Citrus Place

Allegation investigated: Staff did not ensure resident had a care plan Staff are not meeeting residents needs

On June 10, 2026 Licensing Program Analyst (LPA) Ivashia Wright arrived unannounced at the facility to initiate a complaint investigation. LPA was granted entry and met with Executive Director Megan Blacher and explained the purpose of the visit. LPA conducted a tour of the facility, conducted interviews, and requested copies of pertinent documentation. Interview with Executive Director Megan revealed Resident (R1) lives in the independent living units at the facility. Record review of the facility's assisted living, memory care and Independent living resident rosters confirmed R1 lives in the facility's independent living units, which is not licensed by the Department and Community Care Licensing (CCL). LPA Wright further verified this by obtaining a copy of relevant residents’ lease. Therefore, the allegations Staff did not ensure resident had a care plan and Staff are not meeting residents needs has been deemed Unfounded at this time. Unfounded A finding that the complaint is unfounded means the allegation is false, could not have happened, and/or is without a reasonable basis. A exit interview was conducted and a copy of this report along with LIC811 – confidential names list was provided to Megan.the state’s words, verbatim · CDSS document, Jun 10, 2026 · control 18-AS-20260604134410

Allegation investigated: Staff hit resident

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Executive Director Megan Blacher, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and witnesses, file reviews and observations. On July 9, 2025, Community Care Licensing Division (CCLD) received a complaint alleging facility staff hit resident. Additional Witness 1 AW1 reported they responded to a call alleging staff 1 (S1) hit R1’s hand. AW1 reported no bruising was observed on R1 and that the incident was documented. Interview, Executive Director Megan Blacher confirmed that she received a call regarding the incident and instructed management to follow proper procedures. ED stated that R1 was assessed, the alleged staff member was removed from duty pending an investigation, witness statements were obtained, and the required reporting was completed to law enforcement, Community Care Licensing Division (CCLD), and the Long-Term Care Ombudsman. Continued on LIC 9099-C. Substantiated Interviews with two of two staff members corroborated ED’s statements, confirming that the response was immediate, including placing S1 on leave and notifying the family and appropriate enforcement agencies. Interview with R1’s responsible party acknowledged receiving notice of the incident. Furthermore, RP emphasized they observed facility staff to treat R1 well. RP did not have any further concerns with the treatment of R1 at the facility. Attempts were made to interview S1, however, S1 did not respond to calls. A review of records was obtained and a statement made by S1 reported that R1 had a utensil in their hand that was used to hit them. S1 acknowledged making contact with R1’s hand, describing it as moving their hand away. Furthermore, reporting documentation were obtained such as Special Incident Report submitted to CCLD, Suspected Elder Abuse Form SOC 341 and law enforcement incident number. Based on interviews and record reviews, the allegation that facility staff hit resident is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. This poses a health and safety and or personal rights risk to residents in care. The facility will be cited. An exit interview was conducted. A copy of this report was provided to Executive Director Megan Blacher, along with a copy of the LIC9099-C, LIC9099D, and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 18-AS-20250709080828

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Apr 29, 2026

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:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. evidenced by: Based on observation and interviews conducted with staff and witnesses, the staff did not ensure R1 was afforded dignity when they were hit on the hand by R1 while in care which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Administrator will conduct an in service training with all employees regarding resident' personal rights and forms of abuse. Administrator will email LPA a copy of the sign-in training sheet as proof by POC date.

Allegation investigated: facility staff did not provide resident with requested medical aid facility staff yelled at resident facility staff confiscated Resident's dog.

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Executive Director Megan Blacher, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and witnesses, file reviews and observations. On August 18, 2021, Community Care Licensing Division (CCLD) received a complaint alleging facility staff did not provide resident with requested medical aid, facility staff yelled at resident and facility staff confiscated Resident's dog. Regarding the allegation facility staff did not provide resident with requested medical aid, it was alleged staff would not respond to requests for medical assistance. Interview with AW1 acknowledged R1 was hospitalized on three occasions. AW1 reported that R1 was sent to the hospital for chest pains, a second visit was for a witnessed fall and the third was to be sent out to a skilled nursing. Continued on LIC 9099-C. Unsubstantiated A follow up interview with R1 to gather further information could not be conducted due to R1’s passing. Interview with Staff 2 revealed that R1 had a family member who would direct R1 to not take certain medications and on one occasion observed the family member remove a pill from R1’s hand. Additionally, S2 noted that the family member would often contact for medical assistance when it wasn’t needed. A review of records corroborated statements made by S2. On April 24, 2020, the county conservator assigned to R1 contacted the facility and authorized a family member to speak with R1 twice a week for 10 minutes, with the calls to be supervised. Shortly after this communication, paramedics arrived at the facility, reporting that a family member had requested assistance. Upon assessment, paramedics determined that R1 was sleeping on the couch and did not require medical attention. On 4/26/2020, a family member called paramedics reporting that R1 was having a stroke. The fire department responded and assessed R1, determining that R1 appeared normal and stable throughout their assessment. Regarding the allegation facility staff yelled at resident it was alleged that a staff member was verbally aggressive with R1. AW1 reported that they were visiting R1 inside R1’s room when they overheard an individual loudly instructing R1 to shut the door. AW1 stated they did not leave the room and therefore could not confirm whether the voice belonged to a staff member or another client in care. AW1 could only speculate the voice may have been a staff member, describing it as deep and strong. Interview with staff 2 reported they had not observed any staff be verbally aggressive with R1. A review of records such as Special Incident reports and facility consumer notes did not reveal any reference to a complaint or incident relating to the allegation and R1. For the allegation that facility staff confiscated Resident's dog, it was alleged the facility confiscated R1’s dog in June of 2019. A review of records revealed a pet agreement was signed by R1’s representatives on 8/16/2017. Interview with Executive Director Megan Blacher reported that pets are allowed in Assisted Living, however, a policy is in place to ensure proper care. Executive Director Blacher noted that if a resident is incapable of properly caring for the pet, arrangements are made with family unless they decline and then proper authorities would be contacted for assistance. Interview with Staff 2 reported that R1 had a dog that was removed by a family member and not returned back to the facility. Interview with Additional Witness 1 was attempted and did not respond to multiple requests. Interview with R1 could not be conducted due to their passing. Interview with Witness 2 (W2) was attempted and did not respond to multiple requests. No further information could be obtained. Continued on LIC 9099-C. Based on interviews, record reviews, and observations, the allegations that staff alleging facility staff did not provide resident with requested medical aid, facility staff yelled at resident and facility staff confiscated resident's dog have been deemed UNSUBSTANTIATED. A finding that the allegation 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. An exit interview was conducted. A copy of this report was provided to Executive Director Megan Blacher.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 18-AS-20210818134318

Allegation investigated: Staff do not provide residents with activities

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Connections for Living Director Megan Snell, and explained both the purpose of the visit and the details of the allegation. On January 24, 2025, Community Care Licensing Division (CCLD), received a complaint that facility staff do not provide residents with activities. It was alleged that residents were not being provided with activities or were being denied participation. Interview with Additional Witness 1 (AW1) reported that on two occasions, outdoor activities were cancelled without notice. Additionally, AW1 reported that on another occasion, Staff 1 (S1) was observed denying Resident #1 (R1) an outdoor outing due to R1’s wheelchair-bound status. Interview with ED stated she was not aware of any incidents involving residents being denied activities or outings. ED noted the facility has a wheelchair-accessible bus and that outings are available and accessible to all residents. Continued on LIC 9099-C. Unsubstantiated Interview with 3 of 3 residents corroborated that activities are offered by the facility and outings are available for registration. Additionally, no experience of being denied an activity or observing another resident being denied was reported by the residents. LPA conducted multiple attempts to interview S1 were unsuccessful and no further information could be obtained as S1 was no longer employed by the facility. LPA also could not conduct an interview with R1 due to their passing. An interview with R1’s Responsible Party (RP) reported visiting R1 at least once a week and stated that they observed staff consistently provide excellent care. RP indicated they were not aware of any concerns regarding denial of activities or transportation with R1. RP emphasized R1 did not express experiencing concerns related to the allegation. A review of activity records showed that outing schedules and tour sign-up sheets were available and that residents were actively registering for these events. During an unannounced visit on January 31, 2025, LPA Perez observed activity calendars posted in multiple locations throughout the facility, including the main lobby, inside the elevators, and in activity newsletter handouts available in both Assisted Living and Memory Care. Based on interviews, observations, record reviews, and due to the inability to interview pertinent staff, the allegation that facility staff do not provide residents with activities has been deemed UNSUBSTANTIATED. A finding that the allegation 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. An exit interview was conducted. A copy of this report was provided to Connections for Living Director Megan Snell.the state’s words, verbatim · CDSS document, Apr 2, 2026 · control 18-AS-20250124100551

Allegation investigated: Staff do not observe residents for change in condition

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Connections for Living Director Megan Snell, and explained both the purpose of the visit and the details of the allegation. On January 24, 2025, Community Care Licensing Division (CCLD) received a complaint that facility staff do not observe residents for change in condition. It was alleged that R1 and R2 were experiencing cognitive decline and facility staff did not address their change in condition. According to Additional Witness 1 (AW1), both R1 and R2 were permitted to leave the community unsupervised when they should have been placed in a higher level of care. AW1 acknowledged reporting their concerns to management. Information from an interview with ED, stated that R1 and R2 resided in Independent Living and were not Assisted Living residents. A review of facility records, including resident rosters, did not show any documented individuals matching the reported names residing in the assistant living facility. Continued on LIC 9099-C. Unfounded Interview with additional parties corroborated the information. Based on interviews and record review, the allegation that facility staff do not observe residents for change in condition is unfounded due to the listed residents not residing at the facility. A finding that the allegation is unfounded, meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, this complaint is dismissed. An exit interview was conducted. A copy of this report was provided to Connections for Living Director Megan Snell.the state’s words, verbatim · CDSS document, Apr 2, 2026 · control 18-AS-20250124100551

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Executive Director Megan Blacher. The LPA informed the Executive Director of the purpose for the visit. The inspection included the following: The facility licensed with the department is comprised of a memory care unit and assisted living. The facility does have a pool which has a locked gate surrounding it. No fire arms are kept at the facility. LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. All outdoor and indoor passageways are kept free of obstruction and debris. . LPA inspected 10 (10) client rooms and observed the required bed, chair, grab bars for each toilet, and shower used by residents. Resident showers have non-skid mats present. LPA began review of client records. eight (8) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, TB test results, needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be available and complete. LPA reviewed employee records- eight (8) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 09/30/2026. LPA observed personnel records to be available and complete. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen. Medications are centrally stored. There is a locked room in assisted living and an additional locked room in memory care allocated for medication storage. Digital centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Multiple fire extinguishers were observed to be serviced on 10/02/2025. Emergency drills are conducted monthly at the facility with the last drill on 10/31/2025. Based on the information received during this visit today in the areas reviewed, there are no deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809 report was reviewed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Nov 21, 2025

Allegation investigated: Staff did not give resident medication as prescribed

On 3/4/25, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to investigate the allegation listed above. LPA met with Administrator, Vicky Torres who who was informed of the purpose of the visit. It was alleged staff mismanaged Resident 1's (R1's) medication resulting in their hospitalization. LPA toured the facility, conducted interviews, and obtained copies of pertinent records. LPA reviewed R1's admission agreement dated 11/6/23 and section 14 notes medication will be monitored as prescribed by the Resident's doctor. LPA reviewed R1's Physician's Report for Residential Care Facilities for the Elderly dated 11/17/23 noting R1 does not have the capacity to store or administer their own prescription medications. LPA reviewed R1's assessment dated 1/9/25 noting R1 requires total assistance with medications. Administrator Torres was interviewed and reported when residents return from the hospital, the facility faxes the updated physician orders to the pharmacy who then enters the medication orders onto the facility's electronic Quick Medication Administration Record (QMAR). Substantiated The facility reported medication technicians follow the QMAR when dispensing residents’ medications. Medication technicians are able to review a list of routine medications titled “Physician’s Orders” (POs) which are automatically generated from the QMAR. LPA reviewed the POs dated June 19, 2024, noting one (1) tablet of the medication in question is to be dispensed every morning thirty minutes before breakfast and one and a half tablets every Sunday morning thirty minutes before breakfast. LPA reviewed R1’s QMAR from October 2024 to March 2025. The QMAR dated October and November 2024 noted the medication in question was dispensed to R1 from October 1, 2024, to November 25, 2024, as directed in the POs dated June 19, 2024. LPA reviewed R1’s QMAR dated December 2024, which indicated one and a half tablets of the medication in question was dispensed to R1 every Sunday. R1’s QMAR dated December 2024 did not document the medication in question was dispensed to R1 daily. Two (2) staff interviewed reported medication technicians are instructed to create a paper Medication Administration Record (MAR) to document dispensing a medication that is active but for an unknown reason is not listed in the QMAR. The facility provided LPA with an undated paper MAR noting the daily dosage of the medication in question was only dispensed to R1 on the 28th day of an unknown month. LPA reviewed R1’s physician’s orders from the Kaiser Permanent After Visit Summary (KPAVS) dated 12/26/24, noting one (1) tablet of the medication in question is to be dispensed every morning thirty minutes before breakfast and one and a half tablets every Sunday morning thirty minutes before breakfast. The facility reportedly faxed the KPAVS dated 12/26/24 to the pharmacy who entered R1’s medication orders in the QMAR. However, LPA reviewed the POs dated January 23, 2025, which noted only one and a half tablets of the medication in question to be dispensed every Sunday morning thirty minutes before breakfast. R1’s QMAR dated January 2025 corroborated the medication in question was only dispensed to R1 as directed in the January 23, 2025, POs. The facility searched but was unable to produce a paper MAR documenting the medication in question was dispensed to R1 daily in January 2025, as directed in the physician’s orders from R1's KPAVS dated 12/26/24. LPA reviewed the facility’s “Narrative Charting” noting R1 returned from the hospital on 2/23/25 and is to take the one tablet of the medication in question every morning and one and a half tablets every Sunday. LPA reviewed R1’s physician’s order from the KPAVS dated 2/23/25 noting the medication in question is to be administered one tablet every morning thirty minutes before breakfast and one and a half tablets every Sunday, with the next dose due on the morning of 2/24/25. LPA reviewed R1’s QMAR dated February 2025 which documented one and half tablets of the medication in question was dispensed to R1 on 2/2/25, 2/9/25, and 2/16/25 and one tablet daily beginning on 2/25/25. The QMAR dated February 2025 noted R1 was away from the facility from 2/18/25 to 2/24/25. One (1) of two (2) staff interviewed reported dispensing R1’s medication in question on 2/24/25 but was unable to produce a paper MAR to prove it. On 2/25/25, the Department received an incident report from the facility reporting on 2/17/25 R1 was sent to the emergency room due to being verbally unresponsive. LPA also reviewed R1’s Kaiser Permanente Progress Notes (KPPN) dated 3/3/25 noting R1 was recently hospitalized due to a medication error. The KPPN dated 3/3/25 noted R1’s medication in question was incorrectly entered into the care facility’s system and it was determined R1’s symptoms were due to lack of the medication in question. Health Services Associate, Carolina Campos reported supervisors are required to approve new medication orders entered onto the QMAR. The facility reportedly failed to verify the pharmacy entered the correct medication orders from the physician’s orders from R1’s KPAVS dated 12/26/2025, which reflected in the QMAR POs dated 1/23/2025 and resulted in the medication errors. One (1) of two (2) staff interviewed corroborated the allegation. R1 declined to be interviewed. Based on LPA’s interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided to Administrator Torres. *Note LPA was off-site from 1:05 p.m. to 1:35 p.m.the state’s words, verbatim · CDSS document, Mar 4, 2025 · control 18-AS-20250225135432

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 14, 2025

(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 was not met as evidenced by: Based on interviews and records reviewed, a complaint investigation revealed facility staff mismanaged R1's medication resulting in their hospitalization. This poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2025

Plan of correction: Administrator reported they will conduct an in-service staff training regarding proper medication management and documentation. Administrator added they will conduct their own quality assurance checks to avoid future medication errors.

Allegation investigated: Staff did not seek timely medical care for resident

Licensing Program Analyst, (LPA) Armando Perez, conducted an unannounced visit to the facility and met with Connections for living Director, Megan Snell. The purpose of the visit was to inform of the complaint allegation findings regarding the listed allegation. During this investigation, LPA conducted interviews with Administration, staff, clients, and additional witnesses. LPA also obtained pertinent documentation in order to assist with determining the findings. On December 2, 2024, Community Care Licensing (CCL) received a complaint alleging that facility staff did not seek timely medical care for resident. It was reported that facility staff failed to transport Client 1 (C1) to the hospital for evaluation after an injury was observed. Additionally, it was stated the injury was acknowledged during the morning shift and the facility did not seek medical attention until the afternoon. Information obtained from interviews with Administrator stated facility staff observed swelling to C1’s left eye and immediately communicated with C1’s Power of Attorney (POA). ...Continued on LIC9099-C. Unsubstantiated It was advised that C1’s Power of Attorney requested that they are contacted first for non emergency incidents. POA indicated that they will have C1 assessed and determine if further medical evaluation is required. It was determined by POA that the injury to C1 did not require further medical attention. C1’s POA refused emergency medical personnel. At approximately 3 PM, facility staff observed the swelling to increase and medical personnel was contacted at that time. C1 was transported to the hospital to be further evaluated. Information obtained from staff and additional witnesses corroborated the information and indicated that C1’s POA indicated they did not want C1 transported to the hospital. Due to the swelling increasing, medical personnel was contacted. Due to C1’s condition, LPA was unable to obtain additional information pertaining to the incident. Based on observation, record review, client, and staff interviews, it was determined that staff contacted C1’s POA immediately to advise of the injury and was advised not to contact emergency services, causing a delay. Staff continued to monitor and evaluate C1’s injury to assess if further medical evaluation was necessary. Facility staff did later contact medical personnel services where it was determined C1 needed to be transported. Therefore, the allegation is unsubstantiated, means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy of this report was discussed with and provided to the Connections for Living Director Megan Snell.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 18-AS-20241202144300

Allegation investigated: Staff failed to refill resident's medication

Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to deliver findings on the above allegation. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPAs toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as medication administration record (MAR). Regarding the allegation that staff failed to refill resident's medication, the investigation revealed the following: Per MAR, Resident 1 (R1) did not receive Tamulosin HCL on 01/16-01/19/2022 and on 01/31/2022 pending delivery of the medication. Facility staff indicated R1's medications are serviced through the VA pharmacy and facilitated by the resident's family member. Witness indicates facility failed to provide adequate notice when refills were due. Facility documentation on 01/12/2022 shows that the family member had visited the facility and medications were to be delivered. There is no documentation of requests by the facility to request refills during the time of the complaint. Based on records reviewed and interviews conducted, the allegation is deemed substantiated. Citation is being cited in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). Exit interview conducted and a copy of this report as well as appeal rights are being provided. Substantiated Work order and interview with Maintenance Director indicated an order for repair was generated on 01/25/2022. Maintenance Director indicated unsuccessfully attempting to repair the item and then ordering the part on 01/28/2022. Due to the pandemic, specialty items took longer to receive and on 02/09/2022 the framing in the ceiling was repaired with the project completed on 02/10/2022. LPA observed the repaired area in the resident's room. Needs and Services Plan dated 01/11/2022 indicated resident was independent with ambulation and transfers but used a walker. LPA reviewed incident report dated 01/18/2022 showing the resident had come down to the lobby with a bleeding arm at 3:50 AM. Resident was immediately assessed. Per the report and narrative charting, resident's family member was notified of the incident at 4:32 AM with the family member arriving approximately 40 minutes later to the facility. Interview with Administrator at time of the complaint confirmed speaking with the resident's family member frequently regarding the resident's status. Narrative charting documented frequent interactions between resident's family member and staff regarding the status of the resident. Based on interviews conducted and record review, LPA is unable to corroborate the allegations. Therefore the allegations are deemed UNSUBSTANTIATED, meaning although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Dec 3, 2024 · control 18-AS-20220204163100

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Dec 4, 2024

Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing.. and assistance with taking prescribed medications. This req is not being met as evidenced by: Based on record review and interviews conducted, Licensee failed to ensure resident was assisted with medication administration. Resident missed five doses of medications as they were not refilled. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 3, 2024

Plan of correction: Licensee to provide an in-service to staff on medication administration and forward proof to LPA by POC due date.

Allegation investigated: Staff are not providing adequate supervision to residents Staff left resident on the floor for an extended period of time Staff does not administer resident's medications as prescribed

Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to deliver findings on the above allegations. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPAs toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as incident reports. Regarding the allegations that staff are not providing adequate supervision to residents, staff does not administer resident's medications as prescribed and staff left resident on the floor for an extended period of time, the investigation revealed the following: Facility schedule indicates four caregivers and a med tech for 1st and 2nd shifts and two caregivers/ one med tech for the NOC shift. Nine out of nine staff state scheduling is adequate and staff are able to provide resident care including toileting, showering and assistance with eating. LPA observed residents being assisted with meals. Resident 1 (R1) had one witnessed fall and four unwitnessed falls between 04/11/2024 and 05/01/2024. Resident was assessed and sent out for observation on four instances. CONTINUED ON LIC 9099C DATED 12/03/2024 Unsubstantiated Narrative charting documented care plan meeting on 05/02/2022 to discuss fall prevention for resident. Family was to provide a private caregiver and hospice was providing an LVN to stay with resident at night as resident liked to get up and walk. Resident was put on extra safety checks as well per facility documentation. Nine out of nine staff deny residents being neglected and staff state R1 was always wanting to get up and walk. LPA reviewed medication administration records for six residents. Per documentation, all six received medications on 04/07/2024 and any missed medications in April 2024 were documented in the notes. Based on interviews conducted and records reviewed, LPA is unable to corroborate the allegations. Therefore the allegations are deemed UNSUBSTANTIATED meaning although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Dec 3, 2024 · control 18-AS-20240429160126

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a) · Plan of correction due date: Dec 17, 2024

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This req is not being met as evidenced by: Based on interviews conducted, Licensee failed to ensure residents were afforded dignity. Facility staff had two different altercations with themselves. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 3, 2024

Plan of correction: Licensee to conduct an in-service on personal rights and forward proof to LPA by POC due date.

Allegation investigated: Resident was left in soiled diapers/clothing for an extended period of time. Resident was not treated with dignity and respect. Resident's toileting needs were not being met.

LPAs Joseph Alejandre and Kimberly Lyman made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPAs met with Executive Director Vicky Torres and explained the reason for the visit. The investigation into the allegation, resident was left in soiled diapers/clothing for an extended period of time, revealed the following. W1 reported that on August 22, 2020, when they visited R1 they were wearing 2 diapers and they were soiled. LPA interviewed 2 staff who worked at the time R1 lived at the facility. Both staff reported that R1 was never put in 2 diapers and all residents were changed regularly. W1 reported that R1 was left soiled for long periods of time but did not provide any other dates when this took place. R1 could not be interviewed because they passed away in 2022. The former Executive Director reported that they were unaware of any residents that were left soiled for long periods of time. LPA interviewed 3 residents who reported they had no issues with incontinence care. Based on the evidence gathered the allegation is unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Unsubstantiated Regarding the allegation, Resident was not treated with dignity and respect, the investigation revealed the following. W1 reported that R1 was put to bed without being fully dressed. W1 reported that R1 was put to bed with a top but no bottoms. R1 passed away in 2022 and could not be interviewed. LPA interviewed 2 staff members who worked at the facility at the time R1 resided at the facility. Both staff members reported that none of the residents were ever put to bed with only a top on. LPA interviewed the former Executive Director who reported they were unaware of any reports about residents being put to bed without clothing. Based on the evidence gathered the allegation is unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. The investigation into the allegation, Resident's toileting needs were not being met, revealed the following. It was reported that R1 was not assisted with incontinence care. W1 reported that on that on August 22, 2020, when they visited R1 they were wearing 2 diapers and they were soiled. LPA interviewed 2 staff members who worked at the facility when R1 was residing at the facility. Both staff members reported that R1 was always assisted timely with incontinence care. Both staff members reported they did not recall any resident ever having 2 diapers put on them. The former Executive Director did not recall any issues with any of the residents having issues with incontinence care. Based on the evidence gathered the allegation is unsubstantiated meaning although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided. Regarding the allegation, staff did not notify responsible party of resident's change in condition, the investigation revealed the following. It was reported that R1 lost a tooth, and the facility did not inform R1’s responsible party. Photographic documentation was provided showing R1 is missing a tooth. Witness 1 (W1) reported visiting R1 on August 22, 2020, and they were missing a tooth. 2 staff members interviewed did not recall when or how R1 lost a tooth. LPA interviewed the former Executive Director (ED) who worked at the facility when the complaint was filed. ED reported they did not remember R1 and did not recall any resident losing a tooth. The preponderance of evidence standard has been met, therefore the allegation is substantiated. The investigation into the allegation, staff did not safeguard resident's personal belongings, revealed the following. It was reported that R1’s glasses were lost and never found. W1 reported that in September 2020 R1’s glasses were missing along with a picture collage. W1 reported that the Executive Director and staff were notified about the missing items. LPA interviewed 2 staff members and the former Executive Director (ED). Both staff members and the ED did not recall hearing any reports from R1 or their responsible party about any missing items. W1 reported that staff looked for both items but never found anything. W1 reported that they were contacted after R1’s roommate moved out by R1’s roommate’s family and the picture collage was found in R1’s roommate’s closet. W1 reported the picture collage was returned to them in 2022. A review of R1’s file revealed that R1’s file did not have a personal property inventory. LPA interviewed 2 staff members who did not recall R1 losing glasses. W1 does not recall if R1 had their items inventoried. W1 reported they were never provided with a report from the facility concerning the missing items. The facility could not provide any documentation concerning a theft and loss report for R1’s missing items. The former ED at the time the complaint was filed did not recall completing any documentation for R1’s missing items. The facility could not provide an inventory list for R1 or a signed document of R1’s refusal to have their items inventoried. According to CCR 87218(a)(1) the facility is required to complete a personal property inventory for residents. Based on the evidence gathered the preponderance of evidence standard has been met, therefore the allegation, staff did not safeguard resident’s personal belongings is substantiated. Deficiencies are being cited per Title 22 Division of the California Code of Regulations. An exit interview was conducted and a copy of the report was provided along with appeal rights.the state’s words, verbatim · CDSS document, Dec 3, 2024 · control 18-AS-20211020123858

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 4, 2024

(f)Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not being met as evidenced by; Photographic evidence was provided showing R1 with facial hair and untrimmed nails. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 3, 2024

Plan of correction: LIcensee agrees to train care staff on CCR 87464 Basic Services and to provide proof of training to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Dec 17, 2024

Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by; R1 lost a tooth and the responsible party was not notified. This poses a potenational health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 3, 2024

Plan of correction: Licensee agrees to train staff on CCR 87211 reporting requirements and to submit proof of training to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a)(1) · Plan of correction due date: Dec 17, 2024

The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative. This requirement is not being met as evidenced by; A file review for R1 shows R1 did not have a property inventory list, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 3, 2024

Plan of correction: Licensee agrees to complete an inventory list for each resident and to train staff on CCR 87218. Licensee to forward proof of training to LPA.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced case management visit in conjunction with complaint investigation 18-AS-20240429160126. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the course of the complaint investigation, LPAs interviewed staff and reviewed facility documentation. During the investigation it was revealed that Staff 1(S1) had put the staff's hand over Resident 1's (R1) mouth and told the resident to "Shut up." An investigation was conducted and S1 was terminated from employment at the facility. LPA observed R1 during the visit. Resident was relaxing in the memory care unit. The resident appeared clean and taken care of. Based on the observations made during today's visit, the following citation is being cited per California Code of Regulations (Title 22, Division 6, Chapter 8). Exit interview conducted and a copy of this report as well as appeal rights are being provided.the state’s words, verbatim · CDSS document, Dec 3, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Dec 4, 2024

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...This req is not met as evidenced by: Based on interviews conducted, Licensee failed to ensure residents are free from humiliation and intimidation. S1 covered the resident's mouth and told the resident to "Shut up." This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 3, 2024

Plan of correction: Licensee to provide an in-service on personal rights pertaining to resident abuse and intimidation and forward proof to LPA by POC due date.

Allegation investigated: Licensee is not ensuring that staff are sufficient in numbers, qualifications, and competency to meet residents' needs. Staff yell at residents in care. Staff are being discouraged from reporting incidents involving residents in care.

Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to continue the investigation into the above allegations. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPAs toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as facility schedule. Regarding the allegations that licensee is not ensuring that staff are sufficient in numbers, qualifications, and competency to meet residents' needs, staff yell at residents in care and staff are being discouraged from reporting incidents involving residents in care, the investigation revealed the following: Facility schedule indicates Memory Care runs four caregivers and a med tech for 1st and 2nd shift and two caregivers/ one med tech for NOC shift. Seven out of nine staff interviewed state facility staffing levels are good and resident needs are being met. LPA observed an appropriate level of staff working in the memory care on two different occasions. Staff state checking on the residents every 30 minutes to two hours depending on the resident. Nine out of nine staff confirm receiving training. LPA reviewed CONTINUED ON LIC 9099C DATED 11/25/2024. Unsubstantiated select training records and all had documentation of required training hours. Nine out of nine staff interviewed deny caregivers yelling at residents or being abusive in any way. Two residents interviewed deny staff yelling at residents and confirm being treated well. Additional residents in Memory Care were unable to respond to the departments questioning. Facility provided all incident reports requested by the department including those reports for Resident 1 (R1) and R2 outlining any falls that have occurred. Nine out of nine staff deny being told to avoid speaking to the department or not reporting incidents. When conducting interviews with staff, staff was cooperative and communicative in discussions with the department. Based on interviews conducted and records reviewed, LPA is unable to corroborate the allegations. Therefore the allegations are deemed UNSUBSTANTIATED meaning although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to facility representative.the state’s words, verbatim · CDSS document, Nov 23, 2024 · control 18-AS-20240510123439

Allegation investigated: Staff did not prevent resident from pushing another resident

Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to continue the investigation into the above allegation. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the investigation, the department toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as physician reports. Regarding the allegation that staff did not prevent resident from pushing another resident, the investigation revealed the following: On 04/13/2024, Resident 1 (R1) was being escorted back to the resident's room when R2 entered the room and became agitated. R2 pushed R1 and R1 fell and hit the head. R1 was transported to the hospital via 911 and returned with no new findings. Both residents are diagnosed with Dementia and denied the altercation occurred. Staff interviewed confirmed being present when the altercation occurred. Based on interviews conducted and records reviewed, LPA is unable to corroborate the allegation. Therefore the allegation is deemed UNSUBSTANTIATED meaning although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 21, 2024 · control 18-AS-20240415154217

Allegation investigated: Staff are not following food safety protocols. Staff are falsifying medical documentation regarding residents in care. Staff are not reporting incidents involving residents in care. Staff are administering crushed medication(s) to resident(s) in care without physician(s)' permission. Staff are not reassessing residents as necessary.

Licensing Program Analysts (LPAs) Joseph Alejandre and Kimberly Lyman made an unannounced visit to deliver the findings for the complaint investigation for the allegations listed above. LPAs met with Executive Director Vicky Torres and explained the reason for the visit. The investigation into the allegation, staff are not following food safety protocols, revealed the following. LPA toured the kitchen with the Executive Chef. LPA observed the kitchen is clean and organized. LPA observed the refrigerator is kept at 37.0 degrees Fahrenheit and the freezer was at 0.0 degrees Fahrenheit. LPA observed a 2-day perishable and a 7-day non-perishable food supply on hand in the kitchen. The Executive Chef reported that food is delivered 3 times a week and fresh food is always used to prepare all meals. The Executive Chef reported that standard restaurant practices are used, and all food is prepared properly for the safety and enjoyment of the residents. LPA interviewed 4 kitchen staff. 4 out of 4 kitchen staff reported that they always follow kitchen procedures to ensure all food preparation is safe. 4 out of 4 staff reported that only kitchen staff with a food handler’s card are allowed to prepare food. Unsubstantiated 4 out of 4 staff interviewed reported that caregivers will serve trays to residents but are not involved in food preparation. 4 out of 4 caregivers interviewed reported they have served trays to residents and are not involved in the preparation of food. LPA observed breakfast and lunch being served. Food is prepared in the kitchen and brought to the assisted living and memory care. Food is placed in serving warmers and then served to residents by kitchen staff. LPA reviewed facility records and all kitchen staff have valid food handler cards. 6 out of 6 residents interviewed reported that they have no issues with the food and have never been sick because of the food at the facility. LPA did not observe any health and safety concerns during the visit. The facility kitchen was inspected by Riverside County Environmental Services on March 13, 2024 and received a score of 96 out of 100. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Regarding the allegation, staff are falsifying medical documentation regarding residents in care, the investigation revealed the following. LPA reviewed 6 resident files, including physician reports and needs and service plans. LPA did not observe any evidence of records being falsified. LPA observed all 6 files reviewed had a current needs and service plan. LPA interviewed 5 staff members. 5 out of 5 staff members reported that they have never falsified records and have no knowledge of anyone falsifying any records. LPA observed no violations regarding residents’ physician reports or needs and service plans (re-appraisals). LPA reviewed 6 resident medications and medication administration records (MARs). No discrepancies observed. None of the evidence gathered corroborates the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff are not reporting incidents involving residents in care, revealed the following. No specific details were provided about incidents not being reported. LPA reviewed multiple incident reports sent to the Agency. The Executive Director reported that all resident incidents, including falls are reported. 5 out of 5 staff interviewed reported all incidents involving residents are reported to management, reviewed, and sent to the Agency. There is no evidence to corroborate the allegation, therefore the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff are administering crushed medications to residents in care without physicians' permission, revealed the following. A review of resident records shows, 9 residents have physician’s orders for medication to be crushed. LPA interviewed 5 staff members. 5 out of 5 members reported they only crush medication when there is an order from the physician to do so. 5 out of 5 staff members reported that they have never witnessed anyone crushing medication for a resident without an order. 5 out of 5 residents interviewed reported that their medication is not crushed and is administered as prescribed. LPA reviewed 6 resident medications and medication administration records (MARs). No discrepancies observed. None of the evidence gathered corroborates the allegation, therefore the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Regarding the allegation, staff are not reassessing residents as necessary, the investigation revealed the following. LPA interviewed 5 staff members. 5 out of 5 staff members reported that residents are reassessed every 6 months or when there is a change in condition or upon return from a hospital stay. Staff reported the director of nursing completes the assessments every 6 months. LPA reviewed 6 resident files. All 6 residents had a current needs and care plan (re-appraisal). The Executive Director reported that after the needs and care plan is updated they arrange for a meeting with the responsible party to discuss the new care plan and to have it signed. None of the evidence gathered supports the allegation, therefore the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report of the report provided.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 18-AS-20240507140146

Type of visit: Case Management - Other

On 11/21/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver amended complaint findings for complaint control numbers: 18-AS-20231013143500 and 18-AS-20230918160404. LPA met with Executive Director Vicky Torres where LPA explained the purpose of the visit. An exit interview was conducted and a copy of this report was provided to Vicky Torres, Executive Director.the state’s words, verbatim · CDSS document, Nov 21, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with administrator, Vicky Torres. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: The facility licensed with the department is comprised of (2) buildings. Memory care which is a one story building and the assisted living facility is a two story. The facility does have a pool which has a locked gate surrounding it. No fire arms are kept at the facility. The facility is designated as a residential care facility for the elderly serving elderly ages (60) and above. LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 112.7 degrees F.All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. LPA inspected six (6) client rooms and observed the required bed, chair, grab bars for each toilet, and shower used by residents. Resident showers have non-skid mats present. LPA began review of client records. eight (8) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Partial documents were stored in a digital database needing multiple staff to locate and were not provided during a reasonable time frame. LPA waited over an hour to confirm the documents. LPA suggested to look into providing one complete digital file or paper file to be ready for review when needed. Administrator stated that all files will be printed and stored in one file. LPA began review of employee records- nine (9) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 07/24/2025. LPA observed the same issue with personnel files with the facility having multiple staff keeping certain files. Administrator stated she just started earlier this year and will be auditing and updating the files to be accessible much easier and in one location. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen. Medications are centrally stored. There are two locked rooms allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. LPA observed Fire extinguishers to be serviced and within compliance. The facility is conducting emergency disaster/fire drills monthly; last done on 10/04/2024. Based on the information received during this visit today in the areas reviewed, there are no deficiency that are being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809 report was reviewed with administrator Vicky Torres and a copy was provided.the state’s words, verbatim · CDSS document, Nov 20, 2024

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Resident's ceiling is in disrepair Resident's electricity is in disrepair

Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to continue the investigation into the above allegations. LPA s were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPAs toured the facility and interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as facility emails. Regarding the allegations that resident's electricity is in disrepair and resident's ceiling is in disrepair, the investigation revealed the following: Resident 1 (R1) had a leak in the ceiling of the living room of the resident's apartment. Facility documentation indicated an ongoing issue with leaks with the initial leak in October 2021. A new leak occurred in December 2021 and facility documentation shows facility was taking steps to address the leak. Executive Director at time of complaint indicated an issue with water in light switches resulting in the breaker turning off. LPAs observed through documentation that the leak and repair was extensive. LPAs observed repaired ceiling during today's visit. Based on records reviewed and interviews conducted, the allegations are deemed substantiated. Citations are being cited in accordance CONT ON LIC 9099C DATED 11/19/24 Substantiated with the California Code of Regulations (Title 22, Division 6, Chapter 8). Exit interview conducted and a copy of this report as well as appeal rights are being provided.the state’s words, verbatim · CDSS document, Nov 19, 2024 · control 18-AS-20211215084528

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 3, 2024

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 req is not being met as evidenced by: Based on interviews conducted and record review, the Licensee failed to ensure facility was safe and in good repair. Facility had an ongoing issue with ceiling leaks in R1's room. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 19, 2024

Plan of correction: LPA observed the ceiling has been repaired in R1's room. CLEARED DURING VISIT.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Dec 3, 2024

The following space and safety provisions shall apply to all facilities: The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This req is not being met as evidenced by: Based on record review and interviews conducted, Licensee failed to ensure R1's room was safe and healthful. Facility documentation indicates an issue with water being inside the light sockets in R1's room. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 19, 2024

Plan of correction: Licensee to submit a statement of understanding of the regulation and forward proof to LPA by POC due date.

Allegation investigated: Facility staff are not ensuring that resident is adequately fed while in care

Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to continue the investigation into the above allegations. LPA s were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPAs toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as meal tracking form. Regarding the allegation that facility staff are not ensuring that resident is adequately fed while in care, the investigation revealed the following: LPA reviewed meal tracking form during investigation which revealed the resident was on a meal plan. Meal plan indicates Resident 1 (R1) receives three meal trays per day. R1 did not go to the dining room and preferred to eat meals in the room. Two out of two staff indicate with encouragement the resident would come to the dining room. Staff state the resident was being provided meals. Staff indicate assisting residents with television remote controls or whatever else assistance they may need. Based on interviews conducted and records reviewed, LPA is unable to corroborate the allegation. Therefore the allegation is deemed UNSUBSTANTIATED CONT ON LIC 9099C DATED 11/19/24 Unsubstantiated meaning although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Nov 19, 2024 · control 18-AS-20230411105405

Allegation investigated: Facility is not serving meals in a timely manner. Facility is overcooking the residents food. Facility serving food to residents that is not of quality. Facility does not ensure that an adequate amount of food is available to residents.

Licensing Program Analysts (LPAs) Joseph Alejandre and Kimberly Lyman made an unannounced visit to continue the investigation into the allegations listed above. LPAs met with Executive Director Vicky Torres and explained the reason for the visit. LPAs interviewed the Executive Director and staff and residents. LPAs and the Executive Director toured the facility. The investigation into the allegation, facility is not serving meals in a timely manner revealed the following. LPA was at the facility and observed breakfast and lunch being served on November 19, 2024. It was alleged that residents wait up to an hour before being served. LPA observed 12 residents having breakfast. 6 residents interviewed during breakfast reported receiving their food within 10 minutes of ordering. 4 out of 4 staff interviewed reported residents in the dining room in assisted living receive their food within 5 to 15 minutes of ordering. LPA observed 31 residents having lunch. LPA observed that residents were served food within 15 minutes of sitting down. 6 out of 6 residents interviewed during lunch reported that they never had to wait more than 15 minutes for a meal. Unsubstantiated Based on the information gathered during the investigation the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, facility is overcooking residents food, revealed the following. LPA and the Executive Chef toured the kitchen. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the kitchen staff preparing lunch, LPA observed meals being served to residents in the assisted living dining room. 12 out of 12 residents interviewed reported they enjoyed lunch, and it was not overcooked. !2 out of 12 residents interviewed reported they have not been served overcooked food. The Executive Chef reported that standard restaurant practices are used and the quality of the food is checked at each meal and none of the food served to residents is overcooked. 3 out of 3 kitchen staff interviewed reported that none of the food is overcooked. None of the evidence gathered corroborates the allegation, therefore the allegation is deemed, unsubstantiated, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, facility is serving food to residents that is not of qualify, revealed the following. LPA and the Executive Chef toured the kitchen. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the refrigerator and freezer are kept at the required temperature. LPA observed the kitchen staff preparing lunch, LPA observed meals being served to residents in the assisted living dining room. 12 out of 12 residents interviewed reported they enjoyed lunch, and it was not overcooked. 8 out of 12 residents interviewed reported they like the food and have no issues with the food. 4 out of 12 residents reported they would like a bigger selection of food and thought the food could be a little better, but still enjoyed the food. The Executive Chef reported that standard restaurant practices are used, and the quality of the food is checked at each meal and all of the food served to residents is of good quality. 3 out of 3 kitchen staff interviewed reported that the food served is of good quality. The Executive Chef reported that the facility gets the food from a food distribution company and a produce company, deliveries arrive 3 days a week. The Executive Chef reported only quality ingredients are used to prepare the meals. None of the evidence gathered corroborates the allegation, therefore the allegation is deemed, unsubstantiated, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, facility does not ensure that an adequate amount of food is available to residents, revealed the following. LPA observed breakfast and lunch being served to residents. LPA observed kitchen staff preparing lunch for residents. LPA observed in the bistro next to the dining room a counter with ice water and fresh fruit available to residents. The Executive Chef reported that the fresh fruit and water is available from 7 am to 7 pm. The Executive Chef reported that from breakfast time until 7 pm kitchen staff are available and will prepare food for any resident upon request. 3 out of 3 staff interviewed reported that some residents will order food in between scheduled mealtimes but only around once a week. 12 out of 12 residents interviewed reported they are given enough food and have no issues with getting snacks in between meals. LPA observed all meals being served are on a standard 9-inch plate. LPA observed all the meals served at breakfast and lunch had a full plate. For breakfast residents had the choice of eggs prepared any style along with choice of breakfast meat and toast or hot or cold cereal. For lunch residents had a choice of Swiss steak or chicken along with mashed potatoes and vegetables. For lunch a cup of soup or salad was served along with the entrée. Residents have their choice of beverage. None of the evidence gathered corroborates the allegation, therefore the allegation is deemed, unsubstantiated, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Nov 19, 2024 · control 18-AS-20230621124927

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced case management visit in conjunction with complaint visit 18-AS-20211215084528. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the complaint investigation, LPAs reviewed facility documentation and interviewed staff. Interviews conducted and records reviewed indicated R1 remained in the bedroom of the apartment while the living room ceiling was being repaired. Photos show the extent of the damage that occurred in the living room. Interviews conducted show that facility offered to move the resident into another room but responsible party refused due to the room not offering the same safety precautions as the resident's current room. Per physician report dated 09/28/2020, R1 is diagnosed with Mild Cognitive Impairment. Based on the observations made during today's visit, the following citation is being cited per California Code of Regulations (Title 22, Division 6, Chapter 8). Exit interview conducted and a copy of this report as well as appeal rights are being provided.the state’s words, verbatim · CDSS document, Nov 19, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 3, 2024

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This req is not being met as evidenced by: Based on observation, interviews conducted and record review, Licensee failed to ensure R1 was provided safe and healthful accommodations. R1 remained in the resident's room while a substantial repair was being done.the state’s words, verbatim · CDSS document, Nov 19, 2024

Plan of correction: Licensee to submit a statement of understanding of the regulation and forward proof to LPA by POC due date.

Allegation investigated: Personal Rights

On August 14, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to initiate the investigation into the listed allegation pertaining to Personal Rights and met with Business Office Manager and explained the purpose of the visit. During today's visit, LPA toured the facility, along with Nina Guzman and requested and received copies of pertinent documents related to Resident #1(R1). LPA was informed that R1 does not reside at the listed facility but resides at the Independent Community (Manor). Due to Community Care Licensing not having jurisdiction over the listed facility this the allegation has been deemed "UNFOUNDED." Based on interviews, record reviews, and observations the allegation finding has been deemed "Unfounded." An allegation finding of "unfounded," means the allegation was without merit or is false and could not have happened and/or is without a reasonable basis. There were No health and safety concerns observed during today's visit. An exit interview was conducted, and a copy of this report was discussed and provided, along with LIC811- Confidential Names List, to Executive Director, Vicky Torres. Unfoundedthe state’s words, verbatim · CDSS document, Aug 14, 2024 · control 18-AS-20240813130615

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Administrator Lori Spencer who was informed of the purpose of the visit. At the time of the visit the facility has (8) cases of residents who are positive for COVID-19, Personal Protective Equipment (PPE) and precautions were taken during the visit. LPA conducted a tour of the interior and exterior, reviewed facility documents, and observed the following: The facility licensed with the department is comprised of (2) buildings. Memory care which is a one story building and the assisted living facility is a two story. The facility does have a pool which has a locked gate surrounding it. No fire arms are kept at the facility. The facility is designated as a residential care facility for the elderly serving elderly ages (60) and above. Infection Control: LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA observed facility residents in isolation who are positive for COVID-19 with PPE equipment outside their rooms, and meals that are being provided to their rooms. LPA was informed staff are encouraging resident to wear PPE and LPA observed staff wearing PPE while around the residents. The facility has reported the infectious disease to the department, and have a plan on mitigating the spread of infectious diseases. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The facility has carbon monoxide alarms which were located during the time of the visit. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required food supplies to meet resident's needs. Record Review and Resident/Staff Files: LPA reviewed staff files, training, and staff criminal clearance, client files were also reviewed for memory care and assisted living residents. The administrator's file was reviewed which met the department requirements. All required and up to date paperwork. Health Related Services/ Incidental Medical Services: All client medication was locked in a medication room and medications carts. Medication was accounted for and LPA observed staff passing medications and observed the facility has the new cycle of medication for all residents. Centrally stored lists of medications for (5) residents were reviewed. Disaster preparedness: The facility has an emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted 12/22/23. LPA observed all facility exits were clear from obstructions and the facility possess the required evacuation chairs at stairways. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Administrator, Lori Spencer.the state’s words, verbatim · CDSS document, Dec 29, 2023