the rack located in the laundry room which is the "lost and found". LPA observed the rack that the staff pointed to during the interview. Staff further stated that "resident laundry is mixed; however, she and other staff will "separate bedding from clothes" and confirmed that mixing resident dirty clothes when doing laundry "has always been done this way". One care staff, who works on the "pm" and "NOC" was interviewed and was working at the community in June, 2024, stated that resident (R1) would often place her glasses on top of her armoire and the glasses would often be found behind resident's bed, as she insisted on wearing them to sleep. This staff stated (R1's) glasses were found in her blankets, and in the couches in the common areas where she would also take naps.The care staff stated that many residents at the community "shop" in other residents' rooms and take clothes from closets that do not belong to them, due to their diagnosis of Dementia. LPA and the caregiver looked through a box containing many pairs of "lost" glasses and did not observe (R1's) glasses. This staff stated staff will place any clothing found in the correct closet in resident's room. LPA observed eye glasses to be clean on 6/13/24, 7/3/24 and on 7/11/24, when inspecting resident's room. LPA also observed detailed information, with pictures included, regarding resident's glasses, to be posted in resident's room for staff to refer to. Instructions asked that staff contact resident's family member if any pair of glasses is lost and cannot be found and provides a contact number. Also observed was a box of lens wipes for staff to use. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 10, 2024 · control 59-AS-20240605141044

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87265(b)(3) · Plan of correction due date: Oct 11, 2024

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) was provided with regular incontinent care to ensure she was kept clean and dry, on multiple occasions, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Licensee/administrator agree to provide follow up staff training on which residents require more frequent incontinent checks. Consider documentating when 2 hourly checks are made and when resident is changed. Communication with families to also be part of the training. Training agenda due to LPA by 10/11/24 Completed training documentation by 10/24/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Oct 10, 2024

87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) received regular applications of lotion and cream, as ordered, for eczema, and assistance with oral hygiene care, on multiple occasions, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Licensee/administrator to to provide follow up staff training on ensuring creams/lotions are applied as needed and oral hygiene care is regularly provided. Communication with families to also be part of the training. Training due to LPA by 10/24/24. Completed training documentation by 10/24/24.

Allegation investigated: Staff do not distribute a resident's medication as prescribed.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete a complaint investigation for a complaint received on June 5, 2024. LPA met with Magda Luis, Interim Administrator, and with Ashley Stahl, Resident Care Coordinator. LPA stated the reason for today's inspection. During the course of the investigation, LPA interviewed the Administrator, Resident Care Coordinator, (5) care staff, (2) laundry/housekeeping staff, an outside care provider/nurse, and a family member of resident (R1). LPA reviewed multiple documents relating to (R1), including, the Pre-Appraisal, Admission Agreement, Physician’s Report, care plan, charting notes, and the Medication Administration Record (MAR). The results of the investigation are as follows: cont on 9099C-1.. Substantiated 9099C-1.. Allegation: Staff do not distribute a resident's medication as prescribed. Allegation states staff have not ensured that (R1’s) eye drops are administered, as ordered, for a year. The facility initially administered the drops but then resident's health care plan began to administer some of the dosages due to resident refusing. The order for Timolol was discontinued on 5/19/23 without the family member being informed or that the resident was refusing the drops, but was then reinstated a month later. (R1's) family member emailed the Administrator on 2/14/24 to confirm if (R1) is still receiving daily eye drops, per doctor’s orders, stating that resident’s “lower eye lid is red and looks like it’s drooping more”, and the doctor indicated at the appointment earlier that day that her eye looks worse. The Administrator promptly responded that she had just confirmed with a Med-Tech that (R1) has refused eye drops all week and they have reached out to resident's health care plan.The Administrator stated she wasn’t aware that (R1) was refusing the eye drops, and she/staff will have to figure out another way to get resident to cooperate with the drops, as resident has become increasingly more resistant in allowing staff to administer medications and apply crème also. Resident's care plan, dated 6/15/24, states “Resident needs extra distraction for medication time and eye drops. Health care plan is coming to do eye drops during the day time (2x/day), and the Administrator's suggestion is to do a part and then try again for another part, and do not try everything at once”. Resident's family member stated she was told the facility stopped giving the eye drops due to resident refusing. The Administrator stated "(R1) was refusing a lot" and so daughter asked resident's health care plan to assist with the eye drops. Several staff interviews conducted on 7/3/24 confirmed that a representative from resident's health care plan will come to the facility to administer drops to resident daily, in the morning and afternoon, and facility staff will administer the drops in the evening and bedtime. The MAR was reviewed for April - June 2024. MAR notes for April 2024 show resident refused the drops on 4/25/24 and 4/26/24. The MAR notes from 5/11/24 indicate the evening and bedtime drops were not given due to resident's health care provider not showing up. MAR notes from 5/15/24 note resident refused (3) different drops in the morning, but the health care provider would be administering them. *cont on 9099C-2.. 9099C-2.. June 2024 MAR shows resident was prescribed (3) drops and refused drops (4) times and (2) medications, Refresh Classic and Maxitrol (Ophth) were not available to be administered on 6/22/24 for the evening drops. LPA spoke with a nurse from resident's health care program on 6/13/24. He stated he administers eye drops to other residents as well, confirming that resident (R1) "has an existing order" but his company obtained an "overriding order" for them to administer. This nurse explained that he is scheduled to show up at the facility, and if (R1) is at their program, then he will notify the nurse to give the drops to (R1) there. This nurse stated some residents may receive drops at the program, but he doesn't know about (R1) specifically. LPA observed a Med-Tech staff administer eye drops to resident on 7/11/24 (around 12:00 pm), with (3) other staff assisting. LPA observed (R1) to verbally express she didn't want the eye drops, and tried to grab the Med-Tech's hand. The MAR documentation reviewed shows resident (R1) missed scheduled dosages of eye drops in May 2024 and in June 2024 due to resident's health care provider not present to administer the medication, or the medication not being available. Based on information obtained, LPA finds allegation to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 8, 2024 · control 59-AS-20240605141044

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 9, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review, the Licensee did not ensure that resident (R1) received eye drops as ordered on 5/11/24 (evening /bedtime doses) and on 6/22/24 (evening dose), which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: Licensee/Administrator agree to conduct staff training on medication administration involving an outside care provider, refill protocols. Administrator to discuss the training with the company nurse who will be in the building tomorrow, 10/9/24. Administrator will follow up with Dept to confirm a training day for staff. LPA stated 2 weeks can be given for staff training, or by 10/22/24.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on (2) incident reports regarding resident elopements. LPA met initially with Ashley Stahl, Resident Care Coordinator and then Robert Godfrey, Regional Manager and Magda Luis, Administrator. LPA discussed the incident report submitted on 8/20/24 with the Regional Director. The incident reports that on 8/20/24 (8:50 am), resident (R1) went outside with a plate of food and then was able to exit through a gate that the gardener opened. The alarm was triggered and staff were able to bring resident back to the facility, unharmed. The facility Administrator discussed this situation with the gardener who is now aware residents have a diagnosis of Dementia and cannot leave the facility unassisted. (R1) had medications reviewed and has not attempted to leave the facility again. Training was provided to staff to check all walkways when an alarm goes off to ensure all residents' safety. LPA discussed the incident report submitted on 9/10/24, for an incident occurring on 9/6/24 (7:30 pm) with Administrator Magda Luis and Regional Director, Robert Godfrey. The Administrator stated that resident (R2) went for a walk with staff member and the alarm was triggered. A few minutes later, resident (R3) was able to walk through the front door. The Regional Director stated the alarms were going when (R3) exited, and staff immediately ran out to get (R3) and bring them back to the facility. Staff who was walking with (R2) called the police for assistance in bringing (R2) back. The police arrived and brought (R3) back as (R2) returned to the facility. Elopement training was conducted with the "pm" shift. The facility took prompt action in responding to the alarm once it was triggered in both instances. Residents were returned safely. The Administrator stated she is in the process of adding (3) additional strobe lights and additional monitors, and increasing the auditory alarm in the back of the building. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 24, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday August 8, 2024 to conduct a case management visit regarding the facility's process to reorder medications. LPA met with Ashley Stahl, Resident Care Coordinator. LPA and Ashley discussed the facility's process for reordering medications. The facility is currently switching in-house pharmacies. LPA and Ashley reviewed current medications which were listed as ordered and reviewed the facility's MAR on any medications which were not given. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to this facility.the state’s words, verbatim · CDSS document, Aug 8, 2024

Allegation investigated: Staff did not notify responsible party of resident's change of diet. Staff did not provide reporting agency an itemized list of fees. Facility did not notify resident's responsible person of an increase in monthly rent rates.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings to an for a complaint received on 03/15/24. LPA initially met with Editha McCullough, Assistant Administrator, and shortly thereafter met with Toni Jones, Administrator. LPA stated the reason for today's inspection. There are currently (45) residents, (9) of whom are under hospice care, and (1) resident is currently in the hospital. Also present during today's inspection was (R1's) family member who LPA and Administrator spoke with. During the investigation, LPA interviewed the Administrator, Resident Care Coordinator (RCC), (2) culinary staff, Ombudsman, social worker from an outside agency, hospice social worker, and resident (R1’s) family member. LPA reviewed multiple e-mails, hospice notes, physician's orders, and the physician's report and care plan for (R1). The results of the investigation are as follows: *cont on 9099C-1... Unsubstantiated 9099C-1.. Allegation: Staff did not notify responsible party of resident's change of diet. The complaint states that resident’s family member visited the facility in early March 2024 and found out (R1) was put on a liquid diet that she was not made aware of. Resident (R1's) physician's report, dated 2/2/2023, notes resident has a special diet of “mechanical soft finger foods”. The Administrator stated that (R1's) physician signed off on a pureed diet on 1/26/24, after (R1) "got a small piece of soap in her mouth from another resident's room, which caused her lip to swell". LPA observed the hospice order on 1/4/24 for one time dose of Diphenhydramine 25 mg for lip swelling (2 tablets). LPA reviewed a hospice order, written on 1/25/24, to “downgrade (R1's) diet to pureed diet”, and a subsequent order, written on 3/7/24, to “upgrade (R1's) diet to soft mechanical”. The Administrator stated (R1) was placed back on a soft mechanical diet on/around March 2024. (2) culinary staff, who have worked at the community for many years, stated that (R1) has always had a mechanical soft diet but was changed to a pureed diet, for a short time, but has been changed back to mechanical soft diet. LPA observed a posted notice in the kitchen that shows (R1) has a "Mechanical Soft Diet". One culinary staff stated the list is updated regularly when there are new residents or a resident's diet has changed. RCC stated that she told the hospice nurse (R1) prefers finger foods, but the nurse did not agree to change (R1) from a pureed back to a mechanical soft until March 2024, stating "the nurse thought (R1) was eating well on the pureed diet"; however, (R1) would still take other resident's mechanical soft food from their plates. On 6/13/24, LPA observed (R1) to be able to eat soft food for lunch, using her fingers. Both the Administrator and RCC stated the hospice company would have called (R1's) responsible person in Jan and March 2024. when the orders were written. LPA confirmed with a hospice social worker on 6/13/24 that it is documented in their notes that on 1/4/24 and 1/25/24, hospice had "updated (R1's) daughter". The nurse confirmed that their notes did not indicate if the contact was made by phone, e-mail or another way, and that the responsible person of record would have been the family member who was called. The Administrator confirmed that (R1's) other family member was the legal contact person of record and the family member who visited was a secondary contact. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. cont on 9099C-2.. 9099C-2... Allegation: Staff did not provide reporting agency an itemized list of fees. The allegation states that a social worker was not provided with a copy of resident’s (R1's) invoice, showing the total balance owed, when requested by an official from a reporting agency. On 3/20/24, the Administrator stated she sent an invoice to the social worker who had requested a copy and also sent one to the represented Ombudsman, on Friday, 3/15/24. The Administrator stated she provided a copy of the invoice on the same day she received the request. The social worker stated she contacted the facility on several occasions, and left messages each time, but was not contacted back right away but did confirm that she was provided with a copy of the invoice on Friday, 3/15/24. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Facility did not notify resident's responsible person of an increase in monthly rent rates. The allegation states that the facility did not notify the resident's (R1's) family member of an increase in monthly rates starting in January 2024. The Administrator stated she spoke to the responsible person of record in November or December 2023 and confirmed that this primary contact stated she doesn't want to be involved in any way with (R1's) care and that her sister, (R1's) other daughter will be the one involved. LPA reviewed an e-mail sent on 10/31/23 from the primary contact to the Administrator with this information and another email sent on 11/4/23, from the Administrator to the second family member relating this same information. The Administrator stated a letter addressing the annual increase would have been mailed by USPS in December 2023 and it would have been sent to the responsible person, who has been the contact person of record. The Administrator printed a copy of this letter which was generic in nature and stated the letter did not return as "undeliverable" and did not return as signed. in the bottom portion of the letter, indicating the responsible person acknowledges the increase. cont on 9099C-3... 9099C-3... **on 7/3/24, this page was amended to remove specific wording in the first sentence of the first paragraph only.** The Administrator stated on 3/20/24, she sent an annual increase letter for room and board to the responsible person of record because the primary contact didn't say she didn't want to be involved until later in December 2023, confirming she took the primary person off as a responsible person at that time. The Administrator stated that the facility is required to continue to contact the responsible person of record, until there is a change made by the courts. The Administrator stated that the second family member was made aware by phone calls, on several occasions, of the increase, effective January 2024, and billing issues were discussed. The facility continued to reach out to both family members regarding billing issues Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Jun 13, 2024 · control 59-AS-20240315162450

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to a death report submitted for resident (R1). LPA met with Toni Jones, Administrator, and explained purpose of inspection. The facility submitted an incident and death report to the Department on 4/25/24 for resident (R1). The reports note that resident was found unresponsive, but still breathing, on 4/24/24 at approximately 7:30 am. Resident's health care provider was contacted and instructed the facility to send resident out for further medical evaluation. The facility contacted an emergency services provider and provided the information they requested by phone, and the outside service provider determined they did not need to call 9-1-1 for the transport. The facility was notified by the hospital later in the day, on 4/24/24, that resident had passed at approximately 3:33 pm. Because the resident was not under hospice care, the Department is requesting that a county death certificate be provided. LPA requested and received resident's current physician's report and care plan on 4/26/24 from the facility. Page 2 of the LIC624 was provided today. There are no deficiencies issued in this report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 30, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Toni Jones, Administrator, and explained purpose of inspection. Also present was Ashley Stahl, Resident Care Coordinator, and multiple other staff. The facility is licensed for (45) non-ambulatory residents who have a diagnosis of Dementia, (12) of whom may be bedridden, and has a hospice waiver for (17) residents. There are currently (6) residents on hospice. There is a pending increase for (4) additional residents. LPA will conduct an inspection once it is approved by local fire department. LPA and the Administrator toured the interior and exterior of the facility including the common areas, (2) resident rooms, medication room, dining rooms, activity room, salon, kitchen and staff lounge. LPA observed the facility to be clean, in good repair, odor free and the bathrooms to have paper towels, soap, trash cans with lids. LPA observed a 20-second hand-washing poster above each bathroom and kitchen sink. Fire extinguishers observed throughout and were last serviced on 7/24/23. There are (3) exit doors, including the front entrance door, equipped with an egress door alarm. Alarms and pendant cords are checked weekly for correct functioning. One exit door was tested and the alarm sounded. There is an enclosed courtyard with seating for residents. The inside temperature measured 72*F. Hot water measured 108*F in one resident room and 114*F in another. There is sufficient 2+ day perishable and 7+day non-perishable supply of food in the kitchen and the refrigerator/freezer temperatures are recorded daily. Residents do not have access to the kitchen area where sharps are kept. There are (2) activity calendars posted for the month and activity staff will document resident's daily participation in each activity. LPA reviewed (8) resident files. Files were organized and contained current physician's reports and care plans completed within the last (12) months. Medications were reviewed for (2) residents. Orders matched medications being given and medications are being documented when received, when given as a scheduled or PRN medication, and when destroyed or returned to the family. * cont on 809C-1... 809C-1... The medication room and medication carts were organized and there are (2) Med-Techs on the 'am" and "pm" shifts. Weekly medication audits continue to be conducted by both internal and external nurses. Each medication cart has a complete First Aid kit. LPA reviewed (8) staff files. Files contained all the required documentation. Staff have completed the initial and/or continuing required training and documentation was on file or printed during today's inspection. All staff is cleared and associated. Paperwork was submitted in August 2023 to renew Administrator's RCFE certificate (#6053689740- exp 9/11/23) and is pending renewal. Administrator to ensure staff renew their CPR certifications, if needed. All staff have current First Aid certifications. The Infection Control Plan was reviewed along with the Emergency Disaster Plan binder. Administrator printed a blank LIC610E (9 page version) during today's inspection to be completed as supplemental documentation to the plan. Administrator to post visiting hours in the reception area. LPA obtained current copy of liability insurance. LIC308 is posted and has not changed. LPA requested an updated copy of the LIC500, or staffing schedules (for May) be provided to the Department by 5/8/24. There were no deficiencies observed during today's inspection. There is a Technical Advisory note being issued. Exit interview. Copy of report left.the state’s words, verbatim · CDSS document, Apr 30, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to a recent AWOL involving resident (R1) on April 6, 2024. LPA met with Editha McCullough, Administrator Designee, and the stated reason for inspection. During today's inspection, LPA and the Administrator Designee observed the exit door and exit Egress gate where (R1) exited on 4/6/24 at approximately 5:10 pm. The door alarm was tested and (2) staff were promptly observed to be responding to the alarm sound. LPA observed a new alarm device to be installed on the top of the door. The Egress exit gate alarm was also tested and sounded for (15) seconds before the gate opened to the parking lot. The AWOL was reported by phone by the Regional Director on 4/10/24. A written incident report was also submitted on 4/10/24. It was determined later on 4/6/24, by a fence company, that resident (R1) was able to leave the facility unnoticed due to the audible sound only being heard in the main lobby area, and not throughout the facility. The egress gate was confirmed to be perfectly functioning. Resident was returned by the police at approximately (20) minutes later, at 5:35 pm, and resident sustained no injuries. Staff received follow up training on 4/8/24 and 4/9/24 relating to resident elopement procedures, delayed egress and re-arming a delayed egress lock after it's used. Additionally, an additional auditory alarm and a strobe system will be installed in another location to help staff hear when an alarm sounds. Resident (R1) is not able to leave the building unassisted due to a diagnosis of Dementia. Per Title 22, Division 6, Chapter, 8, the following (1) citation is issued on the 809-D page. A Technical Advisory Note is also being issued. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 16, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: Apr 17, 2024

87705 Care of Persons with Dementia. (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: Based on interview conducted and documentation reviewed, the Licensee did not ensure that resident (R1) was not able to exit the facility, unassisted, on 4/6/24 (5:10 pm approximatey), which posed an immediate health and safety risk to residents in care. Resident was returned to the facility, uninjured, 20 minutes later, at approximately 5:35 pm.the state’s words, verbatim · CDSS document, Apr 16, 2024

Plan of correction: The Licensee/Administrator immediately trained all staff on delayed egress, elopment procedures and re-arming a delayed egress lock after each use. In addition, an auditory alarm as well ass a strobe system will be installed in another location in the faciltiy to assist staff hear when an alarm is activated. Documentation of training to be sent to CCLD by 4/17/24. Photo documentation to be provided to CCLD showing that an additional auditory alarm and stobe lights have been installed. Due by 4/30/24.

Allegation investigated: Staff are denying resident visitations.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude a complaint investigation for a complaint received on 1/30/24. LPA met with Editha McCullough, Administrator Designee, and explained the reason for the inspection. During the course of the investigation, LPA interviewed the Administrator, Resident Care Coordinator, a Med-Tech staff, (R1') resident's family member. LPA attempted to interview resident (R1) but was unable to obtain useful information due to resident's diagnosis of Dementia. LPA reviewed documentation related to R1's family member being given restricted in-person visitation hours, including (2) letters sent to the family member in Decemer 2023 and January 2024. The results of the investigation are as follows: **cont on 9099C-1... Unfounded 9099C-1... Allegation: Staff are denying resident visitations. The complaint states that on 1/30/24, resident's family member called the facility to check on resident (R1) and was told she was feeling agitated so was given a Trazadone. Resident's family member requested to visit (R1) later that day, after 5:00 pm, and was told she could not due to the recently imposed restricted visitation hours on the family member. Additional information was received by the Department on 1/31/24 stating resident's family member had received a letter from the facility, on 1/3/24, and then a subsequent letter about violating the agreement made regarding issues addressed at the meeting in December 2023. Family member stated there are no violations and the facility's actions are retaliatory. On 2/5/24, additional information was received that resident's family member returned (R1) to the facility on 2/2/24, around 6:00 pm, after taking resident out for the afternoon, and the facility Administrator, who was present at that time, would not allow her to stay/say good-bye to resident since it was after 5:00 pm. LPA reviewed a letter that was given to resident's family member on 12/28/23, as a follow up to the meeting held on 12/15/23 to discuss concerns raised by resident's family member. The letter lists concerns the facility has had with resident's family member engaging in inappropriate communications with staff members and states the communication arrangements requested by the facility to mitigate these concerns. The letter cites (4) additional concerns/incidents that have occurred regarding communication between staff and resident's family member since the meeting on 12/15/23. The letter then lists additional measures the facility will begin to implement to "keep appropriate communication lines open for (R1's) care and balance that with the rights of other residents and employees at the community", including requesting (R1's) family member communicate directly with facility management, and to not contact care staff directly on their cell phones. LPA reviewed an email received from the Administrator on 1/2/24 that was also sent to same individuals who attended the meeting on 12/15/23. The email expressed how several staff recently stated they are becoming increasingly uncomfortable with resident's family member due to their communications and interactions with her. LPA was provided with copies of statements made by staff confirming this information. A second letter was sent to resident's family member on 1/17/24, noting it is a follow up to the conversation the Administrator had with this family member on 1/11/24. The letter states there are (4) specific parameters being implemented regarding future visitation at the community with the first restriction stating in-person visitation will only be permitted between 9:00 am - 5:00 pm, daily. **cont on 9099C-2.. 9099C-2... It was later clarified that resident's family member can communicate by phone with (R1) until 9:00 pm, but the in-person visitation would remain restricted to the hours of 9:00 am - 5:00 pm. Both the Administrator and RCC confirmed on 1/30/24 that (R1's) family member was recently given restricted in-person visitation rights from 9:00 am - 5:00 pm. The RCC stated that resident's family member did contact her by phone on/around 1/30/24 in the late afternoon, asking if she could visit her mom in the evening, but the request was denied by the Administrator, as resident was previously informed of the restrictions in place. A citation was issued on 1/25/24 for the facility not allowing resident's family member to talk with resident by phone, on 1/20/24, between the regular visiting hours of 9:00 am- 9:00 pm. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided to the facility.the state’s words, verbatim · CDSS document, Apr 9, 2024 · control 59-AS-20240130093332

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to incident reports recently received. LPA met with Edith McCullough, Administrator Designee, and the stated reason for inspection. LPA and Administrator Designee discussed (2) recent incident reports for resident (R1). LPA spoke with a Med-Tech staff, the Administrator Designee and the resident (R1). LPA observed resident to be recovering from the unwitnessed incident where resident bumped her left eye brow and eye area. LPA and Administrator Designee spoke to (R1) and asked her how she is feeling and how the incident occurred. Resident was not sure but said she is feeling okay and had just finished her lunch. Resident indicated that staff at the facility are "nice" and helpful. LPA reviewed hospital discharge paperwork from 4/5/24 where resident was given she was given information for a wound and head injury. Staff say resident is doing fine and is eating independently. LPA and Administrator also observed another resident (R2) who was eating in the dining room, and checked her room. No concerns were noted. LPA spoke to (2) staff members regarding showers. There are no deficiencies cited in this report. Exit interview. Copy of report provided to Administrator Designee.the state’s words, verbatim · CDSS document, Apr 9, 2024

Allegation investigated: Staff sexually assaulted resident in care.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings to an investigation conducted by the Department for a complaint received on 2/26/24. LPA met with Toni Jones, Administrator, and explained the reason for the inspection. Also present was staff, Editha McCullough, who was reviewing staff files in the Administrator's office. During today's inspection LPA conducted (5) staff interviews with both "am" and "pm" caregiver staff relating to other concerns brought to the Department's attention during the investigation. During the course of the investigation, the Department conducted interviews with facility staff, resident (R1), resident's family member, local law enforcement and the Ombudsman and reviewed pertinent documentation. The results of the investigation are as follows: cont on 9099C-1... Unfounded 9099C-1...Allegation: Staff sexually assaulted resident in care. The allegation states resident (R1) was inappropriately touched by care staff (S1). The complaint information received indicated that resident (R1) stated to her family member on 2/11/24 that staff had pushed her on her bed and "touched her"; however, the facility was not made aware of the incident until 2/23/24 when another family member spoke with the Administrator. The Administrator then notified the facility nurse who talked to the resident about the allegation. Out of precautionary measures, resident was immediately sent to the hospital to be medically evaluated; however, an exam was not done due to resident being non-verbal, unable to provide any details, and in denial that a sexual assault had possibly occurred. Local law enforcement responded to the hospital and attempted to interview (R1) and then interviewed several staff, as requested by the facility. Documentation provided by local law enforcement supports there was no evidence to confirm or deny a crime occurred. Law enforcement also spoke to resident's family member who indicated the allegation was not conveyed to the facility Administrator sooner, due to miscommunication with staff. Administrator stated this family member did not communicate anything (R1)had told him on 2/11/24 or on 2/14/24 when he was in the building. The Administrator stated to the Department that resident's spouse told staff, (S2) that staff (S1) had only "been mean to her" and there was no mention of a sexual assault. The Administrator stated to local law enforcement that she spoke to the other (3) staff working on 2/11/24, when the alleged incident occurred, and none of the staff observed any interaction between (S1) and (R1), as (S1) was assigned to a different hall from where (R1's) room is located. The Ombudsman was interviewed on 3/5/24 and indicated (R1) was interviewed at length on 2/27/24 and no disclosures were made about a sexual assault. The Ombudsman stated resident was friendly and relaxed and was insistent that no staff had touched her inappropriately. Resident, (R1), was interviewed by different individuals, and denied being touched inappropriately each time. Due to resident's diagnosis of Dementia and rambling during the interview, this resident was not able to provide any useful information or respond appropriately to questions asked about living at the facility. Attempts were made to speak to (R1's) roommate (R2), but (R2) declined to speak to the Investigators. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. *cont on 9099C-2... 9009C-2.... Staff interviews were conducted on 3/28/24 for the following additional concerns reported: (S1) was reported to be "rough" with not only, resident (R1), but other residents also. One staff stated she recalls (S1) being rough when transferring residents, stating she observed several Residents to show a look of discomfort on their faces. This staff stated she is not sure if (S1) was specifically rough with (R1). A second staff stated (S1) was "slightly rough", and would yell back at residents if residents began to yell at him or call him names. A third staff stated she never observed (S1) to be rough with (R1) or any other residents. A fourth staff who works on the evening shifts stated he observed (S1) to be "verbally rough maybe" with residents but never physically. A fifth staff interviewed didn't recall working with (S1). (S1) was an agency staff that did not continue working at the facility on/around February 2024. Staff were observed to tell residents the kitchen is closed when a resident says they're hungry. One staff stated she has not observed any staff to tell residents they can't have any food or snack and commented that an agency staff might have said the kitchen is closed. A second staff stated she never heard any staff comment that the "kitchen is closed" and a lot of residents have snacks that are stored in the kitchen for between meals. The third staff stated she will go to the kitchen and request a snack be prepared if a resident says they are hungry. A fourth staff stated he has heard registry staff tell residents the kitchen is closed, one or two times, when the snack cart was not left out by the cook at 7:30 pm. This staff explained that agency staff didn't know to ask the Med-Tech for keys to the kitchen to get the cart. A fifth staff stated staff will usually go and get a snack from the kitchen if a resident asks. Staff have been observed to act impatiently with residents who can't feed themselves independently. One staff stated some residents need a lot of cuing but wasn't able to give any examples. Two additional staff stated it is not an issue with staff being impatient in the "am" shift. Two "pm" staff stated they have never seen staff act impatiently with residents and staff is "patient and kind". Staff have been observed to "swat" residents on the backside, in a playful manner. One staff stated she has seen one resident swat several staff in a playful manner, over the last month. A second staff stated there is one resident who complains about certain caregivers as some staff are less comfortable with changing residents than other staff. A third staff stated she has never observed any staff to "swat" a resident. Two "pm" staff stated they have never seen any staff "swat" a resident. Due to a lack of the preponderance of evidence, the above additional concerns were found to be Unsubstantiated. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 28, 2024 · control 59-AS-20240226123853

Allegation investigated: Staff did not ensure medications are dispensed as prescribed for resident in care.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete an investigation and provide findings to a complaint received on 12/26/2023. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During the investigation, LPA conducted multiple interviews, including with the facility Administrator, Resident Care Coordinator, (4) med-tech/caregiver staff, and resident’s (R1) family member. Various documentation was reviewed, including, but not limited to, Medication Administration Record (MAR) for November/December 2023, PRN medication logs, prescription medication orders, Bowel Movement Logs, incident reports and hospital discharge paperwork. Resident (R1) resided at the facility from January 2023 through February 2024. Substantiated 9099C-1. Allegation: Staff did not ensure medications are dispensed as prescribed for residents in care. The complaint alleges that staff did not administer resident (R1)the medication, Loperamide (Imodium), as prescribed. Interviews with resident's family member and facility staff confirm that resident had irregular episodes of loose stool or diarrhea in November 2023. The Bowel Movement Log for November 2023 documents loose stool and diarrhea from 11/10/23 through 11/30/23, with diarrhea noted on (3) consecutive days from 11/28/23 through 11/30/23. Resident obtained a prescription for Loperamide (Imodium A-O) 2 mg oral tablet on 11/30/2023 with orders to Take 2 tablets by mouth after the first stool, then 1 tablet after each subsequent loose stool. Do not exceed 4 tablets in 24 hours. Take with 4 to 8 ounces of water. The MAR documentation for December 2023 shows the initial (2) tablets of Loperamide 2mg were administered on 12/1/23 on the “pm” when it arrived. Staff initials were made on the MAR several more times for 12/1/23 and 12/2/23 with a note added that (2) Imodium tablets were not administered on 12/2/23, as signed. Also, both the scheduled and PRN prescription are listed as a “PRN", and there was a notation on the MAR that dosages were to be recorded instead in the PRN Binder. A notation was made on the PRN log that on 12/3/23 (8:00 pm) (1) tablet of Loperamide 2mg was administered and was “not effective”. The PRN log notes that the next dosage was administered on 12/5/23 (2:00 pm) and (2) tablets were given prior to resident leaving the facility with a family member. The next PRN dosage of (1) tablet, was given on 12/7/23 (1:00 pm), but there are no notes if the medication was effective. The Bowel Movement log shows that resident was also given foods known to help with diarrhea (BRAT diet) on 12/8/23, but there was "still no change" after resident was given (1) Imodium tablet earlier on 12/8/23. The PRN log documents that (1) tablet was given on 12/8/23 (9:00 am) and it was "not effective". On 12/28/23, the Administrator reviewed the PRN log with the LPA and confirmed Imodium was given at 9:00 am on 12/8/23 and resident didn't have another episode of diarrhea for (17) hours, until 2:00 am on 12/9/23. The BM log notes resident had a large episode of diarrhea but was not administered Imodium following this episode. The Administrator commented that the NOC shift staff also didn't log the 2:00 am episode of diarrhea on the Bowel Movement Log, so she made the notation. Resident Care Coordinator stated this NOC staff had taken a break from working at the facility, and the log was implemented during her absence. *cont on 9099C-2. 9099C-2... The family member stated that resident had "more diarrhea on Saturday, 12/9/23 at 2:00 am and then again on 12/9/23, 8:00 am”, was not given Imodium following these episodes. The Administrator stated that resident was sent to the emergency room on the morning of 12/9/23 due to having continuous episodes of diarrhea for (3) consecutive days. The Administrator met (R1) at the hospital and stayed with resident until she returned to the community. Resident’s family member stated that, prior to resident going to the Emergency Room on 12/9/23, she had informed facility staff that resident had tested negative to several lab tests and blood panels ordered by her primary care physician and was on the list for a gastroenterologist referral. The facility submitted an unusual incident to report resident was sent to the Emergency Room on 12/9/23, at 8:20 am for consistent diarrhea for the prior (3) days. The Administrator did not administer the medication following this episode to seek clarification from a physician since the diarrhea had persisted for (3) days continuously, despite being given the medication. Resident returned the same day and the hospital discharge paperwork shows resident was treated for diarrhea and given care instructions to continue taking Imodium, as directed, follow up with primary care physician and schedule to see a gastroenterologist for further evaluation. After returning to the facility late afternoon on 12/9/23, resident was given (1) tablet of Imodium due to having diarrhea at the hospital, and the PRN log documents (1) tablet was administered on 12/9/23 (4:30 pm) and it was effective. Documentation reviewed shows resident did not need to be administered a subsequent Imodium tablet until the morning of 12/11/23 and resident left with family member, so it's not clear it the medication was effective. Resident received the next table in the evening of 12/12/23 (7:28 pm), where it is noted as being effective. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided. 9099A-C-1... One caregiver staff stated on 12/28/23 she usually doesn't hear the phone ring or the door bell sound because she is in resident rooms, and the television and music are on. This staff stated she thinks it's "one phone" only that is used after 5:00 pm, and confirmed that Med-Techs should be answering the phone and caregivers will answer, if needed, commenting she carries her personal cell phone with her, only checks her phone on breaks, and the facility does not give care staff a phone during their shift. The Administrator confirmed that the land line phone is working, and the phone is "always in the reception area". On 12/28/23 (3:00 pm), LPA observed the phone to be at the reception desk and the dial tone to work when the handset was picked up. The Administrator stated the cordless phones (2) were charging at a time but were never locked up and confirmed she had both agency staff and facility staff working the NOC shift on 12/24/23- 12/25/23. The Resident Care Coordinator (RCC) stated the receptionist works from 9:00 am - 5:00 pm, answers the front desk phone, and there are also (3) cordless phones that use "one line" only. The RCC stated "the Med-Tech always has a cordless phone- but there are certain places in the building where the reception isn't as good", explaining there have been multiple different cordless phones used, and this problem has been encountered with each phone used. A Med-Tech Staff, stated the desk phone is always on the desk but staff will sometimes"disconnect it so clients can't use it" if they are in the front common area. This staff stated she will bring out the (3) cordless phones and the Med-Tech always has one, and although there are (3) phones, there is only (1) phone line. If a second line is needed, staff can use the reception line. This staff explained the cordless phones were replaced a few months ago, the new ones hold the charge better, callers can leave a voice message 24/7, and staff can still hear the phone ringing even if staff is on another line. This same staff stated she is not aware of a time when the cell phones were locked in the RCC's office or medication room time and were being charged and not available for staff use and commented, in general, staff do not receive calls during the NOC shift unless a resident is returning from the hospital and pharmacy deliveries end at midnight. cont on 9099A-C-2.. 9099A-C-2.. A second Med-Tech, who worked in December 2023, stated there is always a working phone at the facility, 24/7, and when she was scheduled on shift, she would ensure the reception phone was on the reception desk, as there are (2) main residents who commonly use the phone to call their families. This staff explained how the cell phones can't be used while they are charging, but they will still ring and usually the Med-Techs will keep (1) phone with them during their shift so they can answer the phone. The Med-Tech stated that at 7:00 pm, Med-Techs are usually doing a medication pass but "staff can hear the voice mail when someone is leaving a message" and if there is no answer, it’s because someone is probably using one of the three phones. (R1's) family member stated she "possibly" left a message when trying to contact a staff member one of the times. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff did not ensure the care needs of residents are being met. Complaint alleges that staff were not tending to resident's (R1) care needs at night, on 12/24/23, including monitoring resident for changes, while she was screaming for help while in pain. Resident’s (R1) family member stated when she arrived at the facility on 12/24/23 at approximately 9:30 pm, she could hear resident screaming from the hallway and when she arrived at resident's room, she saw her laying in bed, indicating it "hurts" behind her neck. Resident’s family member stated she talked to staff, (S1) who attempted to call the RCC twice, and there was no answer, so resident’s family member then texted and called the Administrator who arrived around 11:00 pm. (S1) confirmed she worked on the evening shift on 12/24/23 and stayed with resident (R1) in her room for 20 minutes that night, watching TV, and resident did not scream or ask for any pain meds during this time. (S1) indicated that (R1) never complains of pain and sometimes will call (S1) because she doesn't want to be alone and likes to listen to country music. (S1) stated she checks on all her assigned residents during her shift and she and other staff will brush residents' teeth in the morning and at bedtime. cont on 9099C-A-3... 9099C-A-3... The Administrator stated the typical baseline for resident (R1) is to say "God help me..." over and over and (R1) doesn't normally say she is in pain. LPA observed text messages from resident’s family member to the Administrator on 12/24/23 stating resident was in pain. The Administrator commented that resident's family member "didn't initially say (R1) was screaming" but said that in later texts. The Resident Care Coordinator(RCC) stated "the only time I've ever heard (R1) complain of pain was in her stomach due to the diarrhea". The RCC confirmed she was at the facility on 12/24/23 and (R1) was sleeping some of the time, explaining that around 8:45- 9:00 pm, resident "was a little upset because she felt alone in the room- her roommate was sleeping". RCC indicated that staff, (S1) was the caregiver and she passed the "pm" meds, as RCC. RCC commented "just after 9:00 pm, (R1) fell asleep" and then she was fine, without any pain, when the Administrator saw her at 11:00 pm. RCC confirmed that (R1) used to scream until she started taking Trazadone 1-2 months ago, indicating that resident takes (1) routine Trazadone and (1) PRN Trazadone. RCC commented that (R1) used to wake up all night long, and that's why Melatonin was started; however, resident did not ever complain of pain and would say nothing hurts when she was asked. LPA interviewed a second staff (S2) who confirmed she worked "am" shift on 12/24/23 and (R1) was not in any pain that she was aware and resident went out of the community with a family member during her shift. This staff stated (R1) has "not recently been crying in pain" and resident "mostly cries out for help, after she has just woken up from being asleep. (S2) stated "it really depends" on if (R1) is experiencing "loneliness" as her roommate doesn't talk. (S2) commented that before (R1) started taking Melatonin and Trazadone, she would regularly wake up at 2:00 am but has been sleeping through the night since starting the (2) medications. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 13, 2024 · control 59-AS-20231226105149

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Mar 14, 2024

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure resident (R1) was administered PRN Loperamide 2 mg (Imodium), as prescribed, on 12/9/23 (2:00 am) and following diarrhea, which posed a potential health and safety risk to residents in care. (R1) was sent to the emergency room for further evaluation.the state’s words, verbatim · CDSS document, Mar 13, 2024

Plan of correction: Licensee/Administrator have already completed staff in-service training for PRN medications and documentation on the PRN log and MAR. Documentation of training completed in February 2024 and later by 3/14.24.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude a complaint investigation for complaint # 59-AS-20231226105149 and met with Toni Jones, Administrator. LPA explained the reason for the inspection. During the course of the investigation, LPA reviewed several unusual incident/injury reports (SIR) for resident (R1). One SIR reports (R1) having an unwitnesed fall on 10/5/23 in the dining room at approximately 8:45 am. The report states that care staff reported that resident was upset and “having an expression” and trying to get out of the wheelchair. Afterwards staff observed resident had a bump on her forehead, she was sent to the hospital for further evaluation. Resident returned to the community the same day with the recommendation to follow up with her primary care physician in 4-7 days. Interviews with the Administrator and family member confirmed that the care staff (S1) who was with resident when she began to enter a behavior, left the resident unattended, to get another staff to assist, when resident fell out of her wheelchair and sustained bruising on her head and face. Resident’s family member stated staff (S1) walked away from (R1) on 10/5/23 which caused her to fall on her face. The family member provided (2) photos showing a head injury on resident's right side, above the eyebrows, and clarified that when staff walked away, resident stood up and then fell flat on her face. A subsequent incident report was submitted on 10/9/23 for an incident occurring on 10/8/23 (2:30 pm). (R1) was observed to not be at baseline and to be screaming so was given a PRN medication for pain. Resident was sent to the emergency room later in the day, complaining of pain, and was diagnosed with pneumonia and a concussion from the previous fall from 10/5/23. Resident was prescribed levofloxacin and placed on alert charting until returning to baseline. *cont on 809C-1 809C-1..§1569.626 Training requirements for direct care staff states in part: (a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. LPA reviewed training records for staff (S1), who began working as a care giver on 6/28/23. The records document that (18) hours of training was completed from 6/28/23 through 7/4/23 and (1) hour was specific to Dementia care.the state’s words, verbatim · CDSS document, Mar 13, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(3)(A) · Plan of correction due date: Mar 14, 2024

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: (A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living; This requirement is not met as evidenced by: Based on documentation reviewed, the Licensee did not ensure that staff (S1) had completed the required training related to Dementia care, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 13, 2024

Plan of correction: (S1) is no longer employed at the facility as of February 2024. Licensee/Administrator to ensure that all care staff have completed the required initial and/or continuing training hours. LPA to review training documentation during the upcoming annual by 4/30/24.

Type of visit: Office

On 1/31/2023 at 1:30 PM, Non-Compliance Conference meeting was held with Sacramento North Regional Office via Microsoft Teams Meeting. Present in the meeting was Licensee, Mark Cimino, mutiple Ciminocare representatives, Regional Manager (RM) Alycia Berryman, Licensing Program Manager (LPM) Maribeth Senty, and Licensing Program Analyst (LPA) Sabrina Calzada. Topics discussed during this meeting were: Medication management Staffing The licensees were in agreement with the drafted non-compliance plan as outlined in LIC 9111. An exit interview was conducted and a copy of this report will be provided to the facility via email. A copy will be signed and returned to CCLD.the state’s words, verbatim · CDSS document, Jan 31, 2024

Allegation investigated: Medication mismanagement.

Licensing Program Analysts (LPA) Sabrina Calzada and Melissa Parks arrived unannounced to close a complaint received on 1/2/2024. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During the investigation, LPA interviewed multiple staff and a family member of resident (R1). LPA also reviewed documentation, related to resident (R1), including emails, medication documentation, charting notes and other documentation. The results of the investigation are as follows: cont on 9099C-1... Substantiated 9099C-1... Allegation: Medication mismanagement. The complaint alleges that resident (R1) ran out of medications on (2) occasions. Resident’s (R1) family member stated the first time (R1) missed her medications was after the initial (30) day supply of Olanzapine 2.5 mg, taken at bedtime, was started on 7/26/23. The MAR and LIC622 document this prescription was filled and started on 7/26/23, with no automatic refills. The Med-Tech/Nurse communication log also documents that medications were received on 7/26/23, and Olanzapine was logged and stored as well as other medications. MAR documentation for July and August 2023 does not reflect the medication was administered consistently and shows (3) days/dosages were missed in July and multiple days/dosages were missed in August. If the medication was started on 7/26/23, it should have run through 8/24/23. The next prescription, noted as a (3-day) emergency supply, was not filled until 8/27/23. Resident’s responsible person stated that on Tuesday, 8/29/23- there was a medical follow up for this anti-psychotic medication that was prescribed for "auditory hallucinations". The LIC622 documents that a (5) day prescription was filled on 8/29/23, but not started on 9/6/23. Staff interviews indicated that they would reach out to the resident’s responsible person and leave voice messages regarding a medication needing to be refilled and the responsible person did not return the call. The RCC stated that when (R1) first moved in, she had no medical insurance and "everything was still out of state". RCC stated that there was only "one time" when (R1) missed medications, stating she believes the medication was "Olanzapine". The Administrator stated the Med-Tech would call for refills and then call the family member to pick them up, and she was aware of what was needed" for the refills and agreed to pick up the meds when (R1) moved in. Resident’s family member mentioned that a medication ran out for resident again, on Friday, 10/13/23, and she was just notified by staff, and the last dosage to be administered had been poured for the evening of 10/13/23. LIC622 documents that a 90- day supply of scheduled Levothyroxine .88mg, was filled on 10/13/23 and started on 10/14/23. MAR shows resident did not miss any dosages of this medication taken in the morning in October. Exit interview. Copy of report and appeal rights provided. cont on 9099C-2...the state’s words, verbatim · CDSS document, Jan 30, 2024 · control 59-AS-20240102161217

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 1, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on documentation reviewed and interviews conducted, the Licensee did not ensure that resident (R1) did not miss a dosage of Olanzapine on/around August 24-25, 2023, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 30, 2024

Plan of correction: Licensee/Administrator will inquire if they can contract with a local pharamcy regarding obtaining a private pay emergency supply, if the family member doesn't pick up the medications timely. All Med-Tech staff were re-trained or in the process of being retrained, on thorough documentation on the MAR and LIC622 and documenting attempts to contact family members when a refill is needed. Documentation to be provided by 2/1/24 for training and by 2/8/24 for the local pharmacy.

Type of visit: Case Management - Other

Licensing Program Analysts (LPA) Sabrina Calzada and Melissa Parks arrived unannounced to conduct a case management inspection as a follow up to a meeting the facility had with the Department's Technical Support Program (TSP) on December 12, 2023. LPA's met with Toni Jones, Administrator, and explained the reason for the inspection. On December 12, 2023, five random resident medication records were reviewed and errors were discovered in three of the records, as follows: Resident (R1) had missed a dosage of anti-psychotic medication, Olanzapine, for days. A Med-Tech staff stated to TSP staff she had been calling (R1's) physician's office for weeks, trying to get the medication refilled. Later during the meeting, it was discovered that the medication had been received by the facility on 12/1/23, but staff did not look in the centrally stored cabinet. The Administrator was advised to complete an incident report and submit to the Department and to notify (R1's) physician immediately. The incident report was received on the same day, 12/12/23 The Medication Administration Record (MAR) for (R1) for December 2023 has staff notations for days from December 1, 2023- December 12, 2023. The Administrator stated that (5) of the days in December were marked that the medication was "absent", so it wasn't given. The medication, Lorazepam, was listed on resident (R2's) current medication list, but a Med-Tech staff stated this medication had been discontinued on 11/20/23. The discontinuance orders were not able to be found. An updated medication list was printed immediately upon the discovery. The medication Buspar was found in resident (R3's) medication basket, but an order or record of this medication could not be located in resident's files or in the different medication binders. An updated medication list was printed immediately upon the discovery. Due to these errors being discovered by the Department's Technical Support Program, a Technical Advisory Notes are being issued instead of citations. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Jan 30, 2024

Allegation investigated: Staff are denying resident the right to receive confidential calls.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open and close a complaint investigation for the above allegation. LPA met with Toni Jones, Administrator, and explained the reason for the inspection. The allegation states that resident (R1's) family member was denied being able to speak with (R1) on the phone on two occasions, and was told by staff (S1) she could not talk to (R1) because she was not allowed to. A case management inspection was conducted on 1/23/24 in the afternoon, prior to LPA viewing the complaint in the system, regarding this allegation. The Administrator and (R1's) family member were interviewed then. Today, 1/25/24, LPA interviewed the Med-Tech staff (S1) who communicated with (R1's) family member when she called on 1/20/24 and on 1/22/24, just prior to 9:00 pm, and was told she wasn't allowed to speak to (R1), based on current visititation restrictions in place for this family member. **cont on 9099C-1.... cont on 9099C-1. Substantiated 9099C-1... Interview with (S1) on 1/25/24 confirmed that (S1) was on shift on 1/20/24 when (R1) received a phone call on the facility main phone line. (S1) stated that she answered the phone call and told (R1's) family member that she was not able to speak to (R1) due to events that transpired earlier that evening. (S1) stated that (R1) was very upset and confused by what the family member told (R1) about why she had to leave, and (R1) was agitated for hours, despite being given PRN medication for those symptoms. The Administrator was made aware of what had transpired from (S1) after she left the community at 4:30 pm. R1's family member stated another family member was visiting with (R1) on Monday, 1/22//24 when she called to speak to (R1), and (R1) was awake. (R1's) family member called the community to speak to (R1) again on Monday, 1/22/24, at approximately 8:43 pm. (S1) confirmed with LPA that she was on shift at this time and answered the phone call from (R1's) family member. (S1) also confirmed that (R1) had a visit with a different family member from approximately 7:00 pm- 7:45 pm, that night, and that visitor left following (R1) being administered bedtime medications by (S1), and when she began to fall asleep. (S1) stated she walked to (R1's) room while on the phone with (R1's) family member, and observed the lights to be out in (R1's) room and (R1) to be dozing off. Both the Administrator and Resident Care Coordinator confirmed that (R1's) spouse arrived at the community to visit with (R1) on Monday, 1/22/24 at 7:06 pm and stayed until approximately 7:45 pm, when (R1) began to fall asleep. LPA again discussed personal rights of (R1) and how each resident has the right to decide if they want to accept a phone call and how phone calls were not specifically mentioned in the recent visitation limitations placed on (R1's) family member who made both phone calls. The Administrator stated she has since confirmed that any in-person visitation restrictions will remain in place for (R1's) family member, and all residents will be given an opportunity to accept a phone call during regular business hours, from 9:00 am- 9:00 pm, provided the resident is awake and able to take the call. Although the facility believed they were acting in the best interest of (R1) and (R1) has a diagnosis of Dementia, she is not currently conserved and there is not a restraining order in place for the family member who called both times. Both calls were within the regular visitor hours, prior to 9:00 pm, but (R1) was not asked if she wanted to accept the call on 1/20/24, Saturday, when she was awake, but agitated. (R1) was asleep on 1/22/24, Monday, when the phone call was received. . As a result of this investigation, LPA finds allegation to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 25, 2024 · control 59-AS-20240123105606

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Feb 8, 2024

87468.1 Personal Rights of Residents in All Facilities.(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls. This requirement isn not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that (R1) was allowed to accept a phone call from a family member on 1/20/24 at approximately 8:48 pm, which posed a potential personal rights violation to residents in care. Resident was very agitated and staff didn't feel she was emotionally able to take the call at that time.the state’s words, verbatim · CDSS document, Jan 25, 2024

Plan of correction: Licensee/Administrator already received clarification because of the situation and phone calls will be allowed between 9:00 am and 9:00 pm, provided the resident is awake and available to talk. POC is cleared today, 1/25/24.

Type of visit: Case Management - Other

**This report was amended on 1/25/24 due to a complaint with the same allegation being received earlier on the same day, 1/23/24. There was a separate report created for the complaint investigation. The Technical Advisory Note issued in this case management report is being replaced with a citation on the complaint investigation report.**. Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management related to two recent incidents. LPA met with Toni Jones, Administrator, and explained the reason for the inspection. LPA and Administrator discussed how resident's (R1) family member was not permitted to speak to R1 by phone on two separate occasions. The Administrator stated that on 1/20/24, resident's family member called the community at approximately 8:48 pm, and was told by staff (S1) that she was not allowed to speak to resident due to resident being in a behavior, following what had taken place approximately an hour earlier, and due to recent visitation restrictions placed based on (R1's) family member's interactions with staff and others at the community. On 1/22/24, Monday, resident's family member contacted the community at approximately 8:43 pm and asked to speak to (R1). Resident's family member was again told by staff (S1) she could not speak to (R1) due to visiting hours currently in place for the family member. The Administrator stated that (R1) was also already prepared to go to sleep at this time. LPA discussed personal rights of (R1) and how each resident has the right to decide if they want to accept a phone call. LPA discussed how phone calls were not specifically mentioned in the recent visitation limitations placed on resident's family member. The Administrator agreed to discuss any restrictions related to phone calls with (R1's) family member. Also discussed was how (R1's) medications had run out last night and (R1) didn't receive her noon dosage of Buspar when leaving the facility for a few hours this morning with a family member. The Administrator showed LPA documentation that the facility attempted to refill the medication on 1/8/24, 1/15/24, and on 1/17/24, but the physician denied the refill. The pharmacy delivered a 5-day supply this morning, 1/24/24. A Technical Advisory Note is being issued today. There are no deficiencies issued in this report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Jan 23, 2024

Allegation investigated: Facility staff did not provide adequate supervision resulting in resident eloping from facility.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to continue the complaint investigation for the above allegation. LPA met with Toni Jones, Administrator, and explained the reason for the inspection. During today's inspection, LPA obtained copies of documents previously requested for resident (R1), including the physicians report, care notes, medication list, MARs and caregiver notes. Documents were not received earlier due to technology issues. LPA also interviewed the Administrator, Resident Care Coordinator, and (3) facility staff. The results of the investigation are as follows: cont on 9099C-1.. Unfounded 9099C-1....Facility staff did not provide adequate supervision resulting in resident eloping from facility. The complaint alleges that a family member received a call from staff saying that one of the other residents was able to scale the fence and ended up in the parking lot. There is no day/time mentioned when the call was allegedly received nor a staff person referenced. Both the Administrator and RCC stated that it is facility protocol to only contact the responsible person(s) or family member(s) that is involved in an incident, and family members for another resident not involved in an incident would not be contacted. Interviews conducted with facility staff on 1/18/24 did confirm that resident (R1) tried to exit seek a few times in 2023 when living at the facility but was able to be re-directed by staff. Interviews also revealed that (R1) believed a family member was trapped in a car in the parking lot so staff walked her out to the vehicle and showed her that the vehicle did not have any individuals inside. The Administrator and RCC both confirmed that resident (R2) eloped from the community on/around June 29, 2023 and has not tried to leave unattended again. Staff confirmed this incident was also the last elopement incident for (R2) and no other resident has tried to leave the facility unattended either. This allegation was also previously investigated for (R2) and found to be substantiated and a citation was issued. Based on information obtained, this allegation is this complaint report is UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report emailed to the RCC.the state’s words, verbatim · CDSS document, Jan 18, 2024 · control 59-AS-20240102161217

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following receipt of an incident report on 1/4/24. LPA met with Toni Jones, Administrator, and explained the reason for the inspection. LPA discussed the incident report with the Administrator where resident (R1) was sent to the emergency room on 1/4/24 due to needing medication refills. The report states resident returned to the community the same day and medication refill orders were sent electronically to a local pharmacy to be filled. After discussing the incident further with the Administrator, it was learned that (R1's) responsible person had recently changed (R1's) insurance plan, and the refills were unable to be filled by the assigned doctor in another city as (R1) had no way to travel out of town to see that physician. LPA discussed the incident report that was faxed in and had missing information on the first page, explaining the reason why (R1) was sent to the emergency room. The Administrator provided LPA with a paper copy of the incident report where additional information was included that was not included on the faxed copy. The additional information explains that (R1) was sent out was due to the insurance company incorrectly assigning (R1) to a doctor out of the area. The Administrator confirmed (R1) had (3) remaining days of medication when he was sent out. The new insurance is effective 2/1/24. There are no deficiencies issued in this report. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Jan 18, 2024

Allegation investigated: Licensee did not ensure there are qualified night staff able to administer medications to residents in a timely manner.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint received on 12/26/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During today's inspection, LPA interviewed the Administrator, Resident Care Coordinator, (1) caregiver, (1) Med-Tech staff,and (R1's) family member. LPA also obtained copies of recent text messages between resident (R1's) family member and the Administrator regarding the above allegation. The results of the investigation are as follows: The allegation states the facility did not have a qualified staff to dispense medication to residents at night and the administrator had to be called to come in to dispense pain medication. cont on 9099C-1... Substantiated 9099C-1... (R1's) family member stated to LPA on 12/28/23 that she arrived at the facility on Sunday, 12/24/23 at approximately 9:30 pm to visit (R1). This family member stated she heard (R1) screaming upon her arrival to the community and was informed by (R1) that her neck hurt, and she needed pain medication. This family member stated staff then contacted the Resident Care Coordinator by phone at least twice, between 9:30-10:00 pm, and when the RCC did not answer the call, she reached out to the Administrator, by text message. Resident Care Coordinator showed LPA her missed phone calls from 12/24/23. At 11:06 pm, she received a missed call from the Administrator; at 11:11 pm, she received a missed call from (R1's) family member; and at 11:12 pm and 11:13 pm, she received missed calls (2) from care staff, Gertrude. RCC stated she responded at 11:15 pm to staff on duty, but did not receive a response so immediately followed up with the Administrator. LPA reviewed text messages received by the Administrator, at 10:54 pm on 12/24/23, where (R1's) family member states she just arrived at the facility and (R1) indicated "she's hurting all over...and she's not able to sleep... needs Tylenol and maybe another Trazadone". The Administrator stated to LPA she had just missed (R1's) call that night and when she went to check the missed call, she saw the text messages received just prior to the call. LPA reviewed the text message sent from the Administrator to (R1's) family indicating she or the RCC would be at the facility shortly to administer Tylenol since there was an error with the order for Trazadone. Administrator stated to LPA she arrived at the facility at 11:50 pm that night and administered Tylenol to (R1). The Administrator confirmed that following recent changes to the medication room, there was not a Med-Tech staff or other staff on duty, on 12/24/23, at 10:54 pm, who was able to administer the pain medication to (R1) when requested, until she arrived at the community at approximately 11:50 pm, or an hour later. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview with the Resident Care Coordinator. This finding was discussed with the Administrator earlier during the inspection. Copy of report provided to the facility.the state’s words, verbatim · CDSS document, Dec 28, 2023 · control 59-AS-20231226105149

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87413(a)(1) · Plan of correction due date: Dec 29, 2023

87413 Personnel - Operations. (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met as evidenced by: Based on interviews conducted and text messages reviewed, the Licensee did not ensure that there was a Med-Tech staff or other staff on duty on 12/24/23, from approximately 10:54 pm to 11:50 pm, that was able to administer PRN medication for pain to (R1), which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 28, 2023

Plan of correction: Licensee/Administrator agree to immediately schedule a Med-Tech staff or other staff that is trained to administer medications, for all shifts, effective 12/28/23. Administrator confirmed with RCC on 12/28/23 that staff (S1) is scheduled for PM and NOC shift from 12/28/23-12/29/23 and other NOC shifts. Additionally, another Med-Tech was recently hired to work NOC shifts if needed. Documentation of Med-Tech schedule from 12/28/23 - 1/31/24 to be provided to the Department by 12/29/23. Admin will cover 1/27/24 and RCC will cover 1/19/24.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

NOTE: LPA provided an updated copy of this report to the Administrator on 12/28/23, when at the facility. The updated information was added to the original report (prefaced by ***), since the report was inadvertently not final printed. Licensing Program Analyst (LPA) Sabrina Calzada arrived announced to attend a scheduled meeting with resident (R1's) family member(s) and Administrator, Toni Jones and Ombudsman. Also present was Robert Godfrey, Regional Director, (2) staff from (R1's) a placement agency, and (2) additional family members of (R1)- one attended by phone. Multiple concerns were expressed by (R1's) family members related to the care being provided and medication administration. Staff training and better communications with each other was also discussed along with different solutions. Facility staff indicated that there have been immediate staffing changes made related to medication management and administration. Also the facility is considering implementing a software system for medication management. ***The Regional Director discussed with (R1's) family members how their behaviors have been inappropriate, at times, when visiting the facility and included shouting and using obscenities. The Administrator stated that several staff have recently documented in writing how their interactions with (R1's) family members' have made them feel uncomfortable and stressed. The Regional Director requested that (R1's) family members speak directly to him, the Administrator or the Resident Care Coordinator related to any future concerns regarding care being provided and medications being administered. LPA will evaluate and discuss notes from today's meeting with a manager. There are no deficiencies issued in this report. Exit interview. Copy of report providedthe state’s words, verbatim · CDSS document, Dec 15, 2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on some concerns brought to the Department. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During today's inspection, LPA also discussed an incident report recently received for an incident occurring on 11/23/23 for the same resident (R1). LPA spoke to R1's family member who indicated that the facility did not inform them of a change in condition for (R1) and did not complete a specimen kit as requested. LPA discussed the concerns with both the Administrator, Resident Care Coordinator (RCC) and (3) caregivers/Med-Tech staff. LPA reviewed the Medication Administration Record (MAR), and the Bowel Movement log for November 2023 Interviews confirmed that (R1) did have some random and inconsistent changes in her bowel movements during the last month, did not have any symptoms of illness, such as a fever, and Med-Techs were made aware of the changes; however, the Bowel Movement log documentation did not reflect these changes. The log notes from 11/28/23- 11/30/23, (R1) was noted to have "loose bowel movement". The Administrator stated she began communications with family members on 11/29/23, Wednesday, after the change was noticed for (2) days. One of the family members obtained a prescription for Immodium on Thursday, 11/30/23, and it was delivered on Friday, 12/1/23, around 5:00 pm, which was confirmed by the family members. (R1) was administered (2) tablets on Friday, 12/1/23, and staff was instructed to add a note that (2) tablets were administered on 12/1/23, in the "pm" since it was authorized on 11/30/23. Family member was also upset that only (1) specimen container was completed instead of (4). Both the Administrator and RCC stated there were only (3) specimens and there was not an order for staff to complete the test kit. The Med-Tech who was given the test kit stated she was handed the kit from another staff member with no instructions, no order, and had not received any training on how to complete the specimen sample. Nevertheless, the Med-Tech staff and another care staff were able to obtain one specimen container, as requested by the Administrator. Based on information obtained, it appears the facility acted promptly when (R1) was observed to have a change in condition and continues to be in contact with the family. There are no deficiencies issued in this report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Dec 5, 2023

Allegation investigated: Staff are not ensuring that the facility is free of pests Staff are mishandling residents’ medication

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint received on-line anonymously on 11/15/23. LPA met with Ashley Stahl, Resident Care Coordinator (RCC) and explained purpose of inspection. Toni Jones, Administrator, was out of the facility during today's inspection. LPA observed several residents in the common areas during today's inspection. During today's inspection, LPA interviewed RCC and a Med-Tech staff and reviewed PRN medication for (3) residents, (R2, R3 and R4), as referenced in the complaint. LPA also toured the the room for resident (R1) who is also referenced in the complaint. LPA also observed and attempted to speak to several other residents who allegedly reported a rash and had complaints of itching. The results of the investigation are as follows: cont on 9099C-1... Unfounded 9099C-1... Allegation: Staff are not ensuring that the facility is free of pests. The complaint alleges that resident (R1) has roaches in her room. There is no day/time reference provided with the allegation. LPA and a Med-Tech staff (S1) toured (R1)'s room on 11/20/23. LPA observed (R1) to be sitting in a wheelchair and not able to speak clearly. LPA observed the carpet to be clean and did not see any roaches or other bugs in the room on the floor. LPA and the Med-Tech opened several dresser drawers in (R1)'s room, and there were no roaches observed. The Med-Tech stated that (R1) used to have a mini refrigerator in the room and would also eat near the refrigerator, and if there were any bugs in the room, they would be in the area where the refrigerator was. The Med-Tech staff stated she has worked all shifts and has not seen any roaches, or bugs, in (R1)'s room. RCC stated a family member has been moving resident's items from the room in preparation for a move and did not mention any sign of bugs. The complaint also alleges that residents (R1), (R4), (R5), (R6), (R7), (R8), (R9) and (R10), who reside in (7) different rooms, have rashes and complaints of itching. LPA reviewed the resident rooms provided with the RCC and Med-Tech (S1). The RCC stated that none of these residents have complained of a rash or itching in recent months and none of the residents had scabies a few months back. The Med-Tech staff stated that (R5) has not complained of a rash, and (R6) is under hospice care. The same staff stated (R4) uses skin creme on a regular basis as well as (R7) and (R1), (R8) and (R10) have had no rash. Resident (R9) who used to reside in a room that is currently vacant did not have a rash prior to passing. LPA was able to interview (R8) who indicated he has had no itching or rashes since moving to the community. LPA observed (R1) and (R4) in their rooms and did not see a visible rash. The other residents were not in their rooms at the time of the inspection and not able to be interviewed/observed. The Department previously investigated a similar allegation on 9/7/23 and had conducted a tour in the kitchen area, laundry area, staff break room and (2) resident dining rooms, including underneath the kitchen sinks, at that time. In all areas toured, there were no roaches or other bugs observed. Staff interviewed stated that the only roach seen was one trying to enter the resident dining room from the outside, and this was determined to be an isolated incident. LPA was provided with a invoice for service provided on 7/29/23, from an outside pest control company and confirmed that the facility receives regular scheduled pest control treatments. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. 9099C-2.. Allegation: Staff are mishandling residents’ medication. Complaint alleges that (R2, R3 and R4)) do not have a current supply of PRN medication for pain and agitation/anxiety. Complaint also alleges that there is loose medication in the common areas. LPA reviewed the PRN binder with documentation of the PRN and the Medication Administration Record (MAR) for November 2023. LPA and Med-Tech, (S1) reviewed PRN medications for (R2),(R3) and (R4), specifically, as follows: (R2)- documentation shows (R2) takes (3) medications for pain or agitation/anxiety- Acetaminophen, Ibuprofen and Lorazepam. LPA observed a bubble pack of Tylenol that was filled on 10/2/23 and had (25) of (30) tablets remaining. There were no tablets administered in November 2023. The facility received a discontinuance order for Ibuprofen and Lorazepam effective January 2023. RCC to update the PRN list and MAR. (R3) - documentation shows (R3) takes (1) medication for pain or agitation/anxiety- Trazadone 50 mg. LPA observed the bottle for the scheduled order and a bubble pack for the PRN. Resident has not requested or been administered any PRN for November 2023. (R4) -documentation shows (R4) takes (3) medications for pain or agitation/anxiety- Acetaminophen, Lorazepam and Morphine. (R4) is under hospice care. LPA observed a separate bottle for each of these medications on hand. November 2023 MAR shows there was no PRN medication administered for pain and or agitation/anxiety. LPA toured the interior of the facility and did not observe any loose medication in the common areas. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report emailed to the RCC.the state’s words, verbatim · CDSS document, Nov 20, 2023 · control 59-AS-20231115161701

Type of visit: Office

An informal conference was conducted at 1:00 pm on November 16, 2023, with Sacramento North Regional Office via Microsoft Teams. Present in the meeting was Licensing Program Manager (LPM) Maribeth Senty, Licensing Program Analyst (LPA) Sabrina Calzada, Licensee, Mark Cimino, Regional Director, Robert Godfrey, Quality Assurance Coordinator, Adina Nitu, and Administrator,Toni Jones. The purpose of this informal conference meeting is to address the facility’s compliance issues and substantiated allegations surrounding the numerous complaints received since May 2023. Specifically, the Department has concerns stemming from repeated violations following citations being issued. The licensee was told that this Informal conference is a part of the Administrative Action process and that further citations may result in an elevation to a formal non-compliance conference, which could lead to a referral to the Department's legal division for possible revocation of license. The following topics were covered during today's meeting: · Numerous complaints since May 2023- and the facility’s insight. · Substantiated allegations. · Repeated Substantiated allegations. · Steps taken to increase compliance- staffing changes, medication audits, facility processes, enrollment in the Department’s Technical Support Program (TSP) · Importance of training new staff. In an effort to support the facility in maintaining substantial compliance with the Health and Safety Statute and the Title 22 regulations, the Department is developing a plan with the licensee to address causes for concerns. cont on 809-C-1... 809C-1.. Licensee agreed to do the following: · Continue to conduct regular in-service training in response to any current areas of concern at the facility and with various medication topics. · Continue to conduct medication audits- both internally and externally and to follow audit recommendations. · Participate fully in the Department’s TSP engagement- focus areas: medication documentation and organization. · Ensure there are always adequate staffing levels to meet residents’ care needs and to increase staffing when appropriate, such as with an increase in census. · Submit any outstanding Plan of Corrections (i.e. October, November) No deficiencies were cited during today’s meeting. An copy of this report was provided via email to the Administrator with a request to return a signed copy to Community Care Licensing by COB 11/16/23.the state’s words, verbatim · CDSS document, Nov 16, 2023

Allegation investigated: Staff did not ensure resident's medication was ordered in a timely manner.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint received on-line anonymously on 11/6/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During today's inspection, LPA discussed the allegation with the Administrator, Resident Care Coordinator (RCC) and (1) Med-Tech staff. LPA reviewed Medication Administration Record (MAR) documentation for resident (R1) who is referenced in the complaint. The results are as follows: The complaint alleges that a family member of (R1) recently visited (R1) and asked staff the reason why she was not contacted when (R1's) medications ran out. cont on 9099C-1... Unfounded 9099C-1. Administrator stated that (R1) resides in a private room and her family has not visited recently, as one family member lives out of state and the other one lives outside of the local area. Both the Administrator and RCC confirmed there have not been any concerns recently brought to their attention from (R1's) family members, including with medications, and the Administrator stated she and (R1's) daughter discuss (R1's) care regularly. LPA reviewed MAR documentation for October 2023 and for November 2023 and observed there to be (8) medications listed. LPA observed documentation to be complete on the MAR and Centrally Stored Medication Record (LIC622), with the # of refills listed for each medication. A Med-Tech staff confirmed that she and other Med-Tech staff will call the pharmacy to request a refill and note it on the bubble pack as well as on the Fax transmittal. LPA observed notations on a bubble pack(s) that a refill had been ordered. Both the Administrator and Ombudsman were told by (R1's) daughter that neither she or the other family member filed this complaint. The Ombudsman spoke to (R1's) daughter on 11/8/23 who indicated she has no current concerns with medication administration but did in July 2023. The family member reported that all issues have been resolved, her mother receives appropriate care and all medications are ordered timely. Currently, the facility is participating in medication audits with multiple outside companies and has increased medication checks internally. Also mentioned in the complaint was that (R1) was not allowed to have a refrigerator. The Ombudsman and Administrator indicated that (R1) requested to have the refrigerator removed from her room a few months back due to the noise the motor made. Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Nov 9, 2023 · control 59-AS-20231106104515

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following receipt of an incident report. LPA met with Toni Jones, Administrator, and explained purpose of inspection. LPA and Administrator discussed the incident report submitted on 11/8/23 for a bed bug observed by a NOC shift staff on 11/6/23. After being informed, the Administrator immediately contacted a pest control company who conducted an inspection the same day and confirmed there were bugs in (R1's) bed, specifically in the air mattress delivered by the health care company around the end of September 2023. The pest control company also checked resident (R2's) side of the room and bed, and did not detect any bugs present. Neither (R1) or (R2) were observed to have any bug bites on them during the past weeks. LPA was provided with a copy of the invoice showing a volumetric heat treatment was performed on 11/7/23 in (R1) and (R2's) room. The invoice states occupants are required to remain outside of the area sprayed for at least (8) hours on the day of the service and a follow up inspection would be conducted. The Administrator stated residents remained out of the room during the treatment process and the health care company was contacted to inform of the situation, as well as local public health to report the bed bugs. LPA observed the Administrator to call the representative from the pest control company during today's inspection and confirm that a follow-up inspection will be conducted tomorrow, 11/10/23, in the afternoon. Administrator agrees to email documentation of the follow-up inspection. It appears this was a very isolated incident and the facility acted promptly and effectively upon discovering one bug. There are no deficiencies issued in this report. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Nov 9, 2023

Allegation investigated: Staff did not provide medical attention for residents in a timely manner. Staff do not ensure that residents have adequate toiletry supplies. Staff did not prevent an outbreak of scabies. Resident was left soiled for extended period of time. Staff not providing adequate food service to residents in care.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint received anonymously on 10/31/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During today's inspection, LPA discussed the allegation(s) with the Administrator, (3) caregiver staff, and (2) culinary staff. LPA interviewed (4) residents, including resident (R1), as best possible. LPA reviewed the visitor log for October 2023 and the Scabies Infection Line List provided to the county for (4) positive cases in October 2023. LPA also toured common areas and individual resident rooms. The results are as follows: Allegation: Staff did not provide medical attention for residents in a timely manner. The complaint alleges that a resident was heard screaming after falling in her room on 10/31/23, and staff left the resident on the floor after discovering she had fallen. The complainant provided a first name only for this resident. **cont on 9099C-1... Unfounded 9099C-1... The Administrator confirmed there is not currently a resident with this first name and described a recent incident when resident (R1), who has a similarly sounding first name, slid off her bed, which is low to the ground, and onto a fall mat, on 10/29/23, at approximately 2:50 pm. The Administrator stated (R1) will yell for staff if she needs assistance, and staff attended to (R1) immediately after she fell and did not observe any bruising or injuries at that time. The Administrator stated that staff sought immediate medical attention via triage over the phone with resident's health care provider, and it was determined that resident did not need any further medical intervention. LPA discussed the incident with (R1) on 11/1/23, who denied having a recent fall and couldn't confirm if she feels any pain. One staff who was interviewed stated "(R1) might have fallen two months ago" and was not aware of a recent fall indicating she is not currently assigned to care for (R1). Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff do not ensure that residents have adequate toiletry supplies. Complaint alleges there were no supplies such as wet wipes in (R1's) room to assist with incontinence care and also there is no soap/ body wash, toothbrush/tooth paste or lotion in (R1's) room. The Administrator stated that in the beginning of October 2023, she changed the type of disposable wipe staff use to provide incontinent care and showed LPA the dry wipe used previously that required staff to moisten it with a cleansing spray before each use. LPA also observed the pre-moistened wipes currently being used in green packaging. LPA spoke to staff who had just provided incontinent care to (R1). Staff confirmed that they always use wipes when providing care, as they are trained to do so and that they will use a caregiver cart with a bag containing wipes, gloves, and trash bag liners in it. LPA observed the carts with the bag hanging on the outside for easy access. (R1) indicated she receives assistance when needed from staff. LPA observed a package of green wipes in random resident rooms and staff indicated that hospice residents will also have wipes in the room for hospice staff to use. The Administrator stated the Maintenance Director is in the process of placing packages of wipes in each resident room. ***Cont on 9099C-2... 9099C-2...The Administrator stated that as a general rule, hygiene products are not kept unsecured in resident rooms or bathrooms, due to all residents having a diagnosis of Dementia, and that staff will regularly scan resident rooms for hygiene products hospice staff leave behind daily. LPA did not observe any hygiene products left out unsecured and within resident access. The Administrator confirmed that all hygiene products are kept either locked in the laundry area or in the resident drawer in the room with a clip lock. LPA observed that several resident's hygiene supplies are centrally stored for their safety. The Administrator confirmed that resident families will provide hygiene supplies to the facility. Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff did not prevent an outbreak of scabies.Complaint alleges the facility had a scabies outbreak and (2) resident names (R2 and R3) who share a room were provided. The Administrator provided LPA with a copy of the Scabies Infection Line List submitted to the county health department for (4) positive cases reported in October 2023. The Administrator confirmed that (R2) never tested positive for scabies, and (R3), who shares a room with (R2) did test positive. The Administrator confirmed all residents just started back attending their health care day program this week after a 2 week, 4 day postponement, and it is thought that the scabies was brought into the facility from contact at the day program. Additionally, there are no staff ever tested positive. The Administrator indicated she remains in weekly communication with public health for further monitoring through 11/30/23. This allegation was previously investigated and found to be UNFOUNDED on 8/18/23. Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Resident was left soiled for extended period of time.The complainant alleges they have observed facility staff not properly cleaning residents and not using wipes. All staff interviews confirmed that staff provide timely assistance when a resident needs incontinent care. LPA observed staff to be finishing up providing incontinent care to (R1) and to other residents during today's inspection. There is no information provided as to the specific resident(s) the allegation pertains to. LPA did not observe significant incontinent odors present when touring and observed multiple caregiving and Med-Tech staff present. Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. *cont on 9099C-3.. 9099C-3... Allegation: Staff not providing adequate food service to residents in care. The complaint alleges that (R1) has complained the food is not served on time and it is often cold. (R1) stated to LPA that when the food is cold, "I tell them it needs to be warmed". Staff interviews indicated that (R1) is served pureed food in her room and staff will hand feed her with a spoon. One staff stated "(R1) will always say the food is too cold, there is not enough flavor and it needs more sugar". LPA interviewed (2) culinary staff who indicated that food is served hot to residents if it's supposed to be hot. One staff stated "residents will complain if the soup is too hot, but we never get complaints about it being too cold", commenting, "maybe the caregivers don't serve it fast enough". One of the kitchen staff stated when preparing pureed food for (R1), she will take the food directly from the warm stove and place it in a blender. This staff stated that caregivers for (R1) will most often come to the kitchen to request sweets for (R1) more than for any other reason. Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. These allegations are being dismissed without any citations being issued. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Nov 1, 2023 · control 59-AS-20231031105239

Allegation investigated: Staff did not prevent resident from being sexually assaulted. Staff did not seek medical attention for resident in a timely manner. Staff are not providing resident's authorized representative with copies of incident reports

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver investigative findings to a a complaint received on 5/4/23. LPA met with Ashley Stahl, Resident Care Coordinator, and the explained reason for the inspection. The Administrator, Toni Jones, attended today's inspection by phone. During the investigation, LPA conducted interviews with multiple facility staff, (2) family members of resident (R1), (2) medical personnel, the Ombudsman and a law enforcement detective. LPA reviewed documentation for (R1) including, but not limited to, admission paperwork, physician's report, care plan, charting notes, and incident reports. LPA also reviewed documentation for resident (R2), which included police and 9-1-1 incident report from local fire. The results of the investigation are as follows: cont on 9099C-1.. Substantiated 9099C-1.. Staff did not prevent resident from being sexually assaulted. Complaint alleges that (R1) was sexually assaulted on 4/15/23 by another resident (R2) and that resident (R2) was no longer allowed at the facility due to previous behaviors. Staff interviews revealed that while doing rounds on 4/15/23, at approximately 5:00 am, (2) staff found (R2) laying naked on top of (R1) in (R1's) bed. Interviews confirmed that (R1) was observed to be wearing a diaper and a nightgown, and there was a third resident (R3) in the room sitting in a chair. Staff interviews revealed that (R3) was (R2’s) girlfriend and would walk around the facility together. The incident report submitted to the Department states that on 4/15/23, at approximately 7:00 am, (R2) was observed without clothes laying on top of (R1), who was fully clothed, and the residents were separated and (R2) was returned back to his room. The facility incident report notes law enforcement was notified and later came to the facility to investigate and (R2) was transferred to the hospital for further evaluation and had remained there as of 4/17/23 when the report was submitted. The report notes that (R2)'s conservator contacted facility staff on 4/17/23 to advise that (R2) would not be returning to the facility due to his behavior. Staff interviews confirmed that (R2) "was always up during the NOC shift", and would frequently try and exit to the patio courtyard as the alarms would go off and go in other resident rooms. Staff interviews revealed "(R2) always hit on different women from the start of NOC shift until breakfast time", with one staff stating, "I've seen him (R2) with other women- he was just laying there, cuddling". Staff interviews indicated that (R2) was "more physically aggressive”, would push other residents and hit them, and his behaviors were not taken seriously by the Administrator at the time, commenting (R2) was "sent out constantly but would return" and would walk around naked on a regular basis, taking (3-4) staff to get (R2) out of another resident's room. Resident (R2) moved to community in March 2020 with a diagnosis of Dementia, and other conditions and was conserved. (R2's) care plan, dated June 2022, says (R2) needs maximum assistance in redirection due to elopement risk and wandering throughout the building, in residents’ rooms and exit seeking during the day. The care plan also notes (R2) needs maximum assistance to maintain safe and appropriate interactions and due to severe sleep disturbances caused by sun downing. cont on 9099C-2.. 9009C-2... (R2's) Physician's Report, dated 2/22/23 states resident is confused, disoriented, has inappropriate behavior and is aggressive. Electronic charting notes entered by the Administrator and Resident Care Coordinator note that (R2) was showing an outburst and inappropriate behavior on 3/13/23, agitation and change in baseline on 3/15/23 and showed more agitation and a change in condition on 3/29/23. An updated LIC602 was obtained on 3/27/23 noting resident is confused, disoriented, shows aggressive/wandering/sun downing behavior and inappropriate behavior, has bladder impairment, and is now not able to feed himself or do any Activities of Daily Living (ADL's). The Ombudsman investigated the incident and contacted the police department for their report and concluded that the case did not meet criteria for a criminal case due to (R2) having a diagnosis of Dementia and suffering a stroke (3) weeks prior causing him to be more aggressive. The police report based their findings on the Ombudsman's findings. LPA reviewed a copy of a fire (911) incident report, dated 4/15/23, noting facility staff reported (R2's) behavior to be of concern for the safety of other residents as (R2) attempted to interact inappropriately with other residents in addition to (R1). On 4/16/23, (R2) was sent to the Emergency Room for a mental evaluation and was placed on hold due to his pattern of behavior within the community and did not return to the facility. LPA conducted a case management inspection on 4/21/23, after receiving the incident report on 4/17/23. LPA attempted to speak to resident (R1) in the presence of Administrator, but resident was not able to speak and be understood but was in a pleasant mood. LPA did not observe (R1) to show any bruises on her face or lower legs that were not covered by clothing. LPA observed (R1) able to move herself in a wheelchair. The Administrator at the time did not discuss any concerns with the LPA regarding either resident (R1/R2) or mention that another resident (R4) had sustained an unexplained head injury during the same shift, was sent to the Emergency Room and received multiple staples on her head. Staff interviews and interviews with responsible persons for (R4) revealed that (R4) and (R2) may have entered into a altercation and (R4) was hit on the head or fell and hit her head. The incident report submitted for (R4) states that she was found on the floor in her room, at approximately 7:00 am, on 4/15/23, with blood on her head but could not recall how the injury happened. Discharge papers show (R4) was seen in the ER on 4/15/23 for head pain and was diagnosed with head trauma, laceration of head and UTI symptoms, and the laceration was treated with (4) staples. cont on 9099C-3.... 9099C-3.. One staff stated (R1) has "no way to consent since she is non-verbal" and she "can't defend herself". Another staff stated "(R1) mumbles and says phrases only" and would not have been able to consent to (R2) being in her bed. Two staff stated (R1) appeared “traumatized for sure”, (R1's) face had a different color and she had her head down after she and the other staff pulled (R2) off of (R1). Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff did not seek medical attention for resident in a timely manner. Complaint alleges that (R1) wasn’t examined following the incident on 4/15/23 until 4/20/23 when the facilitiy's Nurse Practitioner (NP) came to the facility. The responsible person for (R1) stated that when informed of the incident on 4/15/23, she asked facility staff if (R1) had been taken to the hospital to be checked out and was told she had not been. This family member stated she then demanded that (R1) get checked out, but (R1) wasn’t check out until 4/20/23 by the facilities NP. The family member stated on 6/10/23, she called the NP last week and left a message, but she had not heard back. Charting Incident notes for (R1) document the incident on 4/15/23 (Saturday) and on 4/16/23 notes state there were no changes observed for (R1); on 4/17/23, notes say NP was contacted and would be coming out to “check (R1)” and (R1) has been doing good and is still wandering around the facility. On 4/18/23 and 4/19/23, additional notes were entered that there were no changes. (R1) did not receive any medical attention until 4/20/23 when NP visited the community. Notes say: “NP checked (R1) from head to toe and all skin is good and there are no changes for (R1)”. The NP stated he believes (R1) was on hospice at the time, was frail, and could not provide any other information. A hospice nurse stated that the incident was never confirmed with him but (R1) was not under hospice care at the time. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. cont on 9099C-4... 9099C-4... Allegation: Staff are not providing resident's authorized representative with copies of incident reports. Complaint alleges (R1's) family member requested copies of all incident reports with (R1) and she hasn't received any reports. (R1's) family member stated that (R1) has gone to the Emergency Room 4-5 times in the last (8) years while living at the facility. The family member stated she spoke with a manager to request the reports, and the reports were not made available to her. LPA discussed this request with the current Administrator who indicated that this family member would reach out to the Administrator regarding why she is not currently not in contact with the facility. The current Administrator stated she has not heard from this family member for a while. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (3) citations are issued on the 9099-D pages. Exit interview. Copy of report and appeal rights provided. 9099A-C-1... LPA reviewed the incident report (LIC624) for an incident occurring on 2/11/22- at 10:30 am, when (R1) found on the floor during staff rounds. The LIC624 notes (R1) had no visible injuries but was sent to ER and had remained in the hospital as of 2/14/22, when the incident report was completed. The LIC624 notes this family member was notified. A second family member of (R1) indicated there were several incidences of (R1) having a fall and recently she fell last month in September twice, between Sept 6 and 10th. Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Resident had an unexplained fall sustaining injuries due to staff negligence. Complaint states that before (R1) fell and fractured her hip, she had another unexplained fall and staff do not know what happened. There are no other details provided. A LIC624 was submitted for an incident on 2/11/22- 10:30 am where (R1)found on the floor during rounds with out any visible injuries. (R1) was transported to the hospital and remained there through the time the LIC624 was submitted on 2/14/22- 3+days in the hospital. This person indicated that the assigned hospice nurse found (R1) when she fell in Feb 2022. One family member stated (R1) had some bruising on her face and would provide the Department with photos early in the investigation, but they were not provided. A second family member indicated there were several incidences of (R1) having a fall and recently fell last month twice in September, between Sept 6 and 10th. This family member stated that for the first fall, (R1) was sent to ER and released the same day for no injuries; however, the second time, (R1) fell in the lunch room and was by herself. This family member stated the facility thought it was a "harder fall" and had (R1) sent out to the Emergency Room for CT scans and additional tests , stating "they were more concerned about the second fall". cont on 9099A-C-2... 9099A-C-2... Allegation: Staff did not prevent a resident from engaging in inappropriate behaviors. Complaint alleges that when (R1’s) family member was visiting she heard (R1) screaming and observed another resident (unknown name) attacking her mom on the floor. One of (R1's) family members stated there was another time when (R1) "was attacked by another resident" around 2021-2022. This person stated that the nurse from hospice was there and he had called her due to (R1) having some bruising on her face. Photos were not provided to the Department as previously agreed to. The LIC624 submitted for the incident on 11/17/21 was completed 11/18/21 and involved (R1) and (R5). The incident report states that around 3:00 pm, staff heard (R1) shouting for help and went to assess the situation and found (R1) on the floor and (R5) was kicking (R1). Staff called for a shift manager and both staff were able to separate the residents. Both residents were sent to the ER and (R1) returned to the community with no changes. (R5) remained in the hospital as of when the report was completed on 11/18/21. A second family member confirmed that (R1) was on and off of hospice several times since moving to the facility in 2014 and that she had a lot of falls. This family member stated that (R1)would "walk and walk" prior to moving to the community and liked to be on her feet. Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided. 9099A2-C-1...One staff stated the incident with (R1) and (R2) was "reported the day after" and that they called (R1's) family and left a message for both family members who were alternating as POA's. This staff asserted "neither one answered", but "I know for a fact that I personally called both of them- they called back after my shift ended". Resident charting notes do not indicate that (R1’s) responsible person(s) was contacted immediately following the incident; however, the LIC624 (dated 4/17/23) states that residents’ responsible parties and primary care physician's were notified. The Administrator and RCC agreed to provide staff training on ensuring that notes are entered every time staff makes an attempt to contact the responsible person. Based on information obtained, LPA finds this allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Oct 26, 2023 · control 59-AS-20230504150756

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 27, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and documentation reviewed, the Licensee did not ensure that (R2) and (R1) were provided with sufficient supervision, on 4/15/23, during the NOC shift, to prevent him from entering (R1's) room and laying naked on (R1) while she was in bed, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2023

Plan of correction: Licensee/Administrator agree to conduct staff in-service training regarding sexual abuse and checking rooms, more regularly, throughout more shifts. Agenda to be received by 10/27/23- training documentation to be submitted by 11/9/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Oct 27, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on record review and interviews, the Licensee did not ensure that (R1) received prompt medical attention, following the incident with (R2) on 4/15/23, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2023

Plan of correction: Licensee/Administrator agree to conduct an in-service training on when to call 9-1-1 and seek medical attention needed, Agenda to be received by 10/27/23- training documentation to be submitted by 11/9/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 9, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on interviews conducted, the License did not ensure that (R1's) responsible person was provided with copies of incident reports when requested on/around May 2023, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2023

Plan of correction: Administrator agree to continue to submit LIC624's timely and to provide a copy to the responsible within (7) days of the incident. Administrator to discuss with Resident Care Coordinator and submit documentation to CCLD that this protocol has been discussed and will be regularly followed. Documentation to be submitted by 11/9/23 to CCLD. Administrator will attempt to contact responsible person of (R1) and send all LIC624's, as requested.

The state marks this report as 13 pages; the online copy we transcribed has 12. You can request the full file from the county licensing office.

Allegation investigated: Staff are mishandling resident's medications. Staff does not ensure resident is administered medications as prescribed. Staff leaves resident's mattress soiled. Resident's room is malodorous.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to close a complaint received on-line and anonymously on 07/26/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During the investigation, LPA discussed the allegations with the Administrator, RCC and a Med-Tech staff and toured the facility on several different occasions. LPA went into multiple resident rooms, including the room referenced in the complaint, and also checked several residents's bedding to see if it was soiled. The results are as follows: Allegation: Staff are mishandling resident's medications. The complaint alleges there were medications seen in resident’s room (shared by R1 and R2) when visiting one of the residents. *cont on 9099C-1... Unfounded 9099C-1...The room referenced in the complaint is occupied by (2) residents. LPA toured the room on 7/31/23, 8/22/23, 9/7/23 and 9/26/23 and did not observe any medications to be left out in the room. The complaint does not indicate which resident this allegation pertains to nor were there any specifics provided as to the day of the week, time of day, or name of medication. Based on information obtained during the investigation, LPA finds this allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff does not ensure resident is administered medications as prescribed. Complaint alleges that resident’s family member monitors resident’s medications and facility staff did not notify family member that the resident has been out of her meds for a couple of weeks, and resident'’s doctor was not notified either. The Department received additional anonymous on-line complaint on 7/27/23 alleging the same information. There were again no specifics provided. The Administrator, RCC and a Med-Tech (S2) stated on 10/24/23 there have been no problems with (R2) receiving her medications and indicated she has been on hospice for the majority of the time she has been a resident at the facility. The current Administrator and the RCC stated there was only a problem with (R1) receiving medications on/around March 2023 when the dispensing pharmacy sent medications to (R1's) prior residence. This allegation was investigated previously for (R1). There were no specifics provided as to which resident in the shared room the allegations pertain to. Also, the day of the week, time of day, and name of medication were not mentioned. Based on the lack of specific information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. cont on 9099-C-2... 9099C-3...Allegation: Staff leaves resident's mattress soiled. Complaint alleges that when visiting resident’s room, resident’s mattress is soiled with the urine, the mattress was even wet to the touch. On 7/27/23,the Ombudsman inspected the shared room and did not observe either resident's mattress to be soiled. On 7/31/23, LPA inspected both resident mattresses in the room and observed them to be dry. LPA observed layers on the plastic protector- 1- cloth, 2- sheet, 3- cotton chuck, 4- disposable chuck. (S1) indicated the caregivers have to help with changing sheets as housekeeping gets busy. (S1) confirmed that caregivers will make beds and replace any soiled sheets "right away". (S1) stated (R1's) daughter picks up her laundry every other day and wants to wash (R1's) sheets even if they are soiled.-(S1) commented that maybe once/week they are soiled and (R1's) daughter has never asked them not to separate the soiled sheets, and she has specifically told staff "don't wash the sheets" since the dryer shrinks them. Staff (S1) stated (R2) who also occupies the room is incontinent like 89% of the residents. (S1) stated all incontinent residents have both a cotton and disposable chuck on the sheets. 11% of residents can walk to the bathroom. LPA observed (R2’s) mattress and bedding to be clean and dry. LPA also toured (8) other resident rooms with care staff (S1) and observed all resident beds to have dry, clean sheets on them. LPA toured the shared room again on 8/22/23 with the Administrator. LPA observed (5) layers of protection on the top mattress and then a top sheet and (2) blankets. LPA observed all layers to be dry and appear to be freshly laundered free of any incontinent odors. LPA observed roommates' bed to also be dry in all layers. On 9/7/23, LPA confirmed with a housekeeping staff that she and caregivers change resident sheets, and there are not any female residents that stand out as having significant incontinent issues. This same information was confirmed with a second care giving staff also on 9/7/23. LPA toured the room again, on 9/26/23, with the Administrator. Both residents were outside of their room in the common areas during the inspection. LPA pulled the blankets back to observe the bedding on each resident's bed. LPA observed all bedding, including Chux pads, to be clean and dry and did not observe any urine stains. Based on information obtained during the investigation, LPA finds this allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. cont on 90099C-... 4 9099C-4... Allegation: Resident's room is malodorous. Complaint alleges that when visiting resident’s room, resident’s room smelled like urine again. On 7/27/23,the Ombudsman inspected the shared room and did not observe any smell of urine. On 7/31/23, LPA did not observe any incontinent odors in the shared room for R1 and R2. LPA also toured (8) other resident rooms with care staff (S1) and did not observe any significant incontinent odors in the rooms toured. LPA toured the shared room again on 8/22/23 with the Administrator. LPA observed the room to be neat, bed made and without any incontinent odors and to contain lots of incontinent supplies in the bathroom. There were no incontinent odors present. On 9/7/23, LPA toured (3) additional resident rooms that were observed to be clean, without any significant incontinent odors, and the trash was emptied. LPA also observed residents’ beds to be made. On 9/26/23, LPA observed the shared room and bathroom to be clean and odor free. Based on information obtained during the investigation, LPA finds this allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. There are no deficiencies issued on this report. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Oct 24, 2023 · control 59-AS-20230726152403

Allegation investigated: Staff are mishandling the residents medications Staff have inadequate records keeping for the residents medications Staff have not repaired the pull cord system in the facility

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open and close a complaint received anonymously on-line on 10/17/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During today's inspection, LPA discussed the allegation(s) with the Administrator, Resident Care Coordinator (RCC) and the Maintenance Director. LPA, RCC and (1) Med-Tech staff reviewed medications for (5) residents whose room numbers were referenced in the complaint and also tested random resident pull cords in individual bathrooms. The results are as follows: Allegation: Staff are mishandling the residents medications. Complaint alleges that medications have been out for a month for residents who occupy (4) specific rooms. The Narc count is off and is not accurate Norco and lorazepam is off *cont on 9099C-1... Unfounded 9099C -1... LPA, RCC and a Med-Tech staff reviewed medications for (5) residents who occupy (4) rooms mentioned in the complaint. All medications for (R1) were on hand except for the medication, Lactulose 10/15 g/ml that ran out yesterday. RCC stated that this medication is ordered by hospice and (R1) refuses medications daily and hospice is aware. RCC stated that this medication has a pending discontinuance order. All medications were on hand for (R2. Medications were reviewed for (R3). All medications listed on the most recent physician's orders (Sept 2023) were found to be on hand and are being administered per the orders There were (3) prior medications that (R3) was prescribed from when she was in the hospital. RCC stated these (3) medications were not taken since (R3) returned from the hospital and have been discontinued. RCC is trying to get approval for (R3) to begin Home Heath. Medications for (R4) and (R5) were reviewed and found to be on hand and are being administered currently. LPA observed all documentation on the Medication Administration Record (MAR) and Centrally Stored Medication Record to be current and legible. LPA, Administrator, RCC and (1) Med-Tech staff conducted a narcotic count for (3) randomly selected residents. The count matched the number written on the Narcotic Documentation page for all (3) residents (R6, R7 and R8). Based on review of medications and medication counts, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff have inadequate records keeping for the residents medications. The complaint alleges the central stored binder is a mess. LPA reviewed the Centrally Stored Medication Binders and observed it to be organized with tab dividers. The pages (LIC622) were completed by hand and filed with the more recently logged medications first. LPA observed a few loose, torn pages in each binder, but the binder overall was very neat and organized. LPA discussed ways with the Administrator to possibly eliminate staff having to write the same information repeatedly for the same medications on the LIC622. cont on 9099C-2... 9099C-2... LPA also reviewed the Centrally Stored Narcotic Binder which was recently created by the RCC. The binder was also organized with tab dividers by each resident room. LPA also reviewed the Narcotic counts and observed (1) entry for each shift change and (2) signatures to have been written on most days, after each narcotic count. The Administrator stated that sometimes when a staff works a double shift, she or the RCC acts as the second staff who counted the narcotics. The facility was cited recently for not documenting completely for PRN medication specifically. Ongoing training is being done regarding proper documentation for medications. Based on documentation review, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff have not repaired the pull cord system in the facility. Allegation states the pull cord system is not working with no specific details included. LPA, Administrator and RCC tested multiple (4) bathroom pull cords on 10/24/23. LPA observed each pull cord to light up when pressed and heard the RCC announce on the walky the Administrator was carrying that assistance was requested in the specific room. LPA also observed a staff member to arrive at the identified room promptly after the pull cord was pulled. LPA spoke to the Maintenance Director who confirmed that he and the Administrator check weekly to ensure the pull cords are working properly. The Administrator confirmed that the Maintenance Director will begin in room #101 and pull both the bathroom and resident pull cords and she will be watching the monitors in the RCC's office. The Administrator will then communicate with the Maintenance Director, using a separate walky to not interfere with staff's line during their testing process. The Director stated maybe 1-2 batteries are found to occasionally need replacement, but not on a regular basis. Based on documentation review, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. There are no deficiencies issued on this report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 24, 2023 · control 59-AS-20231017114128

Allegation investigated: Staff was verbally abusive to a resident. Staff are not adequately supervising residents.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the investigation deliver findings to a complaint, received on 7/18/23, for the above allegations. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During the investigation, LPA interviewed the current Administrator, Resident Care Coordinator (RCC), (2) staff and (2) residents. LPA reviewed the incident report binder organized for months April -August 2023. The results of the investigation are as follows: Allegation: Staff was verbally abusive to a resident. The complaint alleges a family member witnessed staff being verbally mean to the residents. There is no date, time or resident names referenced for this allegation. One staff stated on 7/20/23 there is no verbal abuse ever but she will speak firmly with the residents since they have Dementia. A second staff who has worked at the community for many months stated he is not **cont on 9099C-1... Unfounded 9099C-1...aware of any staff speaking abusively to a resident and staff might need to speak firmly but would never speak harshly. A third staff indicated she has never heard any verbal abuse from staff towards residents. (2) residents were asked if they have ever observed staff to talk harshly or rudely to residents. Both residents stated that staff has never yelled, screamed, or used profanity with one resident stating staff is "very helpful, very nice and polite". LPA has never observed any staff to speak harshly or inappropriately to a resident when visiting the community on multiple occasions. Based on information obtained during the investigation, LPA finds this allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff are not adequately supervising residents. The complaint alleges a family member heard staff speaking to a manager on the phone about three seniors yelling, pushing and hitting one another and that when the residents fell to the ground, no management came to see if they were okay. Additional information was received on 7/20/23 alleging to be from a “concerned neighbor” that a male resident left the building again and went over the fence. On 7/25/23, additional information was received from an anonymous staff member reporting that a new resident left the building again and went to the nearby Mc Donald’s. The RCC stated on 7/20/23 that if she were to see (3) residents hitting and pushing she would send them out to the ER, and if the residents were yelling, she stated "they're going to yell - they have Dementia". RCC commented, "we're going to have agitated residents" since it's Memory Care. The current Administrator, who began working at the community in August 2023, stated that she has never observed (3) residents to be involved in the same altercation, and has only seen (2) to be involved. One staff stated she is not aware of (3) residents yelling, hitting and pushing one another, and that if she encounters an issue, she will speak to staff about it right away to correct it. Another staff stated that he doesn’t recall hearing about (3) residents yelling, pushing and hitting each other on/around July 2023 and confirmed that (R1) AWOL’d from the facility only once, the first night he was there, on 6/29//23. A third staff stated staff will respond instantly if there is a fall or altercation. cont on 9099C-2... 9099-C-2.LPA reviewed several months of incident reports that were submitted to the Department and did not see any subsequent AWOL incidents for (R1) or any other AWOL's for any other resident, which the Administrator confirmed to be correct. LPA also did not observe an incident report noting (3) residents were involved in the same incident. (2) residents indicated to LPA that staff will respond promptly if a resident falls or or is in a situation with another resident. Based on information obtained, LPA finds the above allegations to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 59-AS-20230718104900

Allegation investigated: Licensee is not following reporting requirements

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the investigation and deliver findings to a complaint, received on 7/18/23, for the above allegation. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During the investigation, LPA discussed the allegation with the current Administrator, Interim Administrator, Resident Care Coordinator (RCC), (4) staff and reviewed the Incident Binder. Administrator reviewed staff training on the computer and confirmed that all staff have completed coursework in Abuse, Neglect and Explotation in an Elder Care Setting and Resident Rights, Personal Rights and Ethics. Mandated reporting is discussed in these (3) courses. Allegation: Licensee is not following reporting requirement. The complaint alleges that a manager told staff last week not to report, and incidents are not being reported as required. There are no specifics included in the complaint and the complainant is anonymous. cont on 9099C-1.. Unfounded 9099C-1... The RCC stated on 7/20/23 that staff will call her if there is a serious incident and she will then let the Administrator know, who will review the incident reports and send them in. The Interim Administrator confirmed on 7/20/23 that she reviews the incident reports provided to her from staff before submitting them to the Department. The RCC stated on 10/17/23 that she has never disposed of incident reports given to her by staff and she talks about the importance of Mandated Reporting in staff meetings. Additionally, the RCC indicated that staff will complete "individual 1:1 training" in her office on the computer. LPA received information that a prior Administrator would sometimes tell staff not to report incidents to the Ombudsman, and to the Department, but that staff would still report since they are mandated reporters. This was prior to May 2023. The current Administrator stated that she was trained that the person observing the incident should be the one reporting and completing the incident report. She will review the report before sending it to the Department and has never seen any manager or staff rip up an incident report. The current Administrator indicated she will take the internal notes from the incident and write the incident report to be submitted to the Department. One staff stated on 10/16/23, that he and other staff were told at staff meetings that staff “should know what to report and to tell a lead, Med-Tech, staff, but if the incident is unwitnessed, staff can’t write a report if they have not witnessed the incident. A second staff interviewed stated she has never been told personally not to report incidents, has completed training on mandated reporting, and has been talked to in a group by managers. This same staff confirmed she only completes an incident report for what she personally observes and will ask a caregiver to complete a report if he/she has witnessed an incident and then provide that report to her. This same staff stated staff will place the completed incident report under the RCC and Administrator's door and has no way of knowing if the incident ever got reported. Two (2) additional staff stated that they have received training on being a mandated reporter, with one staff confirming she has completed incident reports before. The second staff stated she has observed incidents with other staff present and those staff have completed the incident report and included her name on it. All staff interviewed stated they would not listen if they were told not to report an incident since they are mandated reporters. LPA reviewed the incident binder and observed each month to contain copies of multiple incident reports submitted to the Department. Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 59-AS-20230718114857

Allegation investigated: Staff are falsifying residents' records. Staff are not providing residents activities of daily living (ADL's).

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the investigation and deliver findings to a complaint, received on 7/25/23, for the above allegations. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During the investigation, LPA interviewed the current Administrator, Resident Care Coordinator (RCC), (2) Med-Tech staff and (1) caregiver staff. LPA reviewed the Narcotic Shift Count log from April- August, 2023, and the Controlled Substance Record from January- August, 2023. LPA also reviewed the October shower log. The results of the investigation are as follows: Allegation: Staff are falsifying residents' records. The anonymous complaintant alleges the narcotic count was off, and he/she was told to correct it when it wasn't that staff that made the mistake. cont on 9099C-1... Unfounded 9099C-1... A Med-Tech staff stated that prior to May 2023, she was told to sign the narcotic log that the count was correct, even if it was off by one or two tablets. This staff stated the narcotic count could regularly be "off" by one or two tablets for a resident or two and that record keeping is much better now. The RCC stated that staff would tell her if the narcotic count was off and she would inform the prior Administrator who stated she would "look at it". LPA reviewed the Narcotic Shift Count documentation and observed it to be complete- and "none" was written in most spaces where any discrepancy is noted. There were no notes indicating the medication count was off. LPA reviewed the Controlled Substance Record where a date was entered when the medication was received and then each day it was administered. There were no noted errors based on the entries made on either documentation. There was no specific resident, medication or day/time referenced. Based on information obtained during the investigation, LPA finds this allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff are not providing residents activities of daily living (ADL's). The complaint alleges that staff is asked to correct the ADL binders as well because there are holes and shows that ADLs are not being done. A Med-Tech stated on 7/31/23 that everyday NOC shift will document when care is provided (i.e. incontinent checks) and will fill out logs only if there are issues or concerns, explaining that this is a new system that started a year ago. LPA asked this staff if the facility has enough staffing. This staff asserted, "it depends on the resident's behavior- it varies day to day". The staff stated there are (3) caregivers and (1) Med-Tech and that is "considered fully staffed" and staff will document both "End of shift logs" and shower logs for each resident. The RCC stated on 7/31/23 "residents are getting showers- it is more of lacking of charting". The RCC explained that housekeeping staff has been trained on changing resident clothes to assist caregivers, and there are (3-4) caregivers and (1) Med-Tech scheduled during the daytime hours, and they will also schedule staff through an outside staffing agency. The RCC stated she has never instructed staff to "just sign the book" that the shower was given when it was not. LPA was recently provided with documentation of the weekly narcotic audits being conducted, since 8/28/23, by the Administrator and the RCC. Additionally, the Administrator provided documentation of (2) other medication audits with an outside provider and pharmacy. cont on 9099C-2... 9099C-2...On 7/31/23, LPA Calzada reviewed the July shower log/binder showing documentation for each resident. LPA observed that some days were signed by staff as having given a shower to the resident, and other days were marked "refused". On 10/17/23, LPA reviewed the October shower logs with the RCC for all residents and observed only a few scheduled showers to not have staff initials on the scheduled day. The RCC and Administrator were certain residents received showers on many of these days and would discuss documenting better with staff. A Med-Tech staff stated that she was asked to just sign the ADL binder, when the month had ended, if there were scheduled showers that were not initialed as being given by staff on the log. A caregiver stated that she is trained to initial the shower log binder at the completion of each shift to note which scheduled showers were given. This caregiver indicated she has never been told by lead or manager to just initial the shower was given when it was not. The staff explained that some residents definitely refuse showers and staff will do a "change of face" and notify the Med-Tech. This staff stated staff communication is much better now in recent months and resident concerns and issues are discussed more at the cross over meetings at shift change. There were no resident names or dates giving when the ADL's were allegedly missed. Based on information obtained during the investigation, LPA finds this allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 59-AS-20230725143417

Allegation investigated: Facility does not have sufficient staff to meet the needs of the residents in care.

On 10/12/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegation and met with Resident Care Cordinator (RCC), Ashley Astahl. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. The complaint identified R1 as a resident who did not receive adequate incontinence care and oral hygiene. Records review and interviews found that R1 was discharged in May 2023. The allegation did not state specicific dates or caregivers alleged to not provide care. Interviews found that R1 would need 1-2 staff for incontinence care. While R1 required a high level of physical assist, R1 could usually idenify when they needed incontinence care. Because R1 had frequent incontinence assistance, staff had a schedule of care and checked in with R1 often between schedule care. Unsubstantiated An absence of oral hygiene was not witnessed by those staff interviewed. As R1 is unable to recall historical events, has moved from the facility, and specific details of a specific event are not provided the department does not find sufficient evidence to substantiate this allegation. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with RCC.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 59-AS-20230720164140

Allegation investigated: Staff are mismanaging resident's medications. Staff are not keeping accurate medication records.

On 10/12/23, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Ashley Stahl, RCC, to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. Staff are mismanaging resident's medications- The allegations did not provide specific timelines for when events were alleged to have occured. The alegation of medication mismanagement has been investigated as well by LPA Calzada in concurrent complaints and was substantiated for 87465(a)(4) failures to provide medications as prescribed. Citations were issued on7/20/23, 7/31/23, 8/9/23 and 9/29/23 for related issues that are currently in plans of correction. Therefore an addiional citation is not issued at this time. Regarding Staff are not keeping accurate medication records- Interviews and records reviews found regular lack of consistent and complete recording of PRN use for residents as required. Substantiated There was a regular lack of consistent and complete recording of PRN use for residents as required. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with RCC . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 59-AS-20230823082439

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(3) · Plan of correction due date: Nov 9, 2023

Incidental Medical and Dental Care.(c )(3)A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement was not met as evidenced by records and interviews That found PRN use by residents are not consistently recorded as required. This posed a potential risk to residents.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: Licensee will submit the procedures for administering and documenting resident PRN use and staff training of the procedures to CCL by the POC date of 11/9/23.

Allegation investigated: Staff do not provide adequate supervision resulting in resident hitting another resident in care.

On 10/12/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with RCC Ashley Stahl. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. It was alleged that an altercation occurred between two residents. A date or time was not identified, niether were the residents alleged to be involved. Only that it occured near R1's room and the other resident allegedly stated R1 had hit them. Records reviews and interviews found R1 to have dementia with behavioral disturbance. Staff notes for a period around when the time thecomplaint was made, found no record of such an incident. Interviews found that R1 may raise their voice and swat at staff, staff generally have not witnessed events of R1 hitting other residents. All staff interviewed stated that it could be possible for R1 to strike at another resident who is in R1's space but they have not witnessed such events. R1 generally stays to themselves except for staff Unsubstantiated interactions and care. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with RCC.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 59-AS-20230828113616

Allegation investigated: Staff do not meet the training requirements.

On 10/12/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with RCC Ashley Stahl. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. It was alleged that staff do not receive training as required. A period of time was not identified, niether were the staff alleged to not be trained. LPA reviewed August 2023 staff schedules and a review of staff training- particularly staff who began to work at the facility in Aug 2023. S1 and S2 had the required 20 hours of training before working with residents. Their training is ongoing. Interviews of caregivers with whom S1 and S2 worked stated that all new employees undergo a period of training, without individual care assignments, until they demonstrate compitency. Unsubstantiated As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with RCC.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 59-AS-20230830113344

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver an second amended page to a complaint investigation report (# 59-AS-20230504081443) delivered on 9/29/23. LPA discovered earlier today that the information was incorrectly copied/pasted in the prior amended 9099C-2 page. LPA met with Toni Jones, Administrator, and explained purpose of inspection. LPA provided a copy of the complete complaint findings for the above referenced complaint, which included the most recently amended page (9099C-2), any other amended pages and the original pages that were not amended. There are no citations issued in this report. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Oct 5, 2023

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to issue (2) additional citations related to substantiated complaint findings (# 59-AS-20230504081443) delivered on 9/29/23. There were (7) allegations substantiated but only (5) citations issued. LPA met with Toni Jones, Administrator, and explained purpose of inspection. The following (2) allegations were substantiated on 9/29/23 but were included in citations for (2) similar but separate allegations that were also substantiated. The Department has determined that it is appropriate to issue (2) additional citations for the following allegations: 1- Staff mismanaged resident’s medication and 2- Staff misinformed resident’s family about resident’s hospitalization. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) citations are being issued on the 809-D page attached. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 4, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87507(f) · Plan of correction due date: Oct 5, 2023

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Basd on documentation review, the Licensee did not ensure that item #25- Medication Safety, (listed in the Resident Handbook) which reads: "Medications will be Centrally Stored and monitored by Community Staff ", was followed, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: Licensee/Administrator has already requested to consolidate (R1's) current pharmacy into another pharmacy that will deliver directly to the facility. Administrator will attempt to consolidate all medication distribution into one pharmacy provider. Documentation to be provided by 10/18/23 of any consolidations .

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(5) · Plan of correction due date: Oct 18, 2023

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (5) Good character and a continuing reputation of personal integrity. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that the prior Administrator included accurate information only on the LIC624 submitted to the Department on/around 4/27/23 for the incident ocurring on 4/26/23 regarding (R1) going to the hospital, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: The Administrator who submitted the LIC624 is no longer employed at the facility. The current Administrator reviews all LIC624's prior to submission and will ensure their accuracy. There is no further POC action needed on this one.

Allegation investigated: Staff mismanaged resident’s medication. Staff did not ensure that resident received their medication Staff did not effectively communicate with resident’s family. Staff misinformed resident’s family about resident’s hospitalization. Staff did not give resident’s family copies of resident’s reports/documents upon request. Staff did not ensure that the restroom emergency pull tab was functional. Staff did not ensure that the resident restroom had paper products.

**This page was amended on 10/4/23 to note that all requested documentation was received as requested during the investigation. A new signature was also obtained.** Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete and deliver investigative findings to a a complaint received on 5/4/23. LPA met with Med-Tech, Gina Yanez (GY), who stated the Administrator, Toni Jones, was temporarily out of the building conducting a new resident assessment but would return shortly. LPA met with the Administrator at 1:45 pm. During the investigation, LPA interviewed the current Administrator, Resident Care Coordinator (RCC), (2) family members of resident (R1), and the Maintenance Director. LPA reviewed documentation pertaining to (R1), including but not limited to, physician's report, care plan, charting notes, and incident reports, Medication Administration Record (MAR), Admission Agreement. The results of the investigation are as follows: **cont on 9099C-1... Substantiated 9099C-1... **This page was amended on 10/4/23 to include additional information from the MAR that was provided to the Department during the investigation and to note that a separate citation will be issued on a 809 report, dated 10/4/23, for the following substantiated allegation.A new signature was also obtained ** Allegation: Staff mismanaged resident’s medication. Complaint alleges that (3) bottles of Galantamine (30 pills each) were filled and dropped off 3/17/23 at the facility. On 4/22/23, (R1's) family member was notified by staff that this medication was out and needed to be refilled. (R1's) family member confirmed with the pharmacy that the medication was last filled on 3/17/23 for a quantity of 90 pills and was told that the facility would determine where the missing pills were. (R1's) family members stated the Administrator during this time stated she was not aware of the situation and could not provide a resolution, and the facility “guessed” that the medication accidentally was assigned to another patient when (R1) was moved to that patients room and the medication was accidentally destroyed because the other patient was no longer at the facility. RCC stated on 5/12/23 that before the prior Administrator left the community, (S1) Med-Tech, called the family and said the facility was missing a bottle of medication for her Dementia. RCC confirmed the missing medication was Galantamine and (S1) claimed the bottle was missing, and the February bottle was at home for a while since it was a 90-day supply. RCC explained that (R1's) health care provider said the February bottle/medication was delivered to the family member's house. Both family members who were interviewed confirmed that (R1) never received the medication (3 bottles) with one member stating “she (R1) never got any of the 90-day medications, asserting they "disappeared"., and stated her father, had some supply of the same medication, same dosage, at his residence at another location. MAR for February 2023 and March 2023 appear to have staff initials in each box, as for other medications given on the same day and time (am); however, entries on 3/4 through 3/17 appear to also have a circle around them for the medication, Galantamine. There are no entries on the April 2023 MAR for Galantamine from 4/1- 4/7 or on 4/15 and 4/16, and for (2) other scheduled medications on these same days; there is an entry on 4/1 and 4/2 only for the medication, Tamsulosin, that it was administered in the morning. The MAR for May 2023 has entries on all days for Galantamine, except for on 5/13 and 5/14, which was also observed for medications, Losartan and Lovastatin. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. NOTE: A separate citation was not initially issued on 9/29/23 but is being issued on a separate report, dated 10/4/23. cont on 9099C2... 9099C-2.. **This page was amended on 10/4/23 to correctly state information regarding the MAR. This page was amended again on 10/5/23 due to the added information being inadvertently pasted in the middle of an unrelated sentence from the prior report** Allegation: Staff did not ensure that resident received their medication. On 4/22/23, (R1's) family member was notified by staff that this medication was out and needed to be refilled. (R1's) family member confirmed with the pharmacy that the medication was last filled on 3/17/23 for a quantity of 90 pills and was told that the facility would determine where the missing pills were. One family member stated that as of the day of the meeting, 5/2/23, she and family were never notified of the missing meds and (R1) did not receive this medication for several weeks. RCC stated on 5/12/23 "yes, there were (3) days of missed medications" and confirmed that the facility does use a MAR. LPA was provided with copies of MAR documentation from Jan 2023- May 2023, as requested. MAR for February 2023 and March 2023 appear to have staff initials in each box, as for other medications given on the same day and time (am); however, entries on 3/4 through 3/17 appear to also have a circle around them for the medication, Galantamine. There are no entries on the April 2023 MAR for Galantamine from 4/1- 4/7 or on 4/15 and 4/16, and for (2) other scheduled medications on these same days; there is an entry on 4/1 and 4/2 only for the medication, Tamsulosin, that it was administered in the morning. The MAR for May 2023 has entries on all days for Galantamine, except for on 5/13 and 5/14, which was also observed for medications, Losartan and Lovastatin. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff did not effectively communicate with resident’s family. Complaint states that on 4/26/23, (R1) was taken by a non-emergency ambulance provider to the ER and resident’s family was not aware until the following morning when resident’s granddaughter visited and noticed a hospital admittance band on (R1’s) wrist . One family member stated that no staff told her or her sister that (R1) had gone to the hospital. A second family member stated “staff said they tried calling all of us but they did not leave any messages when (R1) was sent to the hospital”. One member asserted that (R1) did not have a stomachache and was sent to the hospital they sent her to since it is a trauma center and (R1) hit her head. RCC stated on 5/12/23 that the facility documents when they contact residents' family members or POA in their charting notes. There were no charting notes available from 4/26/23 or 4/27/23. The Administrator at the time was not able to be interviewed. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. cont on 9099C-3... 9099C-3... **This page was amended on 10/4/23 to note that a separate citation was not initially issued for this substantiated allegation but is being issued on a separate report, dated 10/4/23** Allegation: Staff misinformed resident’s family about resident’s hospitalization. Allegation states that when (R1’s) family member visited (R1) on the morning of 4/27/23, she observed her to be wearing a hospital bracelet from 4/26/23, from another hospital than resident’s primary assigned one. When (R1’s) family inquired about the ER visit, they were told by facility staff (R1) had been sent to the ER for a UTI and then were later told that day by the Administrator that (R1) was sent out due to complaining of a stomach ache. The Administrator then indicated that (R1) was sent to the hospital in her primary medical group, when she was sent to another hospital in the area. One family member stated that no staff told her or her sister that (R1) had gone to the hospital. A second family member asserted “staff said they tried calling all of us but they did not leave any messages when (R1) was sent to the hospital”. One of the family members asserted that (R1) did not have a stomachache and was sent to the hospital they sent her to since it is a trauma center and (R1) hit her head. The other family member stated that at approximately 3:30pm on 4/27/23, the Administrator contacted (R1’s) other family member and asked her if she was going to pick up the “hard copy” prescription to get filled for the UTI. The Department received an incident report (LIC624), dated 4/27/23, which notes (R1) was sent to the ER on 4/26/23, at approximately 6:00 am by a non-emergency ambulance provider. The incident report notes that at approximately 6:00 am, (R1) had a “change in condition and was experiencing some discomfort” and was found on the floor by staff during room checks. It was decided to sent resident out for further medical evaluation. The LIC624 states that resident was taken to the assigned hospital through her health plan and that staff “contacted family”; however, when the family member called (R1’s) assigned hospital, there was no record that (R1) had visited the night before. Hospital discharge papers confirm that (R1) was sent to another hospital other than her assigned primary care hospital and was seen for a fall and UTI and was prescribed Cephalexin (Keflex 500 mg) for (7) days. Charting notes from 4/26/23 document (R1) was sent to a different hospital than the one indicated on the LIC624. The Administrator later indicated to the family members that (R1) was sent to a different hospital in the area and it was not mentioned that (R1) was sent out due to a fall. It was discovered that (R1) had a UTI after being sent out for the fall. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. NOTE: A separate citation was not initially issued for this substantiated allegation but is being issued on a separate report, dated 10/4/23. cont on 9099C-4.. 90099C-4... Allegation: Staff did not give resident’s family copies of resident’s reports/documents upon request. Allegation reads that (R1)’s family members had a meeting with the Administrator, on 5/2/23, and requested to get a copy of the incident report as well as the Internal Occurrence Report for when (R1) went to the hospital on4/26/23 and copies of all incident reports since resident moved in. The Administrator agreed to provide these copies later in the day but was not able to locate them, and she said she did not have time to look for them. The RCC stated that she attended the meeting also on 5/2/23 and (R1's) family was provided with (1) incident report (LIC624) and (1) In-House incident report during the meeting. RCC stated she heard the Administrator agree to provide copies of all other LIC624's for (R1) and isn't sure if they were provided, but the Administrator was somewhat reluctant to do so. RCC stated that the incident from 4/26/23 is a separate one from the incident in (R1's) records that is documented in the charting notes and on an internal incident report from 4/28/23. (R1) was not sent to the ER on 4/28/23 after speaking with her family member. It should be noted that (R1) had began antibiotic treatment for a UTI following the visit to the hospital on 4/26/23 and could possibly have had a fall again on 4/28/23. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff did not ensure that the restroom emergency pull tab was functional. Complaint alleges that the pull cord in (R1's) restroom was not working from on/around February- May 2023 and was told that it had been fixed earlier than it actually was. Tour conducted on 5/12/23 -LPA tested the pull cord in (R1's) bathroom and observed it to light up as well as the pull-cord near (R1’s) bed. LPA tested the pull cord in a staff bathroom at 11:35 am and observed the red light to appear and tested a pull cord in a second staff bathroom and observed the light to appear at 11:45 am. LPA tested the pull cord in a second resident’s room and observed it to light up when activated. On 5/12/23, RCC showed LPA during the tour that this pull cord's location appeared on the monitor in RCC's office as having been pulled at the noted day/time and was "red" on the screen. The alert for (R1's) room appeared "purple" on the monitor in RCC's office. cont on 9099-C-5.. 9099C-5.. One family member stated on 7/26/23 the pull-cords were "non-functional" in (R1’s) bathroom from Feb 2023- May 2023 and she told the Administrator at the time, but they were not fixed timely. The same family member indicated she has "never seen a necklace or bracelet on (R1)".The Maintenance Director stated he wasn’t working at the facility from February-April 2023 and when he returned to the community on/around July 2023, he replaced all of the batteries to ensure all pull cords were working, both in resident rooms and staff areas. On 5/12/23, RCC stated a report for the response time was printed last week and that last week, not all pull cords were working but now they are working 100%. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff did not ensure that the resident restroom had paper products. Paper towels or wipes were not available in the resident restroom. LPA conducted a tour on 5/12/23 in (R1's) private bathroom. LA did not observe any paper towels or a paper towel dispenser in (R1's) shared bathroom. LPA observed (2) small cloth towels on a single towel rack. RCC stated on 5/12/23 that the facility fills each residents paper products in their individual bathrooms everyday and each resident receives 2 extra paper products On 9/26/23-LPA did not observe any towels, cloth or paper, to be in the bathroom. Administrator stated laundry was being done since (R1’s) laundry hamper was not in her room. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (6) citations are issued on the 9099-D pages. Exit interview. Copy of report and appeal rights provided. 9099A-C-1... Allegation: Staff were not available and visible at the facility. Complaint alleges the Administrator at the time was informed on several occasion, at different times of the day, staff was not available, and at other times a staff member was not visible and able to be located. On 5/12/23, RCC stated that during the AM shift there are 3 caregivers and 1 med tech on duty. RCC indicated that there are 10 staff on duty including house keepers during the AM shift. RCC stated that during the PM shift there are typically 3-4 caregivers and 1 med tech on duty. RCC stated that during the NOC shift there are 2 caregivers that are med tech trained. LPA has observed multiple staff on several visits made to the community from May- September 2023.n Additionally, the Ombudsman has made multiple visits to the facility and has not observed staffing to be insufficient. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff did not ensure that resident was properly dressed. Complaint states that during one visit, (R1) was wearing men’s pants that had an odor of urine; on another visit, (R1) was not wearing any undergarments, and on a third visit, (R1) was in the same clothes she was wearing the day before. LPA observed (R1) on 5/12/23 to be wearing a blue turtleneck sweater, pink bow in her hair, and to be sitting in her wheelchair. RCC showed LPA (R1’s) dresser and closet- LPA observed sufficient clothing and incontinent products on hand. On 7/31/23, LPA and one staff observed (R1) present in her room and to be dressed in clean, dry clothes with no incontinent odors noticed. LPA and the Administrator observed (R1) on 9/26/23 to be dressed in clean, dry clothing and wearing several bracelets. There were no incontinent odors observed Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. cont on 9099A-C-2... 9099A-C-2... Allegation: Staff did not ensure that resident had adequate bedding.During one of visits, (R1) only had one sheet and her personal lap blanket. Her feet had no socks and were ice cold. LPA conducted a tour on 5/12/23 and observed (R1's) bed to be made with (2) sheets and a blanket. An additional (3) crocheted blankets were folded on top of the bedspread. On 7/31/23, LPA observed a plastic protector on the mattress. (S2) showed LPA the different layers on the plastic protector- 1- cloth, 2- sheet, 4- cotton chuck, 5- disposable chuck. (S2) stated incontinent like 89% of the residents. AB stated all incontinent residents have both a cotton and disposable chuck on the sheets. (7) other resident rooms were inspected and all rooms were observed to have clean, dry linens on the beds with no significant incontinent odors present. On 9/26/23, LPA and Administrator observed (R1’s) bed to be made and all layers, sheets, incontinent pads and blankets to be clean and dry. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- Allegation: Staff did not ensure safe keeping of resident’s personal property.Missing items from (R1’s) room which include, slippers, jackets, plant and walker. During one of visits, (R1) was not in her wheelchair and was using a wheelchair with someone else’s name on it. When addressed, staff took her back to her room to switch wheelchairs and returned with a completely different wheelchair other than her own. On 5/12/23, RCC stated (R1's) daughter put a lock on her door. RCC stated she/Admin tell families that "it's Memory Care" and residents wander and things can disappear. RCC confirmed that R1 did have clothes missing and explained that there is a resident that likes to "shop" and goes in (R1's) room. On 7/26/23, R1’s family member stated that things disappear and some residents go in other residents' rooms, mentioning resident, ((R2), who takes items and exchanges them for cigarettes. On 9/26/23, another family member stated that RR has had bracelets stolen from resident, (R2) and "(R2) is a problem" as she has seen (R1's) things in (R2's) room. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 59-AS-20230504081443

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 2, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not ensure that the medication Galantamine, for (R1), was administered as ordered on/around April 2023 and that no medication went missing, which posed an immediate health and safety risk to residents in care. (R1) missed several days of this medication.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee/Administrator agree to continue with staff training, pharmacy audits, and reviewing the documentation every week. Documentation to be provided by 10/2/23 of what has been completed so far.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Oct 13, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not ensure that family members were notified that (R1) was sent to the hospital, and for what reasons, on 4/26/23, which posed a personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee/Administrator conducted staff training in the last month regarding emergency assistance protocols. Documentation to be sent by 10/13/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 13, 2023

87303 Maintenance and Operation a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interviews conducted, the LIcensee did not ensure that all pull cord devices were in working order, including in (R1's) bathroom, from approximately Feb- May 2023, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee/Administrator agree to continue check weekly with the Maintenance Director. All bathrooms and pull cords are being checked weekly. Documentation to be submitted by 10/13/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3) · Plan of correction due date: Oct 13, 2023

Reg 87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (D) Hygiene items of general use such as soap and toilet paper. This requirement is not met as evidenced by: Based on observation on 5/12/23 and 9/26/23, the Licensee did not ensure that there were paper towels or cloth towels available for use in (R1's) bathroom, which posed a potential heatlh and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee/Administrator agree to discuss options regarding installing a paper towel roll holder or dispenser. Provide documentation of solution by 10/13/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 13, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evicenced by: Based on interviews conducted, the LIcensee did not ensure that (R1's) family was provided with all LIC624's since moving to the community after they were requested.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee.Administrator agree to discus with RCC on this process and provide documentation of the protocols to be followed. Documentation due by 10/13/23.