City Creek Assisted Living

Type of visit: Required - 1 Year

On 08/18/2026, Licensing Program Analyst (LPA) Pang Lee arrived at City Creek Assisted Living, a Residential Care Facility for the Elderly (RCFE), to conduct the required one-year annual inspection. LPA Lee met with Health Services Director (HSD) Katelyn Flores and requested that HSD Flores notify Facility Designated Administrator (FDA) Caleb Summerhays of the Department’s presence at the facility. Brief interviews were conducted with HSD Flores and FDA Summerhays. LPA Lee and HSD Flores toured the physical plant to evaluate compliance with health and safety requirements for residents in care. Areas inspected included, but were not limited to, the lobby, staff conference room, staff offices, medication room, kitchen, dining room, resident bedrooms and bathrooms, resident lounge, laundry room, and outdoor areas. LPA Lee inspected eleven resident rooms and observed that the rooms were equipped with the required furniture and sufficient lighting. A public telephone was available for resident use in the hallway near the dining room. The required postings were observed throughout the facility. The facility thermostat was observed between 70 to 74 degrees Fahrenheit throughout the facility, which is within the required range of 68 to 85 degrees Fahrenheit. Toxins were observed locked and inaccessible to residents. Sharp knives were observed inaccessible to residents. Medications were also observed to be properly secured and inaccessible to residents. Hot water temperatures were measured at the bathroom sinks in five resident rooms and ranged from 105.4 to 110.8 degrees Fahrenheit, which is within the required range of 105 to 120 degrees Fahrenheit. CONTINUED LIC 809-C LPA Lee toured the dining room and observed sufficient seating for residents in care. The dining room was clean and in good repair. LPA Lee toured the kitchen, inspected the walk-in freezer, and reviewed the facility's exhaust hood inspection, which was last completed on 05/21/2026. The facility maintained a sufficient supply of at least seven days of nonperishable foods and two days of perishable foods. Fire extinguishers were observed throughout the facility and were last inspected on 06/19/2026. Smoke and carbon monoxide detectors were observed throughout the facility. Smoke detectors were current and in compliance with fire safety requirements. The outdoor area was inspected and contained furniture available for resident use. Emergency walkways were unobstructed, and fences and gates were observed to be in good condition. The facility was observed to be clean, free of odors, and in good repair. Required furniture and sufficient lighting were observed throughout the facility. LPA Lee reviewed 10 resident files. Records reviewed included, but were not limited to, Admission Agreements, Physician's Reports, Needs and Services Plans, Centrally Stored Medication Records, and ambulatory status documentation. Based on records reviewed it was learned that resident 1 (R1) did not have a TB test in the file, however the R1 does have an appointment scheduled for 08/21/2026 at 2:00 PM. LPA Lee also reviewed 11 staff files. Records reviewed included, but were not limited to, criminal background clearances, First Aid/CPR certifications, health screenings, and initial and ongoing training documentation. The records reviewed were observed to be complete. LPA Lee reviewed the medications of 11 residents and found the medication records and medications to be current and complete. The facility’s first aid kit was also inspected and found to be complete. LPA Lee reviewed the facility's fire/disaster drill records, fire alarm system inspection report, and fire sprinkler system inspection and testing records. The facility conducts fire drills at least quarterly. The last documented fire drill was conducted on 05/24/2026. The fire alarm system was last inspected on 02/11/2026 and the fire sprinkler system was last inspected and tested on 02/11/2026. CONTINUED LIC 809-C Moreover, during today’s visit, LPA Lee followed up on concerns regarding roaches at the facility that were brought to LPA Lee’s attention during the investigation of Complaint Control No. 27-AS-20260608195000. On 06/15/2026, LPA Lee conducted a visit to the facility and toured nine resident rooms. During that visit, LPA Lee did not observe any live roaches or other insects in the resident rooms; however, one dead roach was observed in the hallway. LPA Lee also toured the kitchen and did not observe any live roaches. Multiple sticky pest traps were observed in the kitchen. HSD Flores stated that the facility experienced concerns with roaches in the kitchen during May 2026; however, the issue has since been addressed. HSD Flores stated that the facility contracts with Official Pest Prevention for pest control services. During May 2026, pest control services were conducted weekly and included treatment of the kitchen and placement of traps throughout the area. LPA Lee reviewed the facility's pest control records and confirmed that pest control services have been provided from January 2026 to the present. Records indicated that routine pest control services were generally conducted twice per month, with services increased to weekly during May 2026 and continuing into June 2026 and resuming back to twice per month. During today's inspection, LPA Lee toured resident rooms, bathrooms, the dining room, and the kitchen and did not observe any live roaches in the facility. It was learned that the pest control company provided the facility with a monitoring device to detect and track any pest activity. The following documents were provided to LPA Lee during today’s visit: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (4) LIC 610 Current Emergency Disaster Plan (5) Proof of Current Liability Insurance (6) LIC 500 Current Personnel Report Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Aug 18, 2026

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.

Allegation investigated: Staff hit resident. Staff pushed resident.

On 07/08/2026, Licensing Program Analysts (LPAs) Pang Lee, Reza Jamaly, and Kimberly Kulich conducted an unannounced visit to the facility. Upon arrival, the LPAs met with Health Services Director (HSD) Katelyn Flores and explained the purpose of the visit. The purpose of the visit was to deliver the findings related to the allegations above. At the time of the visit, the facility census was 113. It was alleged that staff hit resident and that staff pushed resident. This investigation consisted of interviews with residents, facility staff, and an outside agency, observations, and a review of facility records. LPA interviewed eight out of nine residents. All eight residents denied being hit or pushed by facility staff, reported having no concerns related to the allegations, and stated that they felt safe living at the facility. During an interview with R1, R1's statements were inconsistent and conflicting, and no clear disclosure was made to support the allegations. CONTINUED LIC 9099-C Unsubstantiated LPA also interviewed six out of six staff members. All staff denied the allegations and stated that they had never witnessed facility staff hit or push any residents in care. An interview with an outside agency (OA) also revealed no concerns regarding the allegations. The OA reported that they had never witnessed facility staff hit or push residents and had not received any reports from residents alleging such conduct. During multiple visits to the facility, LPA Lee did not observe any interactions in which staff hit or pushed residents, nor did any residents report concerns regarding physical abuse by facility staff. A review of facility records identified six incident reports dated between December 29, 2025, through June 7, 2026. None of the reports documented any incident involving staff hitting or pushing resident 1 (R1). Additionally, a review of facility personnel records, Licensing Information System (LIS) Facility Personnel Report Summary and the Guardian Background Check System confirmed that there is no current or former employee by the name of Staff 1 (S1) associated with the facility. Based on the interviews conducted, observations made, and records reviewed, there is insufficient evidence to support the allegation that facility staff hit and pushed residents. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with (HSD) Katelyn Flores and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 27-AS-20260608195000

Allegation investigated: Staff do not meet the residents bathing needs Staff do not respond timely to the residents alerts Staff yell at the residents Staff behavior poses as a risk to the residents Staff do not provide adequate supervision to the residents

On 06/08/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA Lee met with Administrator Caleb Summerhays and Health Servies Director (HSD) Katelyn Flores and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 113. A brief interview was conducted with both Summerhays and Flores. It was alleged that facility staff do not meet residents' bathing needs. The investigation included interviews with staff and residents, observations, and a review of facility records. LPA Lee interviewed 5 out of 5 staff members, all of whom denied the allegation and stated that residents receive assistance with bathing and showers as needed. LPA Lee also interviewed 9 out of 9 residents, all of whom denied the allegation and reported that facility staff provide and assist them with showers. CONTINUED LIC 9099-C Unsubstantiated None of the residents expressed concerns regarding bathing services. During facility visits conducted on 02/05/2026, 03/10/2026, and 04/20/2026, LPA Lee toured the facility and resident bedrooms and did not observe any odors of incontinence or other unpleasant smells. During the visit on 04/20/2026, residents observed in the lobby, outdoor patio, and activity room appeared clean and well-groomed. The nine residents interviewed also appeared clean and appropriately groomed. A review of the facility's shower schedule indicated that residents are scheduled to receive showers at least two to three times per week and additionally as needed. Furthermore, LPA Lee reviewed shower logs for 10 residents from January 2026 through March 2026. The records showed that residents received an average of eight to twelve showers per month. Based on interviews, observations, and records reviewed, LPA Lee was unable to corroborate the allegation that staff do not meet residents' bathing needs. It was alleged that staff do not respond timely to residents' call lights. The investigation included interviews with staff and residents, observations, and a review of facility records. Based on the investigation, it was learned that the facility utilizes a call light system in each resident's room. Residents activate the system by pulling a cord, which illuminates a light outside the resident's room to alert staff to ensure that assistance is needed. The activation also appears on call panels located in the front lobby and at the nurse station. Staff then communicate via walkie-talkie with Resident Aides (RAs) regarding the resident's location and need assistance. LPA Lee interviewed five out of five staff members, all of whom denied the allegation and stated that resident call lights are responded to promptly. Additionally, six out of nine residents interviewed reported that staff generally respond to their call lights within five to ten minutes and expressed no concerns regarding delayed staff response times. During a facility visit conducted on 04/20/2026, LPA Lee observed and tested nine call light response events. Staff response times ranged from one to seven minutes, with an average response time of approximately three minutes. A review of facility records revealed that call light response logs were not available. The Administrator stated that the facility recently implemented a new call light system that remains in a trial phase and has not yet gone live; therefore, historical call log reports were unavailable at the time of the investigation. Based on interviews, observations, and records reviewed, LPA Lee was unable to corroborate the allegation that staff do not respond timely to residents' call lights. CONTINUED LIC 9099-C It was alleged that staff yell at residents and that staff behavior poses a risk to residents in care. The investigation included interviews with staff and residents, as well as facility observations. LPA Lee interviewed 5 out of 5 staff members, all of whom denied the allegation. Staff stated that they do not yell at residents and have not observed other staff members yelling at or behaving inappropriately toward residents. LPA Lee also interviewed 8 out of 9 residents, all of whom denied being yelled at by facility staff and being treated inappropriately. Residents reported that staff are “nice” and that they had no concerns regarding staff behavior. During facility visits conducted on 02/05/2026, 03/10/2026, and 04/20/2026, LPA Lee toured the facility and resident bedrooms and did not observe any staff yelling at residents or engaging in behavior that would place residents at risk. Based on interviews conducted and observations made during the investigation, LPA Lee was unable to corroborate the allegation that staff yell at residents and that staff behavior poses a risk to residents in care. It was alleged that facility staff do not provide adequate supervision to residents. The investigation included interviews with staff and residents, as well as facility observations. LPA Lee interviewed 5 out of 5 staff members, all of whom denied the allegation. Staff stated that personal cell phone use is prohibited during working hours. Staff further explained that Resident Aides (RAs), medication technicians, and management are issued facility cell phones that are used as walkie-talkies to communicate regarding resident needs, call lights, and other operational matters. LPA Lee also interviewed 8 out of 9 residents, all of whom denied the allegation and reported no concerns regarding staff supervision or staff using phones while providing care. During the facility visit conducted on 04/20/2026, LPA Lee observed Resident Aides using facility-issued phones to communicate with other staff members regarding resident call lights activated in Rooms 110 and 115. LPA Lee did not observe staff using personal cell phones while on duty, nor were any residents observed to be neglected or unsupervised as a result of staff phone use. Based on interviews conducted and observations made during the investigation, LPA Lee was unable to corroborate the allegation that facility staff do not provide adequate supervision to residents. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Jun 8, 2026 · control 27-AS-20260310101851

Type of visit: Case Management - Incident

On 05/14/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced at the facility to conduct a case management visit regarding an incident report received by the Department. LPA Lee met with Health Services Director (HSD) Katelyn Flores and explained the purpose of the visit. On 04/09/2026, the Department received an LIC 624 Incident Report regarding an incident that occurred on 04/07/2026 involving Resident 1 (R1)’s medication. LPA Lee reviewed the incident report and learned that R1’s Hydrocodone medication, which had been delivered on 04/02/2026, was missing from the narcotic drawer. The facility conducted an internal investigation regarding the missing medication. Per HSD Flores, the medication was delivered from the pharmacy and hand delivered to Medtech, who signed and acknowledged receipt of the medication. HSD Flores stated that two (2) Medtechs then observed and counted the quantity of the medication and logged it into the medication inventory log. According to the facility’s investigation, there was no documentation indicating that the medication had been destroyed or signed out to family members or physicians. Per the facility’s investigation, it was determined that Staff 1 (S1) may have taken the medication. It was further learned that S1 may have ripped and attempted to shred the medication inventory log and narcotic count sheet. The incident was reported to law enforcement and the resident’s physician, and the police report number was provided to the physician. Per HSD Flores, narcotic medications are inventoried every shift (three times daily). CONTINUED LIC 809-C However, the facility was unaware that the medication was missing because the medication inventory log and narcotic count sheets were also removed and destroyed. The issue was only discovered when another Med-Tech questioned HSD Flores regarding the medication, as the staff member had been present when the medication was delivered on 04/02/2026. This resulted in a lapse in the facility’s narcotic medication auditing process. As a result of this case management visit, the facility was found to be out of compliance with Title 22 regulations. The deficiency is cited on the attached LIC 809-D page. An exit interview was conducted with HSD Flores and copies of the LIC 809 report, LIC 809-D page, and Appeal Rights were provided to the facility representative. Failure to correct the deficiency may result in civil penalties.the state’s words, verbatim · CDSS document, May 14, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 22, 2026

87465(h)(2) Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. R1’s Hydrocodone medication went missing and couldn’t be located. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 14, 2026

Plan of correction: The facility will implement having an electronic narcotic inventory so those medications documents cannot be destroyed and be accounted for. The facility will implement having an electronic narcotic inventory so those medications documents cannot be destroyed and be accounted for. Until the electronics gets implanted the medtechs will provide HSD Flores copies of the CSMDR. A statement of acknowledgement will be provided to LPA Lee by 05/22/2026 at the end of day.

Allegation investigated: Staff steal money from resident Staff are not safeguarding resident's personal belongings

On 03/10/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced at the facility to conduct a complaint investigation. LPA Lee met with Administrator Caleb Summerhays and Health Services Director (HSD) Katelyn Flores explained the purpose of the visit. The census is 115 It was alleged that staff stole money from residents and staff are not safeguarding residents’ personal belongings. The investigation included interviews with staff and residents, observations, and a review of facility records. LPA Lee interviewed 7 of 9 residents, all of whom reported no concerns regarding staff stealing money and not safeguarding residents’ personal belongings. All nine residents confirmed they have a lockable drawer in their rooms; however, not all residents choose to use them. All staff interviewed denied the allegations. During the investigation, it was learned that Resident 1 (R1) discovered their wallet was missing during a doctor’s appointment. CONTINUED LIC 9099-C Unsubstantiated Upon returning to the facility, R1 could not locate the wallet. R1 confirmed that the wallet had not been stored in the lockable drawer and stated they had never previously experienced theft, so did not feel the need to secure it. Moreover, R1 denies that staff 1 (S1) took their wallet and money as R1 didn’t not see S1 taking the items. On 02/05/2026, LPA Lee observed nine resident rooms and confirmed that each room has a lockable drawer, with their own keys to the drawer. Moreover, it was also learned that the facility maintains a master key in case a resident loses theirs so that I can be replaced upon request. A review of the facility’s theft and loss policies and procedures indicated appropriate procedures were in place to address incidents such as R1’s missing property. An inventory sheet documenting residents’ personal belongings is completed upon admission and updated as needed to safeguard items. The facility conducted an internal investigation and assisted R1 in searching their room, including a deep clean, to locate the missing wallet and money. Based on interviews, observations, and record reviews, LPA Lee was unable to corroborate the allegations. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 27-AS-20260203091804

Allegation investigated: Staff do not ensure resident's room is clean and sanitary Facility is malodorous Staff do not ensure resident is capable of operating oxygen equipment

On 02/05/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Health Services Director (HSD) Katelyn Flores and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 112. It was alleged that staff do not ensure resident's room is clean and sanitary and that the facility is malodorous. This investigation consisted of interviews with staff, residents, and the resident’s responsible party (RP), as well as direct observations. LPA Lee interviewed seven of seven residents, all of whom reported no concerns regarding their rooms being unclean and unsanitary, and no concerns regarding malodorous conditions within the facility and stated that their rooms are clean daily. Additionally, Resident 1 (R1) stated that housekeeping staff clean R1’s room daily and reported no concerns. CONTINUED LIC 9099-C Unsubstantiated Interviews with facility staff indicated that housekeeping staff are assigned by resident hall and by shift. Each hall (Hall 1, Hall 2, and Hall 3) has designated housekeeping coverage during the AM and day shift and in addition to a janitor. R1’s responsible party reported no concerns regarding R1’s room being unclean, unsanitary, or malodorous, and stated that R1 at times refuses housekeeping services. During visits conducted on 01/06/2026 and 02/05/2026, LPA Lee toured the facility, including multiple resident rooms, and did not observe any rooms to be unclean, unsanitary, or malodorous. On both visits, LPA Lee observed housekeepers assigned to each resident hall cleaning throughout the facility. During both visits, Room 317, occupied by R1, was observed to be clean and free of malodor. LPA Lee observed two plastic cups and tissues on the resident’s chair. It was learned that R1 prefers that the plastic cups and tissues not be discarded when housekeeping offers to remove them. Based on interviews and observations conducted during the investigation, LPA Lee was unable to corroborate the allegations. It was alleged that the staff do not ensure resident is capable of operating oxygen equipment. This investigation consisted of interviews with staff, the residents, the resident’s responsible party, direct observations, and a review of records. Based on interviews with facility staff, it was reported that the resident is capable of operating their oxygen and CPAP machines. Resident 1 (R1) stated that they know how to operate their oxygen and CPAP machines and reported no concerns regarding the allegation. R1’s responsible party also reported no concerns and stated that R1 is able to operate the oxygen and CPAP machines; however, they reported that R1 at times refuses to use the equipment and described R1 as “non-compliant.” On 01/06/2026, with Health Services Director (HSD) Flores present, R1 demonstrated the use of their oxygen and CPAP machines. R1 independently demonstrated turning the machines on and off and properly placing the oxygen tubing in their nose. Based on R1’s Individual Service Plan, R1 is capable of properly using the CPAP machine but at times declines due to low motivation. R1 also receives oxygen treatment, which is self-managed; however, R1 can occasionally be non-compliant with physician orders. Based on interviews and observations conducted during the investigation, LPA Lee was unable to corroborate the allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Feb 5, 2026 · control 27-AS-20251230132456

Allegation investigated: Facility not meeting resident's needs. Facility food provided to the resident does not meet resident’s needs. Resident fell due to lack of supervision. Facility has insufficient staff to meet residents’ needs. Facility staff did not prevent resident altercations. Resident was physically abused while in care.

On 09/25/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Assistant Living Waiver Program Director (ALWP), Leslie Padilla and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 107. A brief interview conducted with ALWP Padilla. It was alleged that the facility is not meeting resident's needs and that the facility food provided to the resident does not meet resident’s needs. This investigation involved observations, a review of facility records, and interviews with both staff and residents. During a visit on 07/24/2025, LPA observed resident aids (RA) assisting residents with mobility needs, including helping residents get out of bed and to the bathroom. Residents were seen attending meals in the dining room during both breakfast and lunch. CONTINUED LIC 9099-C Unsubstantiated Additionally, some meals were delivered directly to residents' rooms. A follow-up visit was conducted on 09/16/2025. During this visit, LPA toured the facility and observed lunch being served in the dining room. Several residents were assisted in the dining area. Three (RAs) were seen helping residents with feeding, opening food containers, and providing supervision. Two med-techs were observed distributing medications, and kitchen staff were seen delivering meals in and out of the dining room. In total, LPA observed five med-techs and seven resident aides on duty. LPA observed Resident 1 (R1) receiving lunch via room service and being assisted with feeding. On both visits, LPA verified that the facility had a sufficient supply of food: a minimum of two days’ worth of perishable and seven days’ worth of non-perishable food items. According to R1’s care documentation, including progress notes from February 2025 to July 2025, R1 receives meals either in the dining room or through room service and sometimes refuses to eat. It was also learned that (R1) was placed on hospice care on 02/14/2025. Hospice services were provided in coordination with the facility. According to the records reviewed, there were ongoing communication, and three care conferences held involving the resident’s responsible party, hospice, and the facility. The notes confirm that R1 is consistently provided with food and liquids. Interviews were conducted with both residents and staff. All 7 out of 7 residents interviewed stated they had no concerns regarding the staff meeting their needs or the adequacy of the food provided. R1 stated that R1 likes the food being served to R1 and is receiving sufficient food and water and has no complaints. Additionally, 7 out of 7 staff members interviewed denied any allegations of neglect and staff are not meeting resident needs. Based on the observations, record reviews, and interviews conducted, there is insufficient evidence to determine whether the alleged violations occurred. It was alleged that resident fell due to lack of supervision and facility has insufficient staff to meet residents’ needs. This investigation involved observations, a review of facility records, and interviews with both staff and residents. During two facility visits conducted on 07/24/2025 and 09/16/2025, LPA Lee observed residents being assisted with activities of daily living (ADLs). Resident aides (RAs), Med-Techs, and kitchen staff were seen supervising and assisting residents in the dining area during mealtimes. It was learned that the facility is divided into three residential halls and in each hall, there are two resident aides and two Med-Techs to support residents in care. Interviews were conducted with 7 out of 7 residents and 7 out of 7 staff members. All interviewees stated that they had no concerns regarding supervision and insufficient staff to meet the residents’ needs. Based on the observations, record reviews, and interviews, there is insufficient evidence to determine whether the alleged violations occurred. CONTINUED LIC 9099-C It was alleged that facility staff did not prevent resident altercations and that residents were physically abused while in care. This investigation involved a review of records and interviews with facility staff and Resident 1 (R1). According to an incident report dated 11/13/2022, R1 was in the dining room with another resident, Resident 2 (R2). R2 was blocking the pathway, preventing another resident from passing. R1 asked R2 to scoot forward to allow the other residents’ through. When R2 did not respond, R1 pushed R2 backward while R2 was seated in a chair. Facility staff immediately assessed both residents. No injuries were observed for either R1 or R2. Interviews were conducted with 7 out of 7 residents, all of whom stated they had no concerns about staff not preventing resident altercations and feels safe living in the facility. They reported that staff do intervene when altercations occur. Furthermore, all residents interviewed confirmed they had not witnessed any residents being knocked and losing teeth due to altercations. In an interview, R1 stated that R1 does not recall any incident where R1 was knocked out by another resident and had six teeth knocked out. Based on the information obtained and interviews conducted, there is insufficient evidence to determine whether the alleged violations occurred. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. An exit interview was conducted, and a copy of this report were provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 27-AS-20250630162820

Type of visit: Required - 1 Year

On 07/24/2025, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA met with Assisted Living Waiver Program Director Leslie Padilla and explained the purpose of the visit. Administrator Caleb Summerhays was not present during today’s visit. The administrator holds certificate number 7026521740 and will expire on 11/17/2025. The facility is licensed for 121 non-ambulatory residents. There are currently 111 residents who reside at this facility. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room, resident lounge and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. LPA measured the hot water temperature in three residents’ bathroom sink and all three water was measured within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mats were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located throughout the facility in each resident’s hall. LPA observed the facility has a has a public telephone stationed by the kitchen for residents use and the facility has the required posters posted. Continued LIC 809-C The facility thermostat was observed at 72 degrees Fahrenheit. LPA observed toxins located in the maintenance and housekeepers’ room and kept locked and inaccessible to residents. LPA observed sharp knives kept locked in the kitchen drawers and inaccessible to residents. LPA checked medication storage and found medication to be locked away and inaccessible to residents. The LPA reviewed six residents’ medications on hand along with their Medication Administration Records (MARs) and found them to be complete. However, at 1:02 PM, LPA observed a Med-Tech pre-pouring residents’ medications for the afternoon medication pass. During an interview, Med-Tech stated that medications are scheduled to be administered at 2:00 PM. The facility’s first aid kit was inspected and found to contain all required components. Additionally, the LPA tested five residents’ call lights, and staff responded appropriately during the visit. LPA requested resident and staff files for review. A total of nine resident files were reviewed and found to be complete. Of the six staff files reviewed, four were incomplete. Staff 1 (S1) is missing their TB test and First Aid certificate. (S2) is missing their health screening results and 20 hours of continuing education training. (S3) is missing their 20 hours of continuing education training. (S4) is missing their First Aid certificate. The following documents will be email to LPA by 07/29/2025 at the end of day 5:00 PM: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (4) LIC 610 Current Emergency Disaster Plan (5) Proof of Current Liability Insurance (6) LIC 500 Current Personnel Report As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with Leslie and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Jul 24, 2025

Allegation investigated: Staff are not ensuring facility kitchen is clean and sanitized Staff are not following proper food sanitation and safety practices Staff are not meeting residents’ dietary needs Staff are not properly addressing pests in the facility

On 05/05/25 Licensing Program Analysts (LPAs) Pang Lee and Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPAs met with Administrator Caleb Summerhays and Health Services Director Katelyn Flores and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is110. It was alleged that facility staff are not ensuring facility kitchen is clean and sanitized, staff are not following proper food sanitation and safety practices and staff are not properly addressing pests in the facility. The investigation included direct observations, a review of facility records, and interviews with both facility staff and residents. LPA Lee conducted facility inspections on 03/18/25, 04/01/25, and 05/02/25. During these visits, the dining area was consistently observed to be clean and well-maintained. LPA Lee inspected the walk-in freezer, which was operating at the appropriate temperature of 0°F. All opened food items were properly labeled with preparation and expiration dates, and all expiration dates were current. LPA Lee also observed kitchen staff preparing meals while wearing gloves and hairnets. The kitchen area appeared clean and sanitary, with no evidence of pest activity noted during any of the visits. Continued LIC 9099-C Unsubstantiated According to the kitchen cleaning schedule, daily cleaning is conducted, and staff are required to initial the log upon completion. A review of facility records confirmed an active pest control contract with Official Pest Prevention. The facility receives bi-monthly interior and exterior treatments. Invoices reviewed from 01/04/24 to the present detail the services provided, including target pests and treatment dates. Interviews were conducted with 9 out of 9 residents. All residents reported that the dining area is clean and that they have no concerns regarding kitchen or dining room sanitation. All nine residents also confirmed that kitchen staff consistently wear gloves and hairnets when serving food, both in the dining room and during in-room meal deliveries. Seven of the nine residents reported not seeing any roaches, although a few mentioned seeing spiders in their rooms. However, 7 out of 9 residents expressed dissatisfaction with the food quality and felt that their dietary preferences were not being met. Interviews with 5 facility staff members were conducted, and all denied the allegations. It was alleged that staff were not meeting residents’ dietary needs. This investigation consists of observations, interviews with staff and residents and a review of facility records. LPA Lee visited the facility on 03/18/25, 04/01/25, and 05/02/25. During these visits, LPA observed kitchen staff placing dietary slips on meal trays to ensure that residents with special dietary requirements received appropriate meals when being deliver to residents in their room. Additionally, residents with special diets were observed being served first in the dining room. LPA Lee interviewed 7 out of 9 residents, all of whom expressed no concerns regarding the staff’s not meeting dietary needs and stated that they don’t like the food being served to them. Furthermore, all 5 staff members interviewed denied the allegations. Records review revealed that when Med Techs receive diet orders signed by the residents’ physicians, the Med Techs then will complete a dietary communication form and provide it to the kitchen supervisor, who then updates the dietary information on the kitchen board. This board lists all residents with specific dietary needs to ensure that all kitchen staff are aware of the residents’ dietary needs. Moreover, a copy of the diet type report and signed order is also placed in the Health Services Director’s (HSD) box for updating the Point Click Care (PCC) portal. The HSD is responsible for updating the PCC portal with any changes to dietary orders. As an additional measure, kitchen staff follow up with the HSD monthly to confirm the accuracy of dietary order lists and ensure compliance with residents’ dietary requirements. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, May 6, 2025 · control 27-AS-20250317103239

Allegation investigated: Staff/resident pulled residents hair Staff stole residents’ money Staff do not intervene when resident calls another resident name

On 05/05/25 Licensing Program Analysts (LPAs) Pang Lee and Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPAs met with XXXXX and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is110. It was alleged that staff/resident pulled residents hair, staff do not intervene when resident calls another resident name and staff stole residents’ money. The investigation included interviews with staff and residents, as well as a review of facility records. LPA Lee interviewed 8 out of 9 residents who stated they had not witnessed any incidents of staff or residents pulling another resident's hair and reported no concerns in that regard. Additionally, all 9 residents interviewed confirmed that when conflicts arise between residents, staff intervene appropriately, assist with problem-solving, and separate individuals when necessary. 8 out of 9 residents stated they feel safe living in the facility. Continued LIC 9099-C Unsubstantiated Furthermore, none of the 9 residents interviewed reported experiencing or hearing of any incidents involving staff stealing residents' money. Resident #1 (R1) stated they do not keep any money at the facility and didn’t have any money. According to R1's Individual Service Plan (ISP), R1 has a diagnosis of dementia and has expressed concerns about people stealing R1’s cigarettes and money and setting R1 on fire. LPA Lee also interviewed all 5 staff members on duty. All denied the allegations and affirmed that they are trained to intervene in conflicts between residents and to assist with resolving disputes. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, May 6, 2025 · control 27-AS-20250311081533

Allegation investigated: Facility staff did not assist resident with meeting their medical appointments resulting in resident's death

On 05/05/25 Licensing Program Analysts (LPAs) Pang Lee and Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPAs met with Administrator Caleb Summerhays and Health Services Director Katelyn Flores and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is110. It was alleged that facility staff did not assist resident with meeting their medical appointments resulting in resident's death. Throughout the course of the investigation, the Department conducted interviews, reviewed facility documents, and reviewed hospital records. The investigation revealed resident 1 (R1) was receiving dialysis treatment at Davita Dialysis Center. R1 had appointments scheduled for the following dates: 12/07/23, 12/09/23, and 12/12/23. A records reviewed indicated that R1 missed all three of the appointments. Per R1’s Certificate of Death, R1 died on 12/12/23 at 2134 hours. Continued LIC 9099-C Unsubstantiated R1’s immediate cause of death is noted as “end stage kidney disease” and “type 2 diabetes.” The duration of the end stage kidney disease was noted as six months. The duration of the type 2 diabetes was noted as years. R1’s Primary Care Physician (PCP) was not able to say for certain if R1’s missed appointments caused R1’s death or contributed to R1’s death. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. In interviews with Administrator Caleb Summerhays and Resident Care Coordinator Leslie, staff acknowledged that R1’s responsible party had not been informed of the resident’s refusal to attend dialysis or of the missed appointments. It was also learned that the facility did not notify the family about the resident’s change in condition. A review of the records revealed that there was no documentation of any communication with R1’s family regarding the resident’s change in condition, refusal of dialysis, and the missed appointments. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Tasha and Melissa and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, May 6, 2025 · control 27-AS-20241118154836

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: May 16, 2025

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… This requirement was not met as evidenced by Based on interviews and records review, facility staff admitted that R1’s change in condition was not communicated to R1’s responsible party and documented, this poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Administrator shall submit plan to ensure the responsible party is notified of change in condition in a timely manner. An In-Service Training shall be conducted for all direct care staff which addresses the procedures put in place to ensure that resident’s responsible party are notified of the residents change in condition. A copy of signatures of staff attending training and an outline of training shall be submitted to CCL by POC date 05/16/25 end of day 5:00 PM.

Type of visit: Case Management - Deficiencies

On 05/05/25 Licensing Program Analysts (LPAs) Pang Lee and Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPAs met with Administrator Caleb Summerhays and Health Service Director Katelyn Flores and explained the purpose of the visit. The purpose of the visit is to follow up on deficiency learned during complaint investigation control number # 27-AS-20241118154836. The current census is110. Through the complaint investigation, it was learned that Resident 1 (R1) was undergoing dialysis treatment at Davita Dialysis Center. R1 had scheduled dialysis appointments on the following dates: 12/07/23; 12/09/23; and 12/12/23. All three appointments were missed. According to facility protocol, if a resident refuses to attend their third dialysis appointment, the Medication Technician (Med Tech) is required to call 911 to have the resident transported to the hospital. Facility staff did not follow this protocol when R1 missed more than two dialysis sessions. Resident Care Coordinator Leslie Padilla and Nurse Melina Dearing both confirmed that Med Tech (PD) was instructed to send R1 to the hospital on December 12, 2023. However, Med-tech did not do so; therefore, the facility did not seek timely medical attention to R1. The following deficiency were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiency can be found on the 809-D page. An exit interview was conducted, and a copy of the 809 report, 809-D page, and appeal rights were given to the facility.the state’s words, verbatim · CDSS document, May 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: May 16, 2025

Amend Report to Type A and change the reaseon for the citation. 87464 (d) Basic Services 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 was not met as evidenced by: Based on interview and record reviews when R1 missed 3 dialysis treatment the facility did not seek medical treatment in a timely manner for R1, which posed an immedicate risk to R1 in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: An In-Service Training shall be conducted for all direct care staff which addresses the procedures put in place regarding basic service to include care, supervision and ensuring that residents are getting medical attention timely. A copy of signatures of staff attending training and an outline of training shall be submitted to CCL by POC date 05/16/25 end of day 5:00 PM.

Allegation investigated: Staff did not allow resident to participate in planning their own care Facility staff do not maintain facility free of odors from incontinence

On 05/02/25 Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Caleb Summerhays and Health Services Director Katelyn Flores and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 112. It was alleged that staff did not allow resident to participate in planning their own care. The investigation included interviews with staff, residents, and external agencies, as well as a review of relevant records. LPA Lee interviewed 6 out of 9 residents, all of whom reported no concerns regarding their involvement in care planning. Additionally, LPA Lee interviewed all 4 staff members, who denied the allegation, and both external agency representatives, who also denied the claim. Resident 1 (R1) stated in an interview that the facility does allow R1 to participate in R1’s care planning. Continued LIC 9099-C Unsubstantiated R1 also confirmed that R1 was not aware of any attempted visit from the day program on 03/24/25. According to R1’s Admission Agreement (page 2, under House Rules/Facility Policies), “visiting hours are open and all residents are encouraged to accept visitors at a time that works best for their individual needs.” Additionally, the facility’s Plan of Operation (page 15, under Personal Rights) states that residents have the right “to have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.” Therefore, the facility did not notify R1 of their visitors on 03 24/5, in violation of both the Admission Agreement and the facility’s Plan of Operation. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Health Services Director Flores and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. Both outside agency representatives confirmed that R1 is actively involved in R1’s care plan and that regular meetings are held with R1 and facility staff. R1 expressed no concerns. A review of R1’s Patient's Rights form dated on 09/10/24 also confirmed this, showing signatures from R1, R1's case manager, placement agency and administrator Caleb. Moreover, on 03/05/25, the facility sent an email to the day program (DP) informing them that R1 would no longer be utilizing their services and that R1 could be discharged from the program. According to a service note from the external agency, R1 verbally expressed that R1 no longer wished to attend day program. This decision was coordinated with Staff 1 (S1) from Social Services at City Creek Assisted Living, and the discontinuation of services was discussed. Additionally, it was discovered that R1 wrote and signed a letter dated 03/14/25, stating, that R1 doesn't want to go to day program. It was alleged that facility staff do not maintain the facility free of odors from incontinence. The investigation included observations, as well as interviews with staff, residents, and two external agency representatives. On 04/01/25, LPA Lee conducted an unannounced visit and toured the facility, including Halls 1, 2, and 3. During the visit, housekeepers were observed cleaning residents’ rooms. LPA Lee inspected 10 resident rooms and did not observe any malodors or incontinence related odors. During today’s visit, 05/01/25, LPA Lee toured the facility with housekeeping supervisor Shante Reyes and no incontinence related odors were observed. Moreover, LPA Lee observed Housekeepers throughout the facility cleaning. LPA Lee interviewed 6 of 9 residents, all of whom reported no concerns regarding facility cleanliness or odors. All 4 interviewed staff members denied the allegation. It was learned that there are two housekeepers assigned in each hall, three halls total during the shift of 7:00 am to 3:30 PM from Monday to Saturday and an additional janitor from 2:00 PM to 6:00 PM, Monday to Friday to clean residents’ rooms and the facility throughout the day. Additionally, two external agency representatives reported having no concerns and confirmed they had not witnessed any odor issues related to incontinence during their visits. Based on information and interview gather there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the investigation revealed the preponderance of evidence standards have not been met. The above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. ________________________________________________________________the state’s words, verbatim · CDSS document, May 2, 2025 · control 27-AS-20250324145954

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 9, 2025

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. This requirement was not met as evidence by: Based on interviews and records review the facility did not notify R1 of their visitors on March 24, 2025, in violation of both the Admission Agreement and the facility’s Plan of Operation. This posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: The Administrator agrees to provide training to facility staff on Personal Rights, specifically focusing on residents' rights related to visitation. The Administrator will also provide LPA Lee with a staff training sign-in sheet, along with copies of the training materials used. Additionally, the Administrator will review the applicable regulation and submit to LPA Lee a signed statement acknowledging that they have read and understood the cited regulation. The Plan of Correction (POC) is due to LPA Lee by May 16, 2025, no later than 5:00 PM.

Allegation investigated: Facility staff does not ensure facility is kept in clean sanitary conditions at all times.

Licensing Program Analyst (LPA) Vincent Moleski and Administrative Assistant Nicholas Morisi arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with Health Services Director Katelyn Flores and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed 13 residents (R1-R13) and 10 staff members (S1-S10). LPA Moleski inspected all common areas in the facility, the kitchen and dining areas, and 13 residents’ rooms (R1-R13). Common areas and resident rooms were generally kept in clean and sanitary conditions, with no obvious hazards to health or safety. All residents interviewed reported that they were satisfied with the cleanliness of the facility, and voiced no significant concerns regarding housekeeping or other sanitation measures. [continued on 9099-C] Substantiated In an interview, S3 said that on weekends, due to limited housekeeping staff, the floors and hallways get “kind of gross.” S6 also said there are not enough weekend housekeepers, although did not voice significant concerns with cleanliness in common areas or resident rooms. S6 said sometimes care staff have to wait to have housekeepers address issues on weekends. S6 said the kitchen, however, is not clean or hygienic. The facility housekeeping supervisor (S2) said that there are six housekeepers on duty during weekday morning shifts, plus a janitor. S2 said that there are three housekeepers on duty on weekends due to staff turnover, and they are actively hiring for these shifts. S9 said that housekeeping staff is “sometimes shorthanded,” but voiced no significant concerns regarding cleanliness. Other staff members interviewed did not have significant concerns regarding the cleanliness of resident rooms or common areas. LPA Moleski toured this facility on 1/24/25. During an inspection of the facility’s kitchen, LPA Moleski observed that it was not kept in clean and sanitary conditions. LPA Moleski observed a variety of food materials dried and encrusted on a stovetop and a nearby countertop, including many strands of various kinds of pasta and other leftover food detritus. LPA Moleski observed grease stains on the stove and on the nearby countertop. LPA Moleski observed a large basin left on the stove, which was not in use, containing leftover grease and food debris. Adjacent walls and appliances had splattered grease stains on them. LPA Moleski observed various pieces of food debris scattered on the floor in the kitchen, stuck in floor drains, beneath appliances, on countertops, et cetera. LPA Moleski photographed these observations. LPA Pang Lee visited this facility four days after LPA Moleski's visit and photographed the exact same dried pasta and other food debris in food preparation areas. In an interview, the facility’s dining director (S7) said that kitchen cleanliness was “not up to standards” at the time of LPA Moleski’s initial visit, and that “some things were not getting done.” S7 said they had been working to correct the issues observed, and had drafted a cleaning task sheet for kitchen staff to ensure that the kitchen was kept clean. S7 provided LPA Moleski with a copy of this task sheet. The department has determined the following as it relates to the allegation that the facility’s staff does not ensure the facility is kept in clean sanitary conditions at all times: [continued on 9099-C] Based on interviews and observation, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Section 87303(a). An exit interview was held with Flores. Appeal rights and a copy of this report were left with Flores. R13 said that pest control personnel had previously sprayed in their room, around the beginning of the year. No staff members interviewed were aware of any issue with cockroaches in R13’s room. In interviews, multiple staff members said that there was a problem with cockroaches in R1’s room when they moved in, because they brought cockroaches into the facility when they moved in. These staff interviews suggested that cockroaches also spread from R1’s room into the nearby staff break room. However, all staff members interviewed said that treatments were done in a timely manner, and that there had been no further issues with cockroaches afterward. In an interview, R1 said that they had not had any issues with cockroaches. LPA Moleski reviewed six months' worth of pest control records for this facility, dated between 07/24 and 01/25. A report dated 7/8/24 indicated that there were German cockroaches in the break room. The break room, kitchen, interior baseboards and exterior foundations were treated using chemical pesticide. A report dated 7/30 indicated that treatment was performed in the laundry room, break room, dumpster area, and dining room were treated. A reported dated 8/29 indicated the kitchen, laundry room, and entire exterior were treated. The report indicated there were "no issues seen" and that there was "low rodent activity." A report dated 9/27 indicated that the facility exterior, exterior foundations, interior, kitchen, bathrooms, and break rooms were treated, and that bait stations were checked. A report dated 10/24 indicated that the kitchen, laundry room, and break room were treated. A report dated 10/28 indicated that the kitchen received "full roach treatment," and baits were added. The author of the report wrote that they "saw no roaches come out while treating kitchen." The dining room and baseboards were sprayed as well, according to the report. A report dated 11/21 indicated that the exterior and exterior foundations were treated. A report dated 12/10 indicated that the exterior, exterior foundations, and the interior baseboards were treated. The author of the report indicated service was done at a bait station. A report dated 12/19 indicated that the interior and interior baseboards were treated. The report also stated that there was a "full roach treatment" in rooms 103, 105, and 107, with liquid and aerosol chemical treatments and bait for roaches. A report dated 12/31 indicated that the interior and interior baseboards were treated, along with the laundry room, the kitchen, and bedrooms 107 and 105. A report dated 1/15 indicated that the exterior, exterior foundations, and interior baseboards were treated. [continued on 9099-C] The department has determined the following as it relates to the allegation that the facility’s staff does not ensure the facility is kept free of insects: Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which 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. No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Flores.the state’s words, verbatim · CDSS document, Mar 13, 2025 · control 27-AS-20250115102932

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Mar 14, 2025

“The facility shall be clean … [and] … sanitary … at all times…” This requirement was not met as evidenced by: Based on interviews and observation, facility kitchen areas were not kept in a clean or sanitary condition, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Mar 13, 2025

Plan of correction: Licensee has drafted a cleaning checklist to correct the deficiency observed and to maintain kitchen cleanliness in the future. This POC will be cleared. vincent.moleski@dss.ca.gov

Allegation investigated: Facility staff are not providing good quality food to residents in care.

On 02/04/25 at 12:12 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Resident Care Coordinator Leslie Padilla and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 116. It was alleged that facility staff are not providing good quality food to residents in care. The investigation included staff and resident interviews, a review of records, and on-site observations. LPA Lee interviewed 5 out of 7 residents, who raised concerns about the food quality. They mentioned that portion sizes were too small, the food was often served cold, and it didn’t meet their special dietary needs. In an interview with Administrator Caleb Summerhays, it was revealed that facility staff 1 (S1) received a written warning for not following residents’ special dietary orders. Continued LIC 9099-C Substantiated According to the records, S1 had indeed received a corrective/disciplinary action for not following the special diet guidelines provided by residents' physicians and the City Creek clinical team and for not providing an adequate portion of food to residents in care. Additionally, it was learned that the facility lacked a full-time employee with qualified training since the facility does have a nutritionist, dietitian, nor a consultation with a qualified professional. During the facility's kitchen inspection on 12/17/24, LPA Lee observed multiple issues. In the walk-in freezer, there were containers that lacked lids and were sealed with saran wrap. These containers also did not have any labels indicating the date the food was placed inside or an expiration date. The items observed included: · A commercial food storage container with bacon bites. · A commercial food storage container with three types of cheese. · 5 pounds of sour cream. When questioned about the protocol, S1 confirmed that food should be stored in labeled containers with lids, not saran wrap, and should include the date the food was stored. During a follow-up visit on 01/29/25, LPA Lee conducted another inspection of the walk-in freezer and found a bucket tray labeled with the date 12/14/24. The bucket contained several unopened packages of boiled eggs with expiration dates of 03/25/25. Also present were bags of bacon bites and ham bites in Ziploc bags, but they lacked open dates or expiration dates. Furthermore, LPA Lee observed unsanitary conditions in the kitchen, including cooking stoves and ovens covered with grime, grease, and food debris. The sink was filled with a dirty pot and appeared unsanitary. Additionally, there was a bag of dirty rags on the floor. Based on information and interview gather there is a preponderance of evidence to prove the alleged violations occurred, as a result the allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of this LIC 9099, LIC 9099-D page and appeal rights was provided to facility.the state’s words, verbatim · CDSS document, Feb 4, 2025 · control 27-AS-20241213111216

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(a) · Plan of correction due date: Feb 12, 2025

87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared, and served in a safe and healthful manner. This requirement was not met as evidence by: Based on interviews, observations and records review, the facility staff did not provide good quality of food to residents in care. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 4, 2025

Plan of correction: Administrator agrees to conduct outside training from a third party for general food service training for all staff, by POC Date 02/19/25. Administrator agrees to email training materials used and sign in and out sheet to LPA Lee at pang.lee@dss.ca.gov by POC end of day 5:00 PM.

Allegation investigated: Facility staff not responding to residents' call lights Facility staff not meeting incontinence care needs of residents. Facility staff not properly addressing scabies in the facility.

On 02/04/25 at 12:12 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Resident Care Coordinator Leslie Padilla and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 116. It was alleged that facility staff not responding to residents' call lights in a timely manner. The investigation included interviews with staff and residents, a review of records, and on-site observations. LPA Lee interviewed 6 out of 8 residents, who expressed concerns about staff not promptly responding to their call lights. Residents reported that it often takes between 30 minutes to an hour for staff to respond, or sometimes there is no response at all. Interviews with facility staff revealed that each hall is assigned one resident aide (RA), and the facility has three halls (Hall 1, Hall 2, and Hall 3). Continued LIC 9099-C Substantiated Residents activate the call system by pulling a string in their room, which lights up an indicator outside the room to alert staff that assistance is needed. 4 out of 6 staff members admitted that the facility’s call system is outdated and inefficient, as it relies solely on visual signals rather than sound. This means that if an RA is assisting another resident in their room, the resident who needs help must wait until the RA is available or if another staff member notices the light. Based on records review the facility does not have a system in place to track the call system's performance, other than periodic inspections to ensure it is operational. During the investigation, LPA Lee observed two separate incidents where residents were unable to get timely assistance. On 12/03/24 at 1:46 PM, LPA Lee observed a resident in room 309 needing help, but no RA attended to them until LPA Lee approached Assistant Administrator Katelyn. Upon inspecting the call light, LPA Lee discovered it was not in good working order. A similar issue was observed on 01/29/25, when a resident in room 206 required assistance, but their call light was also found to be malfunctioning. LPA Lee raised these concerns with Administrator Caleb Summerhays and Assistant Administrator Katelyn Flores, specifically addressing the malfunctioning call lights and the lack of response when the lights are not functioning properly. It was alleged that staff were not meeting the incontinence care needs of residents. The investigation included interviews with staff and residents, as well as observations. LPA Lee interviewed 5 out of 8 residents, all of whom expressed concerns about the long wait times for incontinence care from resident aide (RA) staff. Residents mentioned using the call system to request assistance, but RA staff would take 30 minutes to an hour, or sometimes not respond at all, before providing help. During an observation on 01/29/25, LPA Lee noticed a strong urine odor in resident room 106 and a mild urine odor in resident room 213. In an interview with facility staff, it was revealed that the resident in room 106 requires assistance with incontinence care and tends not to use the urinal. LPA Lee recommended that the resident in room 106 may need additional oversight, such as reminders for incontinence care and more frequent cleaning in the room to reduce the strong urine odor. It was alleged that the facility staff did not properly address scabies in the facility. The investigation involved interviews with staff and residents, as well as a review of facility records. LPA Lee interviewed 4 out of 8 residents, who either raised concerns about scabies in the facility or mentioned hearing about other residents having scabies. Continued LIC 9099-C LPA Lee also spoke with facility staff, who stated that it is unclear if there are any cases of scabies since the residents that was sent to the ER for itchiness did not undergo a scratch or skin test and that it may be scabies. Facility staff did confirm that scabies policies and procedures had been implemented. However, it was discovered that while some residents were placed under isolation precautions, they were not actually isolated. Instead, they continued to share rooms with roommates, potentially exposing others to scabies. According to an incident report dated 11/21/24, one resident was sent to the ER for itchiness and later returned to the facility with treatment for scabies. Additionally, incident reports from 01/08/25 and 01/12/25 indicated that three other residents were also sent to the ER for scabies treatment or possible exposure. The investigation revealed that the facility did not follow the physician's orders for timely follow-up after ER visits. For example, Resident 1 (R1) was supposed to follow up with their primary care provider (PCP) within 5 days, but the facility did so 7 days later. Resident 2 (R2) was supposed to follow up within 3 days but was not seen by a PCP until 5 days later. The facility’s City Creek Scabies Policy, dated 12/01/23, specifies in Procedure #3 that physicians' treatment protocols should be followed, but the facility did not follow-up with PCP in a timely manner. Additionally, the policy on page 358 under Treatment Procedure (c.i.) states that "Contact Precautions should be initiated until 24 hours after the first treatment," yet the residents were not placed under isolation precautions and continued to share rooms with roommates. It was also learned that the facility didn’t consult with local health department to report and possible exposure of scabies in the facility. Based on information and interview gather there is a preponderance of evidence to prove the alleged violations occurred, as a result the allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of this LIC 9099, LIC 9099-D page and appeal rights was provided to facility.the state’s words, verbatim · CDSS document, Feb 4, 2025 · control 27-AS-20241126134828

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 12, 2025

87468.1(a)(2) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all the following personal rights: (2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement was not met as evidence by: Based on interviews and observation, the facility staff did not respond to residents call lights where two residents call lights was in despair and resident was waiting to be assisted. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 4, 2025

Plan of correction: Administrator agrees to conduct outside training from a third party for personal rights training for all staff, by POC Date 02/12/25. Administrator agrees to email training materials used and sign in and out sheet to LPA Lee at pang.lee@dss.ca.gov by POC end of day 5:00 PM. Administrator will also conduct call lights inspections and provided reports to LPA Lee

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Feb 12, 2025

87625(b)(3) 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 was not met as evidence by: Based on interviews and observation, the facility staff did not meet incontinence needs of the residents based on interviews and where two residents’ room had a strong and mild urine odor. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 4, 2025

Plan of correction: Administrator agrees to conduct outside training from a third party for Managed Incontinence training for all staff, by POC Date 02/12/25. Administrator agrees to email training materials used and sign in and out sheet to LPA Lee at pang.lee@dss.ca.gov by POC end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(b)(3) · Plan of correction due date: Feb 12, 2025

87470(b)(3) Infection Control Requirements (b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (3) There shall be separation and care of residents whose illness requires separation, including quarantine or isolation, from others. This requirement was not met as evidence by: Based on interviews and records review, the facility staff did not properly address scabies in the facility where 4 resident was sent out to ER for scabies and returned to the facility without being isolated by other residents as well as not notifying public health. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 4, 2025

Plan of correction: Administrator agrees to conduct outside training from a third party for Managed Incontinence training for all staff, by POC Date 02/12/25. Administrator agrees to email training materials used and sign in and out sheet to LPA Lee at pang.lee@dss.ca.gov by POC end of day 5:00 PM.

Allegation investigated: Staff violated resident's privacy by posting videos of resident on social media

On 01/30/25 at 8:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Caleb Summerhays and Administrator Assistant Katelyn Flores and explained the purpose of the visit. The purpose of this visit is to investigate and deliver complaint finding for the allegation above. The current census is 116. A brief interview was conducted with administrator. It was alleged that staff violated residents' privacy by posting videos of residents on social media. The investigation involved staff interviews and a review of records. During the investigation, LPA Lee spoke with Administrator Caleb who acknowledged the allegation and confirmed its accuracy. He further explained that disciplinary measures had been taken, including the termination of Staff 1 (S1). A review of records and photos showed that S1 had posted five videos/photos of residents on social media, revealing both their identities and personal behaviors. Continued LIC 9099-C Substantiated As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with administrator Caleb and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 27-AS-20250127084201

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Feb 5, 2025

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. This requirement was not met as evidence by: Based on interviews and records review facility staff violated residents’ privacy by posting videos of multiple residents on social media. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Administrator will conduct a Personal Rights of Resident in Facility in-service training from an outside vendor. Administrator will email LPA Lee the date of the in-service training by 02/03/25 end of day. Once training is completed Administrator will also email LPA Lee materials outside vendor used for the training, staff sign in sheets and a statement of acknowledgement of reviewing and understanding the regulation cited.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Pang Lee arrived at facility unannounced to conduct a quarterly visit on 01/30/25, LPA Lee met with administrator Caleb Summerhays and administrator assistant Katelyn Flores and explained the purpose of the visit. The purpose of today’s visit was to conduct a quarterly inspection. LPA toured the facility, including the lobby, dining area, hallways, resident lounge, and the designated outdoor smoking area. Multiple residents’ rooms were also inspected. Furniture throughout the facility, including those intended for residents’ use, was found to be in good repair. Toxins were inaccessible to residents. The facility's indoor temperature was 73°F. During tour of the facility inspections, LPA did not observe any roaches or pests in the residents' rooms and facility. However, LPA noted a strong urine odor in resident room 106 and a mild urine odor in room 213. LPA also observed a resident in room 206 seeking assistance, and it was learned that the call light in that room was not in good repair. In the kitchen, LPA Lee observed the cooking stove and oven to be covered with grime, grease, and food debris. The sink had a dirty pot and appeared unsanitary. A bag of dirty rags was found on the floor. LPA observed there was a sufficient supply of perishable (2-day) and non-perishable (7-day) food. The carbon monoxide detector in the kitchen was in good repair. LPA reviewed the medications for three residents in (Med Charts 1, 2, and 3) and found no discrepancies. Additionally, LPA reviewed 9 facility staff files, and First Aid/CPR certifications were current. LPA Lee followed up with the following: · Facility resident pressure injuries (none at this time) · Update of Facility staff roles, duties, and responsibilities (document was provided to LPA Lee) · Pharmacy addition for filling resident prescriptions (Facility is using Omnicare) · Staff Files (9 staff has current CPR) · Wander Guard System (observed 8 residents wearing wander guard on wrist) As a result of this quarterly visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies will not be cited during this visit; however, deficiencies will be addressed and cited on complaint control number # 27-AS-20250115102932 and complaint control number # 27-AS-20241126134828. An exit interview was conducted, and a copy of the LIC 809 reports was provided to administrator.the state’s words, verbatim · CDSS document, Jan 29, 2025

Allegation investigated: Staff did not assist resident with obtaining medical care. Staff are not addressing a scabies outbreak.

On 09/17/2024 at 2:30 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Caleb Summerhays and Nurse Mel Dearing and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 119. A brief interview was conducted with administrator. Allegation: Staff did not assist resident with obtaining medical care. It was alleged that staff did not assist resident with obtaining medical care. This investigation consisted of records reviewed, interviews with staff and residents. Based on resident 1 (R1)’s Individual Service Plan (ISP) dated on 04/10/2024, resident refuses care often, and caregiver have to reapproach (R1) throughout the day base on his/her mood. Moreover (R1)’s ISP does not indicate that (R1) has any on going issue with maggots oh his or her feet or any open sores. (R1)’s ISP also stated that (R1) refuses showers and only want bed bath and that care staff is able to transfer (R1) to the shower chair; however, (R1) refuses and that care staff does their best when doing bed baths. Continued LIC 9099-C Unsubstantiated (R1)’s LIC 602 Physician’s report dated on 03/05/2024 indicated that (R1) has a history of skin condition/breakdown. Based on (R1)’s Home Health Care Notes, it was learned that (R1) had home health services on 11/02/2023 for venous stasis ulcer. Records also indicated that (R1) was being seen by a nurse from 08/01/2023 to 11/29/2023 for wound care twice a week. (R1) was discharge from home health on 12/06/2023 since (R1) did not have any more skin issues. On 02/09/2024, (R1) resident was opened to nursing services for wound on buttocks with stage 2. On 02/20/2024 (R1) as was closed to home health services as it the wound was healed and that there is no open area or any wounds. LPA Lee also interviewed out of 7out of 7 residents who have no concern with staff not assisting resident with obtaining medical care. Moreover, (R1) denied the allegation and has no concern that staff are not obtaining medical care to (R1). LPA Lee also interviewed 5 out of 5 facility staff who denied the allegations. Allegation: Staff are not addressing a scabies outbreak. It was alleged that Staff are not addressing a scabies outbreak. This investigation consisted of records reviewed, interviews with staff and residents in care. Based on records reviewed (R2) has eczema and sent out to the hospital on 06/14/2024 due (R2) being itchiness and was prescribed Triamcinolone Acetonide. It was also learned that (R3) was seen on 05/10/2024 by a Dermatology Clinic for a widespread eczema like rash and was prescribed Triameinolone ointment. LPA Lee also interviewed 7out of 7 residents who have no concern with staff not addressing a scabies outbreak. Moreover, (R1) denied the allegation and has no concern. LPA Lee also interviewed 5 out of 5 facility staff who denied the allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. A copy of this report was provided, along with Appeal Rights and the LIC 811, the Confidential Names List. Exit interview. It was learned that (R1) had the wheelchair zip tie to keep the arm rest from folding up. Furthermore, (R1)’s medical bed does not crank up to a standing position for caregivers to give (R1) a bed bath. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Sep 17, 2024 · control 27-AS-20240726162242

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Sep 24, 2024

87307(d)(2) Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidence by: Based on records review and observation the facility staff did not ensure that (R1) assistive equipment needs are in good repair. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: During 07/29/24 facility visit, the maintenance staff was able to fix (R1)’s transfer pole and have requested for a new wheelchair for (R1). (R1)’s bed will also be replaced. During today’s visit. LPA Lee observed (R1) had a new bed and wheelchair. POC will be cleared today’s visit.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a health and safety case management visit. The facility is on quarterly visits due to non-compliance concerns discussed during an office meeting on 11/01/2023. LPA met with Administrator Celeb Summerhays and Resident Care Coordinator Leslie Padilla and explained the purpose of the visit. The census is 119. LPA Lee and Leslie toured the physical plant to ensure compliance with Title 22 regulations. LPA observed 11 resident bedrooms, 11 resident bathrooms, lobby area, staff offices, designated smoking area, kitchen, laundry room, activity room, Physical Therapy room and the medication room. LPA Lee observed resident bedrooms to have the necessary furniture and furnishings. Bedrooms were equipped with a bed, chair, dresser, and closet space. Bathrooms handrails and non-skid mats are in good repair. Fire extinguishers were up to date and fully charge. Kitchen hood is also up to date. No emergency exits were obstructed. LPA reviewed food supply to ensure that the facility had a 2-day perishable and 7-day nonperishable food supply. Knives were observed to be locked and made inaccessible. LPA observed laundry room where it was observed that detergent, laundry room and all cleaning supplies were locked and made inaccessible at this time. LPA requested to review 7 resident files and 4 staff files. Staff files and resident files were observed to be current with up-to-date files. During today's visit, LPA Lee also review Med-Tech chart #1 and reviewed 7 resident's medications and along with the residents MAR logs and it was accurate and complete. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed. Citation for resident bathroom urine odor was cited during 08/29/2024 annual facility inspection. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 17, 2024

Allegation investigated: Residents consumed illegal drugs (Fentanyl) while in care.

On 08/23/2024 at 10:03 AM, Licensing Program Analysts (LPAs) Pang Lee and Holly Williams arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Caleb Summerhays and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 117. A brief interview with conducted with the administrator. Allegation: Residents consumed illegal drugs (Fentanyl) while in care It was alleged that residents consumed illegal drugs (Fentanyl) while in care. This investigation consisted of records reviewed, interviews with staffs and resident. Based on the facility’s medication list, the facility did not have any residents prescribed Fentanyl during August of 2023. It was also learned that if a resident is prescribed Fentanyl, it is typically prescribed via a “patch” which the resident places on their shoulder. The patch slowly releases the Fentanyl to aid in pain management. Continued LIC 9099-C Unfounded Based on interview, multiple facility staff interviewed denied ever giving R1 Fentanyl. Moreover, R1 denied the facility staff ever giving R1 Fentanyl. R1 denied knowing taking Fentanyl. R1 admitted to smoking Marijuana at the facility. R1 smokes outside in a designated area specifically for smoking Marijuana. R1 stated the day R1 went to the hospital R1 met a “friend” who gave R1 a “baggie” full of Marijuana. R1 stated that R1 believes the baggie the friend gave R1 might have been “laced” with Fentanyl and that is why R1 tested positive at the hospital. This agency has investigated the complaint alleging " residents consumed illegal drugs (Fentanyl) while in care". We have found that the allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to the facility. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. A copy of this report was provided alone with the LIC 811, the Confidential Names List. Exit interview. R2 returned to the facility and the same treatment was continued which initially worked but again ultimately the rash got worse. R2 was sent to UC Davis again on 07/09/2023 and then discharged back to the facility. On 07/15/2023, R2 was sent to UC Davis again for the rash. This time, R2 was admitted into the hospital. R2 was released to a rehab center for approximately one month. When R2 returned to the facility, the rash was gone. The rash has not returned. Per staff interviewed, R2 is completely bedbound as R2 has sustained a few falls and R2 is now afraid to get out of bed. R2 is given complete showers twice a week. R2 requires assistance with all ADLs. When the rash presented under R2 breast, staff would clean R2’s breast area daily with warm water, soap, and a rag. Staff continued to clean R2 daily and apply the cream and ointments per the doctors’ orders. Based on records and staff statements, staff were aware of the rash and continued treatment per the in-house doctor’s orders. There were gaps in R2 being seen in person by a physician which may have resulted in a different outcome. Facility staff attempted to have doctor treat R2 in person, but the doctor was “unavailable” or “hard to reach” resulting in the staff sending R2 to the hospital on three different occasions. Based on evidence in this report, the case is unsubstantiated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. A copy of this report was provided, along with the LIC 811, the Confidential Names List. Exit interview.the state’s words, verbatim · CDSS document, Aug 23, 2024 · control 27-AS-20230914115212

Allegation investigated: Facility staff do not assist residents with ADLs. Residents calls are not responded within a timely manner.

On 08/05/2024 at 8:46 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Caleb Summerhays and Nurse Mel Dearing and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 116. A brief interview with conducted with Nurse Mel. Allegation: Facility staff does not assist residents with ADLs and residents’ calls were not responded within a timely manner. It was alleged that facility staff does not assist residents with ADLs and that residents’ calls were not responded within a timely manner. This investigation consisted of records reviewed, interviews with staff and residents. LPA Lee interviewed 6 out of 9 residents who has concerns with their ADLs not being met and their calls not responded within a timely manner. Continued LIC 9099-C Substantiated Based on the facility shower log for the month of April it was learned that four residents were not receiving showers by the facility. It was also learned that some residents did not receive shower a week after the previous shower. LPA Lee also reviewed End of Shift Report and it was learned that on 04/19/2024 resident 1 (R1) was upset because the shower schedule is inconsistent and that (R1) wanted a shower. Based on observations on 07/29/2024 at 9:14 AM, LPA Lee observed (R1) and (R2) call lights turned. It was learned that (R1) was waiting to get assistance with toileting and (R2) was waiting to get assistance with changing (R2) incontinence brief. At 9:26 AM, LPA Lee observed two Resident Aid (RA) walked by both (R1) and (R2)’s room without acknowledging and checking on both resident even though their call lights were turned on. At 9:46 AM, Administrator Assistance, Katelyn Becker approached LPA Lee and LPA Lee informed Katelyn about what LPA Lee have observed and that two residents needed assistance with their ADLs. At 9:54 AM (R1) stopped a (RA) who walked by her to get assistance. It took 37 minutes before a (RA) assisted (R1) with toileting. At 9:54 AM, LPA Lee observed a (RA) going into (R2)’s room to assist (R2) with changing (R2)’s incontinence brief. It took 40 minutes before (R2) received the assistance with changing (R2)’s incontinence brief. Per (R1)'s LIC 602 Physician Report (R1) needs assistance with set for toileting. Per (R2) LIC 602 Physician Report it was learned that (R2) wears brief and needs one person assistance for toileting needs. Moreover, LPA Lee and administrator Caleb toured the facility for an annual inspection on 07/29/2024 and observed resident room 213 and room 110 to have a very strong urine odor. LPA Lee pointed out to administrator regarding the strong urine odor in both rooms and LPA Lee asked administrator what does it mean if a resident's room has a strong urine odor and administrator Caleb stated, "it means the resident are not getting changed or cleaned." As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Nurse Mel and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Aug 5, 2024 · control 27-AS-20240507133821

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(B) · Plan of correction due date: Aug 16, 2024

87303(i)(1)(B) Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met as evidence by: Based on 6 out 9 interviews with residents’ facility staff are not responding to residents ‘call light in a timely manner. Based on observations on 07/29/2024, two residents waited over 30 minutes to received assistance with their ADLs needs.the state’s words, verbatim · CDSS document, Aug 5, 2024

Plan of correction: The administrator will conduct an audit and ensure additional training with facility staff to ensure that all residents call lights are answered in a timely manner. Administrator also agrees to submit proof of training and the training materials used along with staff sign in sheet. Administrator will also review regulations being cited today and write a statement of acknowledging. POC will be email to LPA Lee at pang.lee@dss.ca.gov by POC date 08/16/2024 by end of day 5:00 PM.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Aug 16, 2024

87468.1(a)(2) 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: (2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement was not met as evidence by: Based on interviews and observation, the facility did not attend to two residents ADLs needs in a timely manner. (R1) waited for 37 minutes before a staff assisted (R1) with toileting needs and (R2) waited 40 minutes to get (R2)’s incontinence brief change. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 5, 2024

Plan of correction: Administrator agrees to conduct personal rights training for all staff, by POC Date 08/16/2024. Facility Staff agrees to email training documents and sign in and out sheet to LPA Lee at pang.lee@dss.ca.gov by POC date 08/16/2024 end of day 5:00 PM.

Type of visit: Required - 1 Year

On 07/29/2024 at 8:24 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with administrator Caleb Summerhays and Nurse Mel Dearing. LPA explained the purpose of the visit. Administrator assisted with today’s visit. Administrator certificate # is 7026521740 and will expire on 11/17/2025. The current census is 114 with 3 Med-Techs, 5 caregivers, 2 house keepers, 1 laundry attendant, 4 managers and 1 nurse during today’s visit. This facility is a single story building licensed to serve one hundred twenty-one (121) non-ambulatory residents and approved for 12 hospice waivers. LPA and administrator Caleb inspected the physical plant including but not limited to the lobby area, kitchen, dining area, residents’ bedrooms, residents’ bathrooms, laundry room, residents’ lounge/activities area and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be clean. LPA observed the facility to not be free of odor. LPA observed resident room #213 and #110 to have a very strong urine odor in the room. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. LPA observed the last inspection for the kitchen hood conducted on 02/14/2024. LPA observed knifes and toxins kept locked and inaccessible to residents in care. Hot water temperature was measured at 120.1 degrees Fahrenheit in resident’s bathroom sink. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in hall 1, hall 2 and hall 3 and was last serviced on 07/19/2024. All fire exits are free of obstacles and last fire drill was completed on 06/18/2024. LPA observed the facility has two public telephones in the hallway to the dining room. Facility thermostat observed at 71 degrees Fahrenheit. LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed and compared 9 out of 114 medication administration record (MAR) with client’s medication and it was complete. The first aid kit was checked, and it did contain all of the required components. LPA requested residents and staff files for review. LPA Lee reviewed 9 out of 114 resident files and they were complete. LPA reviewed 5 staff files and they were also complete. Staff have criminal record clearance and are associated to the facility. The following documents will be email to LPA Lee (pang.lee@dss.ca.gov) by 08/02/2024 by 5:00 PM by end of day: (1) LIC 308 Designation of Administrative Responsibility (2) LIC 500 Personnel Report (3) Copy of Administrator Certificate (4) LIC 610D Emergency Disaster Plan (5) Proof of Current Liability Insurance As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Jul 29, 2024

Allegation investigated: Facility staff did not report a fall to family

On 06/24/2024 at 1:00 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Caleb Sumerhays and Mel Dearing and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 113. A brief interview with conducted with Caleb and Mel. Allegation: Facility staff did not report a fall to family It was alleged that facility staff did not report a fall to family. This investigation consisted of records reviewed and interviews with staff and residents. LPA Lee interviewed 8 out of 9 residents who did not witness or heard (R1) having a fall. Moreover, 5 out of 5 facility staff did not witness and heard (R1) having a fall. Based on record review there was no documentation of (R1) having any fall in the month of February to April of 2024. Continued LIC 9099-C Unsubstantiated Based on the interviews and statements obtained during the investigation process, the allegation has not been corroborated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint 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. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. A copy of this report was provided to the facility. Allegation: Facility staff do not provide medications on time. It was alleged that facility staff do not provide medications on time. This investigation consisted of records reviewed, and interviews with staff and residents. LPA Lee interviewed 6 out of 9 residents who stated that they are not getting their medications and does have concerns regarding medications. Based on (R1) Medication Administration Record review it was learned that for the month of February 2024 (R1) didn’t receive the following medications for the following dates: Iepezil HCL 10 MG Tablet Tab: take 1 tab by mouth at bedtime for 02/23/2024, Dorzolamide Timolol 22.3-6.8, install 1 drop in each eye twice daily for glaucoma for 02/05/2024, Gabapentin, take 1 cap by mouth three times daily for 02/01/2024, 02/08/2024, 02/11/2024, 02/13/2024, 02/18/2024, 02/23/2023, Latanoprost 0.005%, instill 1 drop in each eye every evening for glaucoma for 02/23/2024, Brimonidine Tartrate Ophth 0.2% drops, install 1 drop in right eye twice daily for glaucoma for 02/07/2024, 02/08/2024, 02/09/2024, 02/10/2024, 02/11/2024, 02/15/2024, 02/16/2024, 02/19/2024, 02/20/2024, 02/232024,02/24/2024 and 02/25/2024. Moreover, for the month of March 2024, (R1) also didn’t received the following medications for the following dates: Gabapentin 300 MG Capsule, take 1 Cap by mouth three times daily for breve pain for 03/02/2024, 03/04/2024, 03/20/2024, 03/26/2024 and Brimonidine Tartrate 0.2%, instill 1 drop in right eye twice daily for glaucoma for 3/01/2024, 03/04/2024, 03/05/2024, 03/08/2024, 03/21/2024, 03/22/2024, 03/24/2024, 03/26/2024 to 03/31/2024. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Caleb and Mel and a copy of this LIC 9099, LIC 9099-D page and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Jun 24, 2024 · control 27-AS-20240329100952

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

87465(a)(4) 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 was not met as evidence by: Based on interviews and records review: the licensee did not ensure that (R1) received (R1)’s medications as prescribed. (R1) MAR log was missing initial for multiple medications for the month of February 2024 and March 2024. It is unknown if medication were administered to (R1). This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Jun 24, 2024

Plan of correction: Licensee/administrator agrees to conduct Incidental medical and dental training for all Med-tech and any staff that handles residents’ medications. Licensee/administrator will email LPA Lee training materials and staff sign in sheet by POC date 07/01/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 24, 2024

87468.1(a)(2) 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: (2) To be accorded safe, healthful, and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: Based on interviews and records review: the licensee/administrator did not ensure that (R1) was assisted with feeding per (R1)’s Individual Service Plan. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Jun 24, 2024

Plan of correction: Licensee/administrator agrees to ensure that all residents who requires assistance with feeding are receiving assistance. A statement of understanding and acknowledge of the regulation cited will be emailed to LPA Lee by POC date 07/05/2024 by end of day 5:00 PM.

Allegation investigated: Staff did not provide incident reports to resident’s authorized representative. Staff did not dispense medication as prescribed.

On 05/14/2024 at 11:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Caleb Summerhays and Nurse Mel Dearing and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 113. A brief interview with conducted with Nurse Mel. Allegation: Staff did not provide incident reports to resident’s authorized representative It was alleged that staff did not provide incident reports to resident’s authorized representative. This investigation consisted of interviews with staff and resident responsible party and records reviewed. LPA Lee interview 4 facility staff who denies the allegation stating that resident (R1) did have a fall but that (R1) didn’t sustain any injuries. LPA Lee attempted to interview (R1) on 03/04/2024 and 03/14/2024, who refused to be interviewed. Continued LIC 9099-C Substantiated Based on interview with Resident Care Director, Aashana Pillay admitted that (R1) had two falls and was admitted to the hospital in January and that a phone call was made to (R1)’s responsible party; however, a written report was not provided to (R1)’s responsible party. Based on record review it was noted that (R1) is a high-risk fall resident. It was learned that on 01/26/2024, (R1) had two un-witnessed falls. During the second fall on 01/26/2024, (R1) was admitted to Kaiser. Based on records it was noted on (R1)’s chart that (R1) was admitted to Emergency Department (ED) on 1/26/2024 after a fall with possible syncope, diagnosed with severe sepsis from possible community pneumonia. LPA Lee also reviewed (R1)’s After Visit Summary from Kaiser Permanente visit from 01/27/2024 to 01/29/2024 which states that “you were treated in the hospital for severe sepsis due to community acquired pneumonia, orthostatic hypotension.” Moreover, on (R1)’s progress notes from City Creek it was documented on 01/27/2024, that resident was admitted to Kaiser south for further evaluation and infection. Since (R1) had two falls on 01/26/2024 and was treated for severe sepsis, per Title 22 regulations 87211(a)(1)(B) any incident which threatens the welfare, safety or health of any resident a written report shall be submitted to the person responsible for the residents within seven days of the occurred events. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Allegation: Staff did not dispense medication as prescribed It was alleged that staff did not dispense medication as prescribed. This investigation consisted of interviews with staff and resident responsible party and records reviewed. LPA Lee also interviewed 4 facility staff who denies the allegations. On 03/04/2024 and 03/14/2024, LPA Lee attempted to interview (R1) who refused to be interviewed. It was learned that on 11/08/2023 resident 1 (R1) had an appointment for dental work and required that (R1) to be off (R1)’s Pradaxa medication for 48 hours prior to (R1)’s dental procedure. Based on record review, on 11/06/2024 at 9:58 AM, City Creek was notified to hold (R1)’s Pradaxa medication (blood thinner) via email from (R1)’s responsible party. On 11/06/2023 at 12:16 PM, Resident Care Director Ashana Pillay emailed (R1)’s responsible party requesting for a doctor’s order for the Pradaxa hold. Continued LIC 9099-C On 11/08/2023, City Creek received (R1)’s doctor’s order from Kaiser Permanente to hold (R1)’s Pradaxa. LPA Lee reviewed (R1)’s MAR log and (R1) was given Pradaxa medication on 11/06/2024 at 8:00 AM and Pradaxa medication was not given to (R1) on 11/06/2023 at 8:00 PM. (R1) Pradaxa medication was also not administer on 11/07/2023 and 11/08/2023. Furthermore, on 11/27/23 (R1)’s responsible party emailed City Creek notifying that (R1) has a dental appointment on 12/06/2023 at 11:00 AM and will need (R1)’s Pradaxa to be hold for two days prior to (R1)’s appointment. On 11/28/2023 at 12:25 PM, Resident Care Director Ashana Pillay, emailed (R1)’s responsible party stating that the screen shot send does not give an order stating to put medication on hold and that the cardiologist has to give specific order, stating to put Pradaxa on hold for dental procedure prior to appointment for two days starting date and end dates. On 12/01/2023 at 9:07 AM (R1)’s responsible party emailed, Resident Care Director Ashana Pillay to confirmed to hold (R1)’s Pradaxa medication. On 12/04/2023 at 8:25 AM, Resident Care Director Ashana emailed (R1)’s responsible party stating that she was not able to open the attachment that was sent to her and that she was waiting for the medical note from (R1)’s doctor. It was also learned that Resident Care Director Ashana Pillay reached out to (R1)’s responsible party to informed that the doctor’s order/letter was inadequate since it did not contain a date. Based on (R1)’s MAR log, it indicated that (R1)’s Pradaxa medication is suspended on 12/04/2023 to 12/05/2023; however, (R1)’s medication was administered to (R1) on 12/04/2024 for 8:00 AM pass and 12/05/2024 for 8:00 PM pass due to no doctor’s hold order in place. Moreover, on 01/04/2024 at 7:35 AM, responsible party emailed Ashana to informed that (R1) has a dental appointment on 01/10/2024 with an attachment of a doctor’s order in placed dated on 12/22/2023 stating that every time patient has dental work: this patient” (R1) “will be undergoing dental treatment, In light of (R1)’s medical history, please proceed with dental treatment with the following precautions: Avoid epinephrine if local anesthesia is used. Prophylactic antibiotics are not recommended. Ok to hold Pradaxa for 2 days before the procedure if excessive bleeding is anticipated.” Based on charting records review dated on 01/08/2024 at 12:05 PM, (R1) will have Pradaxa held from 01/08/2024 to 01/10/2024 for dental procedure and that staff is aware. It was also charted on 01/08/2024 at 20:52, refused, on 01/09/2024 at 9:41 AM, resident refused, on 01/10/2024 at 5:41 PM, resident said no and told us to come back tomorrow, on 01/10/2024 at 8:08 PM, resident refused and on 01/10/2024 at 8:57 PM, resident refused. LPA Lee reviewed medication administration record and it was learned that on 01/08/2024 to 01/10/2024 (R1)’s medication Dabigtran Etexilate (blood thinner) medication was given to resident when there was a doctor’s order in placed to hold (R1)’s blood thinner medication. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Tasha and Melissa and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, May 15, 2024 · control 27-AS-20240223095550

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: May 31, 2024

87211(a)(1)(B) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (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… (D) Any incident which threatens the welfare, safety or health of any resident… This requirement was not met as evidence by: Based on interview and records review, the administrator did not ensure that (R1)’s responsible party received a written report in regards to (R1)’s fall which resulted in (R1) being hospitalized on both 01/26/2024 to 01/29/2024 and 04/13/2024 to 04/17/2024. This poses a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, May 15, 2024

Plan of correction: Administrator agrees to ensure that residents responsible receives a written report of any incident that pertains to residents that may cause any serious injury and threatens the welfare, safety, or health of any residents. Administrator will review regulations cited/and regulation 87211 Reporting Requirements and write a statement of acknowledgement of reading and understand the regulation. POC will be emailed to LPA Lee by POC due date 05/20/2024 by end of day 5:00 PM.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 24, 2024

87465(a)(4) 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 was not met as evidence by: Based on records review, the administrator did not ensure that (R1)’s medication for Dabigtran Etexilate (blood thinner) was put on hold for 01/08/2024 to 01/10/2024 according to physician’s order since (R1) had a dental extraction on 01/10/2024. This poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, May 15, 2024

Plan of correction: Administrator agrees to ensure that all resident’s physicians are followed per physician’s order. Administrator will review regulations cited/and regulation 87465 Incidental Medical and Dental Care and write a statement of acknowledgement of reading and understand the regulation. POC will be emailed to LPA Lee by POC due date 05/24/2024 by end of day 5:00 PM.

Type of visit: Case Management - Other

On 05/14/2024, Licensing Program Analyst (LPA) Pang Lee arrived at facility unannounced to conduct a case management visit. LPA met with administer Caleb Summerhays and Nurse Mel Dearing and explained the purpose of the visit. The census is 113 with 6 Resident Aid, 1 Resident Aid Lead, 3 Med-techs, 1 Residential Habilatation and 10 supervisors. The purpose of this case management is due to following up on some concerns during complaint investigation control number 27-AS-20240223095550. LPA Lee reviewed resident 1 (R1)’s file. Based on records review (R1)’s LIC 602 Physician Report dated on 07/26/2023, (R1) is diagnosed having dementia. During complaint investigation on 03/04/2024, LPA Lee was given (R1)’s Individual Service Plan Assisted Living Waiver (ISP) that was dated on 03/02/2023. During today’s visit it was learned that (R1) does have a current (ISP) dated on 03/19/2024 and that the facility didn’t ensure that LPA Lee received (R1)’s current (ISP). It was also learned that (R1) has (ISP) completed every six months with nurse Steven Heppell from Elder Options and (R1)’s (ISP) is reviewed with City Creek Nurse Mel Dearing and (R1)’s responsible party. Based on records review (R1)’s Kaiser notes dated on 10/28/2023, (R1) has history of falls and that (R1)’s last hospitalization was from 10/27/2023 to 10/30/2023 due to falls and orthostatic hypotension, as a result Lasix, Aldactone and lisinopril were held. (R1) also had two unwitnessed falls on 01/26/2024 and was admitted to Kaiser South and discharged on 01/29/2024. Moreover, on 04/13/2024, (R1) also had multiple falls within 24 hours and was transported to Kaiser via paramedics. (R1) then was discharged on 04/17/2024 and was evaluated for seizure, head injury. Per LIC 624 dated on 04/18/2024, City Creek stated that (R1) will be monitor and on alert charting conduct for 72 hours. Based records review, (R1) was on alert charting for 72 hours with progress notes dated on 04/18/2024, 04/19/2024, 04/20/2024, 04/21/2024 and 04/22/2024, 04/23/2024 and 04/24/2024. Based on records review (R1) was assessed for Fall risk using “Morse Fall Scale” on 10/30/2023 and is considered a high-risk fall resident. It was also learned that a fall prevention plan was put in placed for (R1). Continued LIC 809-C On 04/15/2024 another fall risk using “Mores Fall Scale” was conducted as well. On 04/02/2024, (R1) was evaluated for physical therapy; however, it was noted on outside agency assessment form that (R1) is not willing to participate and corporate in physical therapy. Based on (R1) After Summary Kaiser discharge notes on 01/29/2024 it indicated that (R1) was treated in the hospital for severe sepsis due to community acquired pneumonia, orthostatic hypotension. LPA Lee asked Nurse Mel if there was any other resident during January that also was treated for pneumonia as well. Nurse Mel stated that no other residents was treated for pneumonia during that time frame. Based on City Creek records review regarding LIC 624 incident report during the month of January there was no indications that there were other residents admitted to the hospital due to pneumonia. No citations were cited during today’s visit. An exit interview was conducted with Nurse Mel Dearing and a copy of this report was given to Nurse Mel Dearing.the state’s words, verbatim · CDSS document, May 14, 2024

Allegation investigated: Staff did not ensure resident’s assertive device was accessible. Staff did not communicate with resident's authorized representative. Resident's call button was in disrepair.

On 05/07/2024 at 8:25 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Caleb Summerhays and Nurse Mel Dearing and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 113. A brief interview with conducted with Nurse Mel. Allegation: Staff did not ensure resident’s assertive device was accessible It was alleged staff did not ensure resident’s assertive device was accessible. This investigation consisted of interviews with staff and resident responsible party, records reviewed and observations. LPA Lee interview 4 facility staff who denies the allegation stating that (R1) does not like to use (R1)’s walker and puts the walker in (R1)’s closet. On 03/04/2024 and 03/14/2024, LPA Lee attempted to interview (R1) who denies being interviewed. Continued LIC 9099-C Unsubstantiated On 03/04/2024 at 8:55 AM LPA Lee observed resident 1 (R1) bedroom # 213. In (R1)’s bedroom, LPA Lee observed two signs above resident's bed. The first sign states, " PLEASE PLACE WALKER IN FRONT OF RESIDENT AT ALL TIMES." The second sign states, "DO NOT REMOVE WALKER FROM BEDSIDE." LPA Lee observed (R1) wheelchair was placed next to (R1)’s bed to the right of (R1) and (R1)’s walker was placed by the foot of (R1) bed. On 03/14/2024 at 11:32 AM, LPA Lee also observed (R1)’s walker next to (R1)’s bed. On 04/4/2024 at 8:34 AM, LPA Lee visit the facility to follow-up on a different complaint and LPA Lee observed (R1)’s walker and wheelchair are next to (R1)’s bed. During today’s visit 05/07/2024 at 2:44 PM, LPA Lee observed (R1) lying in bed with a sheet covered (R1)’s face. LPA Lee observed (R1)’s wheelchair next to (R1)’s bed and the walker was next to (R1)’s bed as well. Based on (R1)’s Individual Service plan assisted Living Wavier it indicates to ensure walker and or wheelchair is within reach at all times. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Allegation: Staff did not communicate with resident's authorized representative It was alleged staff did not communicate with resident's authorized representative. This investigation consisted of interviews with staff and resident responsible party and records reviewed. Four facility staff denies the allegations. LPA Lee reviewed email records and it was learned that on 11/06/2023 at 12:16 PM, Resident Care Director, Ashana Pillay sent an email regarding (R1)’s doctor’s order to (R1)’s responsible party. On 11/28/2023 at 12:25 PM, Ashana also emailed (R1)’s responsible party regarding (R1)’s medication hold. On 12/04/2023 at 8:37 AM, another email from Ashana to (R1)’s responsible party regarding (R1)’s dental work and Pradaxa medication. On 12/05/2023 at 9:40 AM, another emailed was sent to (R1)’s responsible party from Ashana regarding (R1)’s dental work and Pradaxa medication. On 12/05/2024 at 9:40 AM, another email sent to (R1)’s responsible party to follow-up on (R1)’s dental work and Pradaxa medication from Ashana. On 01/17/2024 at 12:31 PM, an email was sent to (R1)’s responsible party regarding (R1)’s charger. Continued LIC 9099-C On 01/17/2024 at 1:28 PM, another email from Ashana to (R1)’s responsible party to follow-up on (R1)’s charger. On 01/18/2024 at 9:44 AM, an email was sent to (R1)’s responsible party from Ashana regarding (R1)’s care conference notes. . On 12/05/2023 at 6:22 AM, an email was sent to (R1)’s responsible party from administrator Caleb Summerhays regarding (R1)’s dental work and Pradaxa medication. On 01/16/2024 at 8:07 AM, an email was sent from Caleb to (R1)’s responsible party regarding (R1)’s care conference notes. On 01/24/2024 at 8:15 AM, an email was sent out to (R1)’s responsible party from Caleb regrading responsible party’s concerns. On 01/25/2024 at 1:06 PM, an email was sent from Caleb to (R1)’s responsible party regarding (R1)’s care conference notes. On 01/27/2024 at 7:43 AM, an email was sent out to (R1)’s responsible party regarding (R1)’s walker not in place. On 01/31/2024 at 12:16 PM, an email was sent out to (R1)’s responsible part from Nurse Mellina Dearing regarding (R1)’s medicine changes and concerns. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Allegation: Resident's call button was in disrepair. It was alleged resident's call button was in disrepair. This investigation consisted of record reviews, observations and interviews with staff and resident. On 03/04/2024 At 8:55 AM, LPA Lee checked 9 resident call lights and 9 out of 9 call lights were in good repair. During 03/14/2024 visit, LPA Lee also tested 7 resident’s call string. It was learned that 7 of those call strings are in good repair. It was learned that when LPA Lee pulled the residents call string, the residents light outside of the residents’ room would turn on. Moreover, it was learned that once the residents’ lights outside of resident room are turned on it will then trigger to the call panel in the front lobby and to the nurse station. Four facility staff denies the allegations. LPA Lee interviewed 9 residents and 5 out of 9 residents denies that the call button is in disrepair. LPA Lee also asked to review call log records and it was informed to LPA Lee that the facility does not have call logs and that they only have call lights that will trigger outside of residents’ room and to the nurse station and to the front lobby. Continued LIC 9099-C The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 7, 2024 · control 27-AS-20240223095550

Allegation investigated: Residents are exposed to supervisor ill-mannered behavior.

On 05/07/2024, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced facility visit to open and closed a complaint investigation LPA Lee met with Administrator Caleb Summerhays and Nurse Mel Dearing and explained the purpose of today's visit. The census is 113. During today’s visit, LPA Lee toured the facility and observed 9 residents’ bedrooms. LPA Lee also interviewed 9 residents. 8 out of 9 residents denied the allegation and has not witnessed supervisor raising their voices to other staff/Resident Aids. LPA Lee also interviewed 7 facility staff and 5 out of 7 facility staff denied the allegation and has not experienced and witness supervisor being unprofessional and raising their voices at other staff. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed. An exit interview was held, and a copy of the report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 7, 2024 · control 27-AS-20240501155846

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a health and safety case management visit. The facility is on quarterly visits due to non-compliance concerns discussed during an office meeting on 11/01/2023. LPA met with Administrator Celeb Summerhays and Nurse Mel Dearing and explained the purpose of the visit. The census is 113. LPA Lee and Nurse Mel toured the physical plant to ensure compliance with Title 22 regulations. LPA observed 9 resident bedrooms and bathrooms, lobby, activity area, smoking area, and medication room. LPA Lee observed resident bedrooms and bathrooms to have necessary furniture and furnishings. Bedrooms were equipped with a bed, chair, dresser, and closet space. Bathrooms handrails and non-skid mats are in good repair. Fire extinguishers were up to date and fully charge. No emergency exits were obstructed. LPA reviewed food supply to ensure that the facility had a 2-day perishable and 7-day nonperishable food supply. LPA observed laundry room where it was observed that detergent, laundry room and all cleaning supplies were locked and made inaccessible at this time. Knives were observed to be locked and made inaccessible. LPA requested to review 3 resident files and 3 staff files. Staff files and resident files were observed to be current with up-to-date files. LPA Lee reviewed 3 resident medications in chart 1 and it was up to accurate and complete. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 7, 2024

Allegation investigated: Staff did not ensure that resident received medical attention while in care.

On 03/14/2024 at 11:21 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA Lee met with Health Services Supervisor Katelyn Becker and Resident Care Director Aasahana Pillay and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 110. A brief interview was conducted with Katelyn and Asahana. Allegation: Staff did not ensure that resident received medical attention while in care. It was alleged that staff did not ensure that resident received medical attention while in care. This investigation consisted of records reviewed, interviews with staff, residents, a VA Doctor at VA Martinez, and a Rehab Specialist at VA Martinez. LPA Lee interviewed 10 residents and 9 out of 10 residents have no concerns with staff not ensuring that resident receives medical attention while in care. Four facility staff denied the allegations. Throughout the investigation, it was learned that resident 1 (R1) was not receiving (R1) Ophthalmologist appointments. Continued LIC 9099-C Unsubstantiated The investigation revealed that (R1)’s Primary Care Provider (PCP) comes to the facility once a week for (R1)’s primary visits and to refill (R1)’s medications. On 05/02/2023 (R1)’s PCP informed the facility that (R1) needed to be referred to an Ophthalmologist for (R1) Glaucoma. It was also learned that (R1) can only be referred to a VA Ophthalmologist; therefore, (R1) had to be reestablish with a VA PCP to get referred to a VA Ophthalmologist. Based on records review, on 07/12/2023, the facility was able to establish a VA PCP for (R1). In addition, (R1) was also referred to a VA Ophthalmologist and had an appointment on 09/21/2023, per (R1)’s prior PCP recommendation. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Lee was unable to corroborate the allegations. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegation regarding staff did not ensure that residents received medical attention while in care is unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 27-AS-20231222104828

Allegation investigated: Due to lack of supervision residents wandered away

Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to deliver complaint findings regarding current complaint allegations . LPA Ivey Canady explained the purpose of the visit and was met by Caleb Summerhays The Department has determined the following as it relates to the complaint allegations: Due to lack of supervision residents wandered away On 2/26/2024 LPA Ivey Canady conducted an interview with facility administrator regarding current facility allegation. According to interview with facility staff and facility record review from documents received on 9/15/2023, R1 and R2 were accounted for during facility room rounds and R1 did not leave the line of site from facility staff. It was learned that the facility has installed a Wanderguard system to limit occurances of resident AWOLS. Based on a properderance of the evidence the allegation Due to lack of supervision, residents wandered away is unsubstantiated. An unsubstantiated finding 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, therefore the allegation is UNSUBSTANTIATED.Per California Code of Regulations (CCRs) - Title 22 nothe state’s words, verbatim · CDSS document, Feb 26, 2024 · control 27-AS-20230914115212

Allegation investigated: Staff did not dispense medications to residents as prescribed. Staff are improperly storing narcotics.

On 02/22/2024 at 12:30 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA Lee met with administrator Caleb Summerhays and Mel Dearing and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 111. A brief interview with conducted with Nurse Mel Dearing, Social Services Director, Leslie Padilla and Resident Care Director, Aashana Pillaly. Allegation: Staff did not dispense medications to residents as prescribed. It was alleged that Staff did not dispense medications to residents as prescribed. This investigation consisted of records reviewed, and interviews with facility staff and Omnicare. It was learned that the facility was using “Quick MAR” to document and distribute residents’ medications. On December 11, 2023, the facility then switched to a new system called Point Click Care (PCC). LPA Lee interviewed 4 out of 4 facility staff who confirmed that the only difference in resident’s medication was the time the medications was given. Continued LIC 9099-C Unsubstantiated Based on interviews with Nurse Mel Dearing and Omnicare account Manager it was informed to LPA Lee that some resident’s medications, the doctors doesn't justify the specific time of when the medication is to be given to resident. Medications only states once a day, twice a day or 3 times a day. Residents’ medications were given at 8:00 AM if residents medication states once a day. Residents’ medications are given to residents at 8:00 AM and 5:00 PM if residents are to take their medications twice a day. If residents’ medications indicate three times a day, then resident’s medication are given to resident at 8:00 AM, 12:00 PM and 5:00 PM. Based on interviews with Omnicare, it was learned that usually the provider will send residents order to the facility and then the facility will send the order to Omnicare and Omnicare will enter the order and push the order through into PCC which will generate residents medication list for the facility. Based on records review 10 out of 10 residents’ routine medications were in both Quick Mars and PCC. Upon reviewing residents PRN medications in Quick Mars and PCC there were discrepancies due to the transition of the two programs. It was learned that Omnicare was working with the facility in auditing residents’ medication. Moreover, some of the residents' PRN medications are either discontinued or are new orders that has not been entered into PCC. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Allegation: Staff are improperly storing narcotics. It was alleged that Staff are improperly storing narcotics. This investigation consisted of observations, records reviewed, and interviews with facility staff. LPA Lee interviewed 4 out of 4 Med-techs who denied the allegations. On 01/17/2024 complaint visit LPA Lee asked to look at Med Chats 1, 2, and 3. LPA Lee did not observe resident 1 (R1) and (R2) narcotics in any Med Charts. LPA Lee also looked at other residents’ narcotics in the med chart 1, 2, and 3 and it was learned that narcotics in the med carts are for residents residing in the facility. During today’s visit, LPA Lee also requested to look at Med Chart 1, 2 and 3. LPA Lee observed narcotics stored in the med cart are for residents who are still residing at the facility as well. In addition, LPA Lee reviewed (R1) LIC 622 Medication Destruction Record and it was learned that (R1)’s narcotics was destroyed on 12/01/2023 on the day that (R1) was deceased. Continued LIC 9099-C LPA Lee also reviewed (R2) LIC 622 Medication Destruction Record and it was learned that (R2)’s narcotics was destroyed on 12/04/2024 on the day that (R2) was deceased. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Feb 23, 2024 · control 27-AS-20240111134408

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced to conduct a case management visit to follow up on two incident reports. LPA met with administrator Caleb Summerhays and Nurse Mel Dearing and explained the purpose of the visit. The current census is 111. The Department received an LIC 624 Unusual Incident Report on 12/31/2023 at 3:37 PM, regarding an incident that occurred on 12/27/2023. Resident 1 (R1) was found choking on a watermelon. Med-tech tried to do the Heimlich maneuver but was unsuccessful and alpha one was called, and resident was transported to Methodist. LPA Lee reviewed (R1)’s LIC 602 Physician’s Report. Based on records reviewed, (R1) is not on any special diet and (R1) is able to feed self. During today’s visit LPA Lee interviewed (R1) who stated that (R1) did not chew the watermelon before swallowing and that the watermelon went down the wrong pipe. (R1) also confirms that it was an accident and that (R1) will before be swallowing. Based on an interview with Nurse Mel the facility will ensure to remind (R1) to chew (R1)’s food and eat slowly. It was also learned that (R1) does not have a change in eating habit and reassessment was completed verbally with (R1) and it was documented. The Department received an LIC 624 Unusual Incident Report on 02/19/2024 at 10:50 AM regarding an incident that occurred on 02/09/2024. Resident 2 (R2) accused Staff 1 (S1) of stepping on (R2)’s ankle. During the interview with (R2) and facility staff it was learned that statements from (R2) and staff are inconsistent; therefore, it is unclear exactly what happened. During the interview with (R2), (R2) stated that (R2) doesn’t remember who stepped on (R2)’s ankle. In addition (R2) also stated that (R2) doesn’t remember how the incident happened. LPA Lee asked (R2) if LPA Lee can look at (R2)’s left ankle and (R2) gave Continued LIC 809-C LPA Lee consent. LPA Lee observed (R2) having an ankle dressing on (R2)’s left ankle. LPA Lee interviewed (S1) and (S1) denies the allegation. LPA Lee also interviewed (S2) who (R2) reported the incident. (S2) stated that (R2) informed (S2) that (R2) hurt (R2)’s ankle as (S1) helped (R2) to transfer from bed to wheelchair. (S2) stated that (R2) didn’t indicate how (R2) hurt (R2)’s ankle. On 02/09/2024 (R2) was sent out to Methodist Hospital for evaluation. LPA Lee reviewed (R2) discharge document on 02/09/2024 and the reason for the visit was not documented and discharge diagnosis was also not documented. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was given to the facility.the state’s words, verbatim · CDSS document, Feb 23, 2024

Allegation investigated: Illegal drug activity on the premises Staff did not provide a safe and comfortable environment for residents Staff did not provide toiletries to residents Staff did not provide privacy to residents Untrained staff

Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to deliver complaint findings regarding current complaint allegations . LPA Ivey Canady explained the purpose of the visit and was met by Melina Dearing. The Department has determined the following as it relates to the complaint allegations: Illegal drug activit on the premises, Staff did not provide a safe and comfortable environment for residents, Staff did not provide toiletries to residents, Staff did not provide privacy to residents and Untrained staff Continues on LIC9099-C Unsubstantiated On 2/16/2024 LPA Jamie Ivey Canady conducted an investigation regarding current facility allegations. It was learned the facility has designated an area in the facility between hall 200 and hall 300 for residents that have medical prescriptions to smoke medical marijuana. Based on facility record review, all facility residents that smoke medical marijuana have physician prescriptions and the prescriptions are documented in resident facility files. According to interviews with facility staff, the only residents that smoke medical marijuana in the designated areas are residents with prescriptions. Therefore the allegation Illegal drug activity on the premises is unsubstantiated. An unsubstantiated finding 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, therefore the allegation is UNSUBSTANTIATED. On 2/16/2024 LPA Jamie Ivey Canady conducted an investigation regarding current facility allegations. According to facility record review, all visitors are asked to sign in at the front reception all area. For resident safety, doors are locked at 8pm when the front desk facility staff leave for the day. Residents can come in and out of the facility using the key pad and all residents have a passcode to get in and out of the facility. There is also a doorbell at the front of the facility that also rings in the MedTech room that alerts staff that someone is at the door. The facility is currently in the process of renovating resident rooms and are at 50% completion. It has taken approximately 2 working days for each room to be renovated. All resident belongings are transported into temporary accommodations while resident rooms are being completed. And transported back into the resident rooms after completion of the renovation. Residents have a variety of blankets and comforters in each room. Each resident has a regular blanket and comforter that is provided by the facility. Residents also are provided with clean linens on each resident shower day on average of twice a week. Based on facility staff interviews and facility resident interviews, the allegation Staff did not provide a safe and comfortable environment for residents is unsubstantiated. An unsubstantiated finding 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, therefore the allegation is UNSUBSTANTIATED. Cont 9099C On 2/16/2024 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an investigation regarding current facility allegations. According to facility staff interviews, toiletries for facility residents are purchased on a monthly basis. According to Staff and resident interviews, there are plenty supplies of toothbrushes and toothpaste in the facility and the facility is well stocked with other toiletries as well. On 2/16/2024, LPA toured the facility and observed resident bathrooms to have all Title 22 regulated items as required. Therefore the allegation Staff did not provide toiletries to residents is unsubstantiated. An unsubstantiated finding 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, therefore the allegation is UNSUBSTANTIATED. On 2/16/2024 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an investigation regarding current facility allegations. Based on interviews with facility staff, many of the residents have shared rooms and during bathing time for residents, facility staff respect their privacy regarding in and out of the shower. The facility provides towels and linens to cover them and when it is necessary to close doors the staff closes the doors. According to staff interviews, additional linens were purchased for the facility residents in the past 30 days. During LPA facility tour, LPA observed there to be blinds or curtains in all facility resident rooms for privacy. Based on interviews with facility residents, there are no complaints regarding not having privacy in the facility. Therefore the allegation, Staff did not provide privacy to residents is unsubstantiated. An unsubstantiated finding 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, therefore the allegation is UNSUBSTANTIATED. On 2/16/2024 and 2/20/2024 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted an investigation regarding current facility allegations. LPA requested, received and reviewed facility MedTech training documents for the months of 8/2023 and 9/2023. Based on facility record review, the facility is conducting MedTech training in accordance with Title 22 regulations. Based on record review, 9 Sections of MedTech training for new facility MedTech staff were conducted over a 3 day span from 8/29/2023 - 8/31/2023. Based on interviews with facility residents, there has been no experiences with MedTech staff being untrained and not knowing how to carry out their duties properly. Therefore the allegation "Untrained Staff' Is unsubstantiated. An unsubstantiated finding 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, therefore the allegation is UNSUBSTANTIATED. No Deficiencies have been cited during today's visit. Exit interview conducted and copy of today's report was given to facility staff Melina Dearing.the state’s words, verbatim · CDSS document, Feb 20, 2024 · control 27-AS-20230914115212

Allegation investigated: Staff pushed resident which resulted in a fall. Staff did not treat resident with dignity and respect.

On 02/12/2024 at 8:30AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Administrator Caleb Summerhays and Nurse Mel Dearings and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 110. A brief interview was conducted with both Celeb and Mel. Allegation: Staff pushed resident which resulted in a fall. It was alleged that staff pushed resident which resulted in a fall. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible party. LPA Lee interviewed 9 out of 9 resident and 8 of those 9 residents stated they have not experienced and witnessed any facility staff pushing residents which resulted in a fall. LPA Lee also interviewed 5 out of 5 facility staff who denies pushing and witnessing any facility staff pushing resident which resulted in a fall. LPA Lee called the number provided by the complainant for additional details to assist in this investigation, and no further information could be obtained. Continued LIC 9099-C Unsubstantiated In addition, LPA Lee was not able to confirm with resident 1 (R1) about the incident on 12/25/2023. Based on the information gathered, it is unclear that staff pushed resident which resulted in a fall. Therefore, the allegations cannot be corroborated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Allegation: Staff did not treat resident with dignity and respect. It was alleged that staff did not treat resident with dignity and respect. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible party. LPA Lee interviewed 9 out of 9 residents and 7 out of those 9 resident stated they have not experienced and witnessed facility staff not treating residents with dignity and respect. LPA Lee also interviewed 5 out of 5 facility staff who denies that facility staff doesn’t treat residents with dignity and respect. In addition, LPA Lee called the number provided by the complainant for additional details to assist in this investigation, and no further information could be obtained. LPA Lee was not able to confirm with resident 1 (R1) about the incident on 12/25/2023. Based on the information gathered, it is unclear that staff did not treat resident with dignity and respect. Therefore, the allegations cannot be corroborated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Feb 12, 2024 · control 27-AS-20231226112314

Allegation investigated: Staff did not ensure that resident received their medication(s) as needed.

On 02/08/2024 at 12:30 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Resident care director Aashana Pillay and Nurse Mel Dearing and explained the purpose of the visit. The purpose of this visit is to deliver a complaint finding for the allegation above. The current census is 93. A brief interview with conducted with Mel. Allegation: Staff did not ensure that residents received their medication(s) as needed. It was alleged that staff did not ensure that residents received their medication(s) as needed. This investigation consisted of records reviewed, interviews with staff, residents, and outside agency. LPA Lee interviewed 4 out 4 facility staff who denied the allegations. Nurse, Mel Dearing stated that her staff are administering residents’ medications; however, the staff lacks documenting that residents’ medications has been administered to resident; therefore, it is unclear if resident’s medications were being administer to residents. LPA Lee also interviewed 9 out 9 residents and 6 out of 9 residents stated that they are not getting their medications from facility staff. Continued LIC 9099-C Substantiated Furthermore, based on resident 1 (R1) Quick MAR records for the month of March 2023, it was learned that 12 out of 14 medications were not marked as being administered to (R1). For the month of September 2023, it was learned that 12 out of 16 medications were not marked as being administered to (R1). For the month of October 2023, it was learned that 14 out of 14 medications were not marked as being administered to (R1). For the month of November 2023, it was learned that 15 out of 15 medications were not marked as being administered to (R1). (R1) medications for Brimonidine Tartrate 0.2% Solution and Dorzolamide HCL-Timolol MAL 22.3-6.8 solution were not marked as being administered to (R1) for the month of March, September, October, and November. Based on records review, and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, citations for deficiencies can be found on the LIC 9099 -D. Failure to correct deficiencies may result in additional civil penalties. Appeal Rights provided. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 8, 2024 · control 27-AS-20231222104828

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(6) · Plan of correction due date: Feb 23, 2024

87465(6) Incidental Medical and Dental Care The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement is not met as evidenced by: Based on observation, interviews and record review, the licensee did not comply with the section cited above. Facility staff did not ensure MARs were being maintained for R1. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 8, 2024

Plan of correction: The administrator will ensure that all facility staff who handle medications are re-trained in administering and documenting medications when given to residents in care. Administrator will send LPA Lee copies of staff training sign in sheets with facility staff signatures and the materials used for the training. POC will be emailed to LPA Lee by POC date 02/23/2024 by 5:00 PM end of day.

Allegation investigated: Facility did not obtain a building permit prior to alterations to the building.

On 02/01/2024 at 11:55 AM, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced facility visit to open a complaint investigation and delivered the finding. LPA Lee met with Nurse Mel Dearing and Maintenance Director Joseph Simon and explained the purpose of today's visit. The census is 110. Allegation: Facility did not obtain a building permit prior to alterations to the building. It was alleged that the facility did not obtain a building permit prior to alterations to the building. This investigation consisted of records reviewed, interviews with staffs and observations. Throughout the course of the investigation, it was learned that the facility took down a Sophet wall and a receptionist desk on 06/22/2023 and then on 06/29/2023 the facility added a structured wall to the area and did not obtain proper permits. During a fire inspection follow-up in July 2023 the facility was given directions to submit permits and plans to Sacramento County Building Department and Metro Fire to address the added structure wall. Continued LIC 9009-C Substantiated During today’s visit, it was learned that the facility attempted to obtain permits after; however, the facility did not want to pay the fees associated with the permit. In September of 2023 the facility decided to resort to taking down the additional structure wall. A review of their facility sketch confirms that this additional structure was not approved during licensure. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Mel Dearing and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 27-AS-20240131084542

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87305(a) · Plan of correction due date: Feb 9, 2024

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement has not been met as evidenced by: Based on LPA's observation, records review and interviews the licensee did not comply with the section cited above. The facility did not obtain a building permit prior to alterations to the building by removing a sophet wall and receptionist desk and adding a structured wall and then later removed the structure wall, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: Licensee agrees to read regulation 87305(a) and submit a signed written declaration of understanding via email to LPA Lee (pang.lee@dss.ca.gov) stating that a building permit will be obtained prior to construction or alternations at the facility.

Type of visit: Case Management - Incident

On 12/01/2023 at 8:15 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to the facility to conduct a case management visit in relation to 6 incident reports received. LPA met with Resident Care Director, Aashana Pillay and explained the purpose of the visit. LPA was later met by Administrator, Caleb Summerhays and Licensed Vocational Nurse (LVN), Mel Dearing. The 10/24/2023 at 2:15 PM, the department received an incident report that occurred on 10/16/2023 with resident 1 (R1). R1’s blood sugar was low, and resident was unresponsive. Resident was transported to Methodist Hospital via paramedics. LPA Lee interviewed (R1) who stated that (R1) blood sugar is being checked by staff 4 times a day between every meal and bedtime. (R1) stated that (R1) has no concerns. It was learned that (R1) is on a sliding scale for insulin injections. It was learned that Med-tech goes around and do their med pass and assist R1 with (R1) glucose check. (R1) does own glucose check and the med-tech will let (R1) know what (R1) glucose reading is and confirms it with (R1) with the insulin units that is needed for (R1). LPA Lee reviewed (R1) UIR, Physician Report, Individual Service Plan, Progress Notes and Discharge/Follow-up Instructions. Based on records reviewed, (R1) is recommended to have a follow-up with primary care provider within 2 to 4 days. It was learned that (R1) had an appointment on 11/01/2023 to follow up on (R1). It was also learned that the facility had all the documentation for (R1) in file. On 11/13/2023 at 9:30 AM, the department received an Incident Report. Incident occurred on 11/04/2023 with (R2). Per incident report, (R2) had an unwitnessed fall and was found lying on the floor supine position head between a rocking chair in another resident room around 1549 with a tear on left elbow. (R2) stated that she did not hit her head. (R2) was transported to Sutter General Hospital for further assessment. Continued LIC 809-C LPA Lee interview with facility LVN, Mel Dearing, it was learned that (R2) is on a contract with Sutter Pace Program that does not offer hospice services to their resident and Sutter Pace Program only offers comfort care. The facility does not accept residents with “comfort care” and only resident with “hospice” services; therefore, (R2) is no longer residing at the facility. It was learned that (R2) needed a higher level of care and is transferred to a skill nursing facility, Saylor Ln Health Care. LPA Lee reviewed (R2) UIR, Physician Report, Individual Service Plan, Progress Notes. Based on interviews and records reviewed it was learned that (R2) was placed on fall monitoring and the facility implemented closer supervision of resident. A “Morse Fall Scale” was conducted with (R2). Per (R2) after summary there was no follow-up needed. On 11/13/2023 at 9:28 AM, the department received an UIR. Incident occurred on 11/05/2023. (R3) had a fall and was found on the floor laying on her back in the hallway around 1433. (R3) was transported to Kaiser South Hospital for further assessment. LPA Lee reviewed (R3) UIR, Physician Report, Individual Service Plan, Progress Notes. Based on interviews and records reviewed it was learned that (R3) was placed on fall monitoring and the facility implemented “Morse Fall Scale” with (R3). It was also learned that (R3) has an appointment scheduled with (R3) PCP for 12/5/2023 to follow-up on 11/05/2023 Kaiser Permanete after summary discharge. It was also learned that (R3) LIC 625 Appraisal/Needs and Service Plan was updated after (R3) was discharged on 11/05/2023. (R4) had two unwitnessed falls. On 11/06/2023 at 4:29 PM and 11/13/2023 at 9:34 AM, the department received two unusual incident reports. The first Incident occurred on 10/30/2023. (R4) had an unwitnessed fall at 0020 in (R4) room. (R4) stated that (R4) was trying to transfer from bed to wheelchair and hit (R4) head on the nightstand. The second incident, (R4) had an unwitnessed fall and was found by laying on the floor in a supine position in (R4) room. Resident stated (R4) hit (R4) head. On both occasion (R4) was transported to Mercy General Hospital for further assessment. LPA Lee reviewed (R4) UIR, Physician Report, Individual Service Plan, Progress Notes. Based on interviews and records reviewed (R4) was placed on fall monitoring and the facility has implemented “Morse Fall Scale” with resident. Per discharge notes it is recommended that (R4) has a follow-up appointment with (R4) PCP. It learned that (R4) was seen by Dr. Patrick on 11/08/2023 at 9:45 AM per follow-up directions from discharge notes. On 11/15/2023 at 9:30 AM, the department received an unusual incident report. Per incident report, incident occurred on 11/12/2023 around 1230 med tech was called to (R5) due to (R5) being short of breath, med tech attempted Heimlich Maneuver. Later resident showed signs of shortness of breath and another Heimlich Maneuver was attempted. There were no signs of dislodging in (R5) throat; however, (R5) was heavily drooling. LPA Lee interviewed (R5) who stated that (R5) has no concerns and is aware that (R5) can only eat soft food. (R5) stated “soft food only.” LPA Lee reviewed (R5) UIR, Physician Report, Individual Service Plan, Progress Notes. Based on interview and records reviewed (R5) is on mechanical soft and honey thicken liquid. (R5) had a follow-up appointment on 11/17/2023. Facility had fall prevention plan in place. Per California Code of Regulations (CCR) - Title 22 - no deficiencies were observed. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 1, 2023

Type of visit: Office

A Non-Compliance Conference (NCC) was conducted on this day, 11/01/2023, by the Sacramento South Regional Office via Teams meeting. The purpose of this Non-Compliance Conference meeting was to follow up with the facility after an initial NCC was held on 10/13/2023. Due to facility staff availability the NCC meeting was rescheduled for today. Present in the meeting was Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, LPM Stephen Richardson, Licensing Program Manager (LPM) Lisa Rios, Licensing Program Analyst (LPA) Jamie Ivey Canady, LPA Pang Lee, facility board member Ryan Williams, facility board member Scott Clawson, Director of Nursing Melina Dearing, Adminstrator Caleb Summerhays and AShawna Pillay, Resident Care Director. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process as well. Since the facility has been re-licensed in 2021, there have been 16 Type A citations and 8 Type B citations. The focus of the concerns at this time were as followed: - Multiple medication violations including Insulin not being provided by a skilled professional - Care and Compliance - Facility resident pressure injuries - Update of Facility staff roles, duties, and responsibilities Continued on 809-C - Pharmacy addition for filling resident prescriptions - Onboard of Clinical Consultant - Wanderguard System Licensee agreed to do the following in order to bring the facility into compliance: Please provide the following to LPA by 11/7/23. - Provide the Department with an updated LIC500 - Licensee shall provide updated Plan of Operation that includes new staff department head personnel roles, responsibilities and duty statement - Licensee shall provide the Department with a plan of how the facility will assess and monitor resident skin issues. - Licensee shall create a plan and policy on residents with dementia - Licensee will provide the Department a plan for proof of staff, staff training and monitoring required staff training to include updated staff training documents for CPR/First Aid of facility staff - Licensee shall provide the Department with proof of staff certified to assist residents with insulin and a plan regarding how the facility handles insulin assistance when certified staff is not on site. Licensee has accepted the offer of Technical Support Program (TSP) offered by the Department Exit Interview Licensee/Administrator signature on file.the state’s words, verbatim · CDSS document, Nov 1, 2023

Allegation investigated: Resident was physically assaulted by another resident while in care.

Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by Caleb Summerhays. The investigation was conducted by LPA Ivey Canady. The investigation consisted of interviews with residents, interviews with staff, and review of facility resident and medical files. The Department has determined the following as it relates to the allegations: Resident was physically assaulted by another resident while in care. Continued on LIC 9099 - C... Page 1 of 2 Unfounded On 9/25/2023 LPA Ivey Canady requested, received and reviewed facility and resident files regarding current allegations. Based on review of R1 facility and medical files, R1 has been diagnosed with cognitive decline. According to interviews with R1 and facility staff, R1 is not clear on claimed occurrences. During staff interviews and facility file review, it was learned that R1 displays behaviors associated with diagnosis as described in facility medical file. In accordance with facility appraisal needs and service plan, facility is providing R1 with agreed upon and planned services. Based on review of facility service plan and staff notes, facility is also proactively providing R1 staff implementations of the objective plan listed on the needs and service plan. According to interview with R1, there was no actual physical attack that occurred with R2. Based on interviews with residents and staff, there is no evidence of physical interaction of any kind between R1 and R2. Therefore the allegation Resident was physically assaulted by another resident while in care is Unfounded. Due to the information gathered LPA finds the allegation to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report and appeal rights were provided to the facility. On 10/24/2023 LPA Ivey Canady requested and received facility Surety Bond, facility resident files, and facility resident fund transaction files for review. According to Surety Bond received by the facility on 10/1/2019, facility is covered for transactions for residents up to the amount of $500 for all residents. According to facility transaction records, receipts, resident interviews and staff interviews, facility assisted R1 and R2 with the purchase of personal essentials with the total amounts not exceeding $42 per transaction per month. Regarding facility file review, R1 Individual Service Plan and facility Pre-placement appraisal, R1 has been diagnosed with cognitive impairment and dementia. According to facility Pre-Placement Appraisal for R1, R1 is a smoker and is listed as smoking 3 times per day. Based on facility transaction receipts, facility staff provides a monthly service of purchasing cigarettes for and personal items for R1 and R2. According to bank transaction receipts dated 06/23/2023 and 08/29/2023, and facility staff interviews dated 10/11/2023, facility staff provides R1 and R2 transportation to a banking institution for the purpose of withdrawing funds to use for the purchase of cigarettes and other personal items. Based on facility transaction receipt review and facility transaction log receipt review, R1 and R2 funds withdrawn in reviewed transactions are used for the purpose of purchasing cigarettes and personal items for R1 and R2. Therefore the allegation -Staff member is financially abusing resident while in care is Unsubstantiated. An unsubstantiated finding 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, therefore the allegation is UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Oct 26, 2023 · control 27-AS-20230522082455

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to conduct a case management regarding a discovery during a complaint investigation in reference to complaint number 27-AS-20230522082455. LPA Ivey Canady met with administrator Caleb Summerhays and explained the purpose of the visit. During the investigation for complaint number 27-AS-20230522082455 it was learned R1 has been diagnosed with dementia and as such is unable to conduct personal financial business. Based on this information, LPA conducted a interview with administrator Caleb Summerhays, and the facility has decided to pursue payee services for R1. Furthermore, according to the administrator, the facility will continue transactions for all residents using a payee service or conservator as needed. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 26, 2023

Allegation investigated: Resident sustained a pressure injury while in care.

On 10/25/2023, at 10 am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived at the facility unannounced to continue to conduct a complaint investigation regarding the allegations noted above. LPAs met with Administrator Caleb Summerhays and stated the purpose of this visit. Throughout this investigation, LPAs interviewed staff members and reviewed R4’s files, including resident charting notes, resident care plans, activity of daily living (ADL) notes, Home Health notes, and resident physician orders. Regarding the allegation, resident sustained a pressure injury while in care, the licensee did not demonstrate evidence that pressure wound was monitored adequately and timely. Review of Resident_4 (R4) charting notes and home health notes indicated that R4 was observed to have an open sore on the coccyx area on 5/25/23. On 5/31/23, charting notes indicate that the wound is worsening. {Con't on 9099-C} Substantiated R4 was sent to hospital on 5/31/23 and returned to the facility on 6/1/23 and the pressure wound was assessed to stage 2. Based on an interview with Staff_1 (S1), there was no evidence between 5/25/23 and 5/31/23 to address the care of R4’s pressure wound. Based on record review and interview with S1, there was no evidence to indicate adequate care and monitoring was provided to the R4’s wound between 6/1/23 and 6/8/23. Based on record review, Home Health Agency assessed R4’s pressure wound to stage 3 on 6/7/23. Based on review of R4’s ADL notes, facility staff performed bed mobility for R4 daily; however, there is no specific documentation regarding the care and monitoring of R4’s pressure wound. During an interview with S1, LPAs requested additional evidence (including documentation) that address wound care, monitoring and progress of R4; however, S1 indicated that S1 does not have evidence to provide. Based on records review, and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, citations for deficiencies can be found on the LIC 9099 -D. An immediate civil penalty of $1000 is issued in addition to citation due to injury related to violation of Section 1569.312(e) due to repeat violation. Failure to correct deficiencies may result in additional civil penalties. At the time of the complaint visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49(f). An exit interview was held with administrator Caleb Summerhays, and a copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 25, 2023 · control 27-AS-20230130141811

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(e) · Plan of correction due date: Oct 26, 2023

1569.312 Basic services requirement. Every facility...shall provide at least the following basic services: (e) Monitoring...residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This was not met as evidenced by: Based on interviews and record reviews, the licensee did not ensure to provide adequately, and timely care and monitoring of R4’s pressure wound while in care at the facility, which resulted in the escalation of R4’s pressure wound to stage 3. This poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Licensee to submit a plan in place to ensure residents are being checked regularly. Plan to be submitted to the Department by the POC due date. Licensee to submit staff training on resident monitoring. Proof of training date be submitted by POC date and proof of completed training be submitted to the Department within 15 days after the training date.

Type of visit: Case Management - Other

On 10/25/2023, at 3:00pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived at the facility unannounced to conduct a case management visit. LPAs met with Administrator Caleb Summerhays and stated the purpose of this visit. The Department received a fax from City Creek on 8/22/23 regarding Resident_1’s (R1) blood pressure medication. Per review of the faxed document indicated that R1 was taking a prescribed blood pressure medication requiring blood pressure reading prior to self-administration. Further review of the faxed document indicated that it was addressed to R1’s physician in which the facility requesting for the prescription order to change without the need to take blood pressure reading prior to self-administration. Interview with Staff_1 (S1) on 8/30/23 reveal that the fax was sent to the Department accidentally and it was meant to be faxed to R1’s physician. Per interview with S1 it was also revealed that during their recent medication inventory of all facility residents’ medication, staff discovered an oversight on R1’s medication requiring a vital sign reading prior to self-administration. S1 informed LPAs that med techs who are not appropriately skilled professionals have been assisting R1 with blood pressure medication and taking R1’s blood pressure readings. LPAs also conducted medication audits and observed medication passing of random residents in care on 8/30/23. Based on records reviews and interviews, there is a preponderance of evidence to conclude that staff inappropriately assisted R1 with self-administration of medications. Per California Code of Regulations Title 22, Division 6, Chapter 8) citations for deficiencies can be found on the LIC 809-D. An immediate civil penalty of $250 is issued in addition to citation due to repeat violation. Failure to correct deficiencies may result in additional civil penalties. An exit interview was conducted with Administrator Caleb Summerhays and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 25, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Nov 1, 2023

87465(a)(4) The licensee shall assist residents with self-administered medication as needed. This was not met as evidenced by: Based on record reviews and interviews, licensee did not ensure R1’s blood pressure medication was being administered appropriately. This poses a potential health and safety risk to person in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Licensee to review RCFE medication guide from the technical support resource guide and submit declaration of understanding to the Department by POC due date

Type of visit: Case Management - Other

On 10/25/2023, at 1:00pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived at the facility unannounced to conduct a case management regarding a discovery during a complaint investigation regarding the allegation from 27-AS-20230130141811. LPAs met with Administrator Caleb Summerhays and stated the purpose of this visit. LPAs Bilger and Villanueva interviewed staff members and reviewed Resident_4’s (R4’s) files, including resident charting notes, resident care plans home health notes, activity of daily living (ADL) notes, and resident physician orders. Based on record review, R4 was assessed with stage 3 pressure wound on the coccyx area by home health agency on 6/7/23. Based on interview with S1 on 8/30/23, facility did not submit an exception for prohibited health condition regarding R4's condition to the Department once R4 was assessed with stage 3 pressure wound. Per California Code of Regulations (Title 22, Division 6, Chapter 8) citations for deficiencies can be found on the LIC 809 -D. An exit interview was held with administrator Caleb Summerhays, and a copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 25, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87615(a)(1) · Plan of correction due date: Nov 1, 2023

87615 (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This was not met as evidenced by: Based on interviews and record reviews, the licensee retained a resident with a stage 3 pressure wound without obtaining an exception from the Department. This posed a potential health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Licensee to review the regulation on prohibited health condition and submit a statement of understanding of this regulation. to the Department by POC due date.

Allegation investigated: Staff does not ensure that facility alarm system is in place, resulting in multiple dementia residents leaving unnoticed.

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint investigation finding. LPA met with Administrator Caleb Summerhays, and explained the purpose of the visit. The complaint has determined the following as it relates to the following allegation: Staff does not ensure that facility alarm system is in place, resulting in multiple dementia residents leaving unnoticed. LPA reviewed facility records. Resident 1 (R1) left the facility during the morning of 05/19/2023. R1 called Alpha 1, a medical transport company, to be transported to the hospital. Alpha 1 drove R1 to the hospital. R1 was checked into the hospital. At 3:30 PM, the facility learned R1 was out of the community when the hospital called to obtain information regarding R1. Continues on LIC 9099 -C... Substantiated Continued from LIC 9099 According to Staff 1 (S1), Staff was unaware that R1 left during the entire morning shift. According to an interview with Resident 1 (R1), R1 was unable to recall the incident; however, R1 was able to express how one would call for help if needed. Due to the incident, R1 was placed on alert charting and to be checked on every hour. Staff are required to sign a hourly check sheet to state the staff saw R1 inside the facility. Based on records review, NOC shift hours 10:00 PM - 6:00 AM are rarely completed. 7 out of 28 days reviewed were signed off by staff. AM Shift, 6:00 AM - 2:00 PM, filled out the hourly log 21 out of 28 days. PM shift, 2:00PM - 10:00 PM, filled out the hourly log 19 out of 28 days. Although an hourly check log has been implemented, staff do not ensure they are completing the hourly checks. Based on records review, and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, citations for deficiencies can be found on the LIC 9099 -D. Failure to correct deficiencies may result in additional civil penalties. Appeal Rights provided. An exit interview was held, and a copy of the report was provided. ...Continues from LIC 9099 - A LPA reviewed July 2023 Medication Administration Records (MAR) for R2. The MAR orders match the Physician Orders provided. LPA observed MAR notes indicating when the resident was out of the facility. On the days the resident was in the facility, staff signed off for each order in the MAR. LPA attempted to interview R1; however, interview was deemed unsuccessful. Records show the facility obtained a new LIC 602 dated 07/23/23. Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was given to Program Director Caleb Summerhays. ...Continued from LIC 9099 - A LPA interviewed Staff 3 (S3). S3 stated that the facility has improved over the years in regards to quality of food. S3 feels that the residents are fed well and they are given balanced meals. Residents are involved in the menu planning process. S3 stated that if the facility needs to change the menu, they are able to update it weekly. S3 stated that snacks are offered in the morning, in the afternoon, and in the evening time. Residents are able to request additional snack items while the kitchen is operating. Before kitchen staff leave for the evening, the kitchen staff will prepare sandwiches and/or leave fruit and other food options out in the dinning hall. According to an interview with a resident's family member, the family member feels the residents are fed well. The family member stated the resident has not complained of the food and the resident has lived there for many years. According to an interview with Resident 3 (R3), R3 loves the food, is able to get snacks, and has a personal fridge for after hour items. Staff does not ensure that residents are properly assessed for medical issues According to an interview with S2, S2 is in charge of assessing all new intakes. S2 stated there has never been any residents that have not been assessed. S2 informed LPA that if any resident needs to be sent out, they will be sent out. S2 stated the facility is constantly calling doctors to update the resident's LIC 602. According to records reviewed by LPA, records were observed to have a pre-appraisal, an updated needs and services plan, and an updated LIC 602. Staff does not ensure that residents have dental hygiene products. Staff does not ensure that residents have bedding. LPA observed the facility. LPA observed the cleaning supply closet, two (2) linen closets, and two (2) supply closets. LPA took pictures for reference. The cleaning supply closet was stocked with toilet paper, paper towels, cleaning supplies for the bedrooms and bathrooms. The linen closet had 3 shelves full of towels, bedding, and comfortersThe second closet also had a linen closet full of bed sheets and comforters. According to S3, S3 stated anytime a resident ask for items, the staff put the code in to get the items. It is usually fully stocked. They have a main one they use, and they have a back up supply. Continues on LIC 9099 - C... ...Continued from Page 2 of LIC 9099 -C LPA interviewed residents. R4 stated bedsheets are brought by family. Any items R4 needs, the family sends it in a package. R5 stated the facility helps with the bedsheets every Tuesday. R5 was observed to have dental and hygiene products in the bathroom. R6 stated R6 does not remember when staff change the bedding, but knows that "they just do it.". R6 was observed to have hygiene supplies and dental supplies located in R6 bathroom. Staff does not ensure that facility is at a comfortable temperature for the residents. The facility was observed on 08/01/23, 08/23/23, 09/12/23, and 09/28/23. During each visit, the facility temperature was observed to be within the regulatory range, which is a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. Based on observations, interviews, and record review, the aforementioned allegations are unfounded and the allegations are false. Per California Code of Regulations, Title 22, Division 6, chapter 8, no deficiencies are being cited. An exit interview was held, and a copy of the report provided.the state’s words, verbatim · CDSS document, Oct 3, 2023 · control 27-AS-20230726091832

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(k)(6) · Plan of correction due date: Oct 31, 2023

87705 Care of Persons with Dementia k) The following initial and continuing requirements must be met... (6) ... facility staff shall ensure the continued safety of residents if they wander away from the facility. This requirement was not met as evidenced by: Based on records review and interviews, the licensee did not ensure staff checked on all residents, resulting in R1 leaving the facility for the entire day and making it to the hospital without staff knowledge. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 3, 2023

Plan of correction: Licensee stated they have created an hourly check log and will conduct a refresher training. Licensee has also implemented a new alarm system for residents with dementia. Resident bracelets will cause an alarm to sound if they exit the building. LPA to receive in-service sheet by POC due date.