Clearwater at Glendora

Allegation investigated: Staff are not providing adequate food service

***This report supersedes the report dated 07/06/2026. The report has been updated to correct the finding statement. No other changes have been made, and all other report findings remain unchanged.*** Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint investigation visit on 07/06/2026 to deliver findings regarding the above allegation. LPA was greeted by Executive Director William Boles and facility staff. LPA explained the purpose of the visit. During the investigation, LPA reviewed and obtained copies of the Resident Roster, Staff Roster, R1's Face Sheet, R1's Admission Agreement, R1's Care Plan, R1's individualized food menu, food service delivery logs, Resident Meal Documentation Forms, concierge email communications, and the employee Performance Counseling Memo related to the incident. LPA also conducted a tour of the facility and interviewed five (5) staff members (S1–S5) and four (4) residents (R1–R4). The investigation further included a review of the facility's meal delivery documentation and records pertaining to the allegation. (continued on 9099C) Substantiated Allegation: Staff are not providing adequate food service It is alleged that facility staff failed to provide adequate food service by not delivering a scheduled meal to a resident receiving in-room meal delivery services. Specifically, it is alleged that R1 did not receive her lunch on June 26, 2026, despite being enrolled in the facility's meal delivery program, and that similar incidents have occurred on prior occasions. During staff interviews, staff explained that R1 receives her meals in her room and that the culinary staff are responsible for preparing and delivering meals to residents receiving in-room meal service. Staff reported that the facility utilizes meal tracking tools, Resident Missed Meal Documentation Forms, and concierge communication to monitor meal deliveries and identify missed meals. Staff also stated that residents' families may occasionally arrange outside food deliveries or take residents into the community for meals and notify the concierge when a facility meal is not needed. Initially, staff were unaware of any missed meal involving R1 on 06/26/2026. However, after reviewing concierge email communications and additional documentation, staff confirmed that R1 did not receive her scheduled lunch on 06/26/2026 because a staff member failed to deliver the meal. Staff further confirmed that the employee received disciplinary action for failing to follow the facility's meal delivery procedures. R1 stated that her meals are routinely delivered to their room and recalled missing a meal. R1 reported that when they do not receive a meal, they contact their daughter rather than notifying facility staff. Interviews with R2 through R4 revealed no concerns regarding the facility's meal service or food delivery, and the residents reported they consistently received their meals as scheduled. Documentation reviewed, including concierge email communications, meal delivery records, and the employee Performance Counseling Memo, corroborated that R1 did not receive her scheduled lunch on 06/26/2026 and that the facility addressed the incident through employee disciplinary action. Based on LPA's interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 28-AS-20260629103741

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(1) · Plan of correction due date: Jul 24, 2026

(b) The following food service requirements shall apply: (1) Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day. Exceptions may be allowed on weekends and holidays providing the total daily food needs are met. Not more than fifteen (15) hours shall elapse between the third and first meal. This requirement was not met as evidenced by: Based on interviews and records reviewed, it was determined that the facility failed to provide R1 with her scheduled lunch meal on 06/26/2026, as required. The facility's failure to ensure R1 received her scheduled meal poses/posed an immediate risk to the resident's health, safety, and personal rights.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: The licensee shall submit a written plan describing how the facility will ensure residents receiving in-room meal service receive all scheduled meals. The licensee shall provide proof that staff have been trained on the meal delivery procedures and how missed meals will be documented and prevented.

Allegation investigated: Staff did not keep resident from being inappropriately touched by another resident

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the reported allegations. LPA met with Executive Director William Boles and explained the purpose of today's visit. The investigation consisted of the following: LPA obtained copies of staff/resident rosters, Face Sheet and Special Incident Report for Resident #1, conducted interviews with Local Law Enforcement, 1 Witness (W1), 5 Staff (S1-S5), 5 Residents (R1-R5) and toured the Memory Care wing at facility that has a current census of 38. (continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff did not keep resident from being inappropriately touched by another resident. It is alleged that on 5/3/26 facility staff did not maintain a safe environment resulting in R1 being sexually assaulted by R2 at the facility. LPA interviewed Local Law Enforcement who also investigated this allegation and they informed LPA that the outcome was a DA reject due to both individuals having a diagnosis of dementia and both residents having cognitive disabilities that make it difficult to determine if either of the residents knew what they were doing was/is wrong or inappropriate. LPA interviewed R2 in their private room and they denied the allegation, R2 stated they don’t touch people, have never assaulted anyone and has never had anyone assault them. LPA interviewed R1, they denied the allegation, stating that they have never been assaulted and feel safe at the facility. Interviews with R3-R5 were conducted and each resident denied the allegation and stated that they have never been touched inappropriately and feel safe at the facility. LPA conducted interviews with 5 staff and each denied the allegation, staff stated that although R1 and R2 are often very friendly with each other and seem to enjoy each other’s company there was no thought of this being assault. S3 stated that although the incident of both residents being R2’s room and touching each other’s arms did happen there was nothing during their investigation to determine this as sexual assault. Interviews with S3-S5 revealed that staff are aware that R1 and R2 are friendly with each other and are monitored to ensure they are not in each other’s private rooms, if both residents are not observed in the common areas staff will conduct rounds to ensure both are safe and not left unattended inside of one their rooms. LPA interviewed 1 witness and they stated during their visits they have seen R1 and R2 speaking and interacting in common areas such as dining and activity area, however, they have never seen them touching or left alone in an unattended area. Additionally, LPA toured memory care wing to ensure both R1 and R2’s bedrooms are not neighboring each other and there is sufficient space separating both rooms and are on opposite ends. Based on statements and interviews conducted with staff/residents/witnesses, there was not enough supportive evidence to concur with the reported allegation. 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. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 28-AS-20260629161155

Allegation investigated: Staff are not providing adequate food service

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint investigation visit on 07/06/2026 to deliver findings regarding the above allegation. LPA was greeted by Executive Director William Boles and facility staff. LPA explained the purpose of the visit. During the investigation, LPA reviewed and obtained copies of the Resident Roster, Staff Roster, R1's Face Sheet, R1's Admission Agreement, R1's Care Plan, R1's individualized food menu, food service delivery logs, Resident Meal Documentation Forms, concierge email communications, and the employee Performance Counseling Memo related to the incident. LPA also conducted a tour of the facility and interviewed five (5) staff members (S1–S5) and four (4) residents (R1–R4). The investigation further included a review of the facility's meal delivery documentation and records pertaining to the allegation. (continued on 9099C) Substantiated Allegation: Staff are not providing adequate food service It is alleged that facility staff failed to provide adequate food service by not delivering a scheduled meal to a resident receiving in-room meal delivery services. Specifically, it is alleged that R1 did not receive her lunch on June 26, 2026, despite being enrolled in the facility's meal delivery program, and that similar incidents have occurred on prior occasions. During staff interviews, staff explained that R1 receives her meals in her room and that the culinary staff are responsible for preparing and delivering meals to residents receiving in-room meal service. Staff reported that the facility utilizes meal tracking tools, Resident Missed Meal Documentation Forms, and concierge communication to monitor meal deliveries and identify missed meals. Staff also stated that residents' families may occasionally arrange outside food deliveries or take residents into the community for meals and notify the concierge when a facility meal is not needed. Initially, staff were unaware of any missed meal involving R1 on 06/26/2026. However, after reviewing concierge email communications and additional documentation, staff confirmed that R1 did not receive her scheduled lunch on 06/26/2026 because a staff member failed to deliver the meal. Staff further confirmed that the employee received disciplinary action for failing to follow the facility's meal delivery procedures. R1 stated that her meals are routinely delivered to their room and recalled missing a meal. R1 reported that when they do not receive a meal, they contact their daughter rather than notifying facility staff. Interviews with R2 through R4 revealed no concerns regarding the facility's meal service or food delivery, and the residents reported they consistently received their meals as scheduled. Documentation reviewed, including concierge email communications, meal delivery records, and the employee Performance Counseling Memo, corroborated that R1 did not receive her scheduled lunch on 06/26/2026 and that the facility addressed the incident through employee disciplinary action. Based on LPA's interviews which were conducted and record review, the preponderance of evidence standard has not been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Jul 6, 2026 · control 28-AS-20260629103741

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(1) · Plan of correction due date: Jul 24, 2026

(b) The following food service requirements shall apply: (1) Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day. Exceptions may be allowed on weekends and holidays providing the total daily food needs are met. Not more than fifteen (15) hours shall elapse between the third and first meal. This requirement was not met as evidenced by: Based on interviews and records reviewed, it was determined that the facility failed to provide R1 with theor scheduled lunch meal on 06/26/2026, as required. The facility's failure to ensure R1 received her scheduled meal poses/posed an immediate risk to the resident's health, safety, and personal rights.the state’s words, verbatim · CDSS document, Jul 6, 2026

Plan of correction: The licensee shall submit a written plan describing how the facility will ensure residents receiving in-room meal service receive all scheduled meals. The licensee shall provide proof that staff have been trained on the meal delivery procedures and how missed meals will be documented and prevented.

Allegation investigated: Staff did not provide responsible party with resident's records in a timely manner.

Licensing Program Analyst (LPA), Mayra Cota, conducted 10-day complaint investigation visit regarding the above-mentioned allegation. LPA met with Debbie Valdez, Business Office Director, and the reason for the visit was explained. The investigation consisted of the following: LPA obtained copies of staff and resident rosters, toured the facility, and conducted interviews with Staff 1 (S1) and (10) residents. The investigation revealed the following: ***Continues on LIC 9099-C*** Substantiated The investigation revealed the following: It is alleged that resident’s responsible party has been attempting to obtain a copy of their records, but facility has not provided them even after requesting the record in writing. It is also alleged that responsible party has not been given any indication from the facility as to when they will receive them. Interview with S1 indicated that the facility has a protocol in place for record requests. However, interview with S1 revealed that upon S1’s initial hire to the facility, S1 was still becoming familiar with the facility’s policies regarding resident document requests. When the initial request from R1’s responsible party was made to the corporate office to obtain R1’s records on 4/23/2026, S1 stated that they were waiting for corporate to follow-up due to S1 still becoming familiar with their role in the release of resident records. S1 stated that the facility did not refuse to provide R1’s responsible party with the requested records. S1 stated that R1’s responsible party eventually obtained R1’s records via email on 5/22/2026 during a visit they conducted to the facility. S1 stated that the facility does not have a specific turn-around time to follow up on record requests; however, S1 acknowledges that there was a communication breakdown and the request was not followed up by staff. S1 further indicates that staff communication could have been better and staff could have “acted quicker” to provide R1’s records to their responsible party. Interviews with (10) residents indicated that their needs are being met by facility staff and have no concerns regarding their care. Interviews conducted corroborate the allegation that the facility did not provide R1’s responsible party with resident’s records in a timely manner. LPA substantiated the allegation above based on the evidence obtained during this investigation. A finding of substantiated means the allegation is valid because the evidence meets the preponderance of the evidence standard. LPA cited the deficiency below per California Code of Regulations (CCR) Title 22. Exit interview was conducted with Debbie Valdez, Business Office Director, and a copy of the report, LIC 9099-D and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Jun 1, 2026 · control 28-AS-20260525161832

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: Jun 22, 2026

87468.1(a)(9) Personal Rights of Residents in All Facilities: (a) Residents...shall have all of the following personal rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement is not met as evidence by: Written request for resident records (R1) was not followed up on in a timely manner due to inadequate communication from staff.the state’s words, verbatim · CDSS document, Jun 1, 2026

Plan of correction: Licensee will submit plan for resident record requests to be conducted effectively and in a timely manner. The plan will indicated a description of staff duties for each step in the record request process. Licensee will email the plan to LPA by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced Case Management Visit-Incident on 05/08/26, stemming from incident reports received on 04/28/26, 05/01/26 and 05/06/26. LPA was greeted by Business Office Director Debbie Valdez and the purpose of the visit was explained. During today’s visit, LPA Gonzalez obtained copies of the following documents for R1 and R2: physician report, service plan and resident assessment. LPA toured the facility and interviewed S1. According to Unusual Incident/Injury Report received on 04/28/26, staff reported that resident #1 (R1), a memory care resident, was observed to have walked out of the building into the main parking lot of the facility. Staff was able to successfully redirect R1 back inside and R1 was escorted back to the memory support unit. An internal investigation was conducted and S3 was terminated due to admitting to allowing R1 to exit alone without supervision. R1’s service plan was updated and R1’s primary care physician was notified. continued on LIC 809C According to Unusual Incident/Injury Report received on 05/01/26, staff reported that resident #2 (R2), a memory care resident, was observed exiting their apartment through the window. Staff followed R2 to the parking lot and redirected R2 back into the community. R2 began exhibiting aggressive behaviors. R2 had a one-on-one companion put in place immediately to prevent further behaviors. The window in R2’s apartment was reinforced to prevent another occurrence. R2’s primary care physician was notified. According to SOC 341 Report of Suspected Dependent Adult/Elder Abuse received on 05/06/26, staff self-report that R2 engaged in an inappropriate behavior by having R3 up against the wall and R2 had their hands down R3’s pants. R3 said “no” and pushed R2 away. Staff intervened and redirected R2 and R3 back to their rooms. Families and law enforcement were notified. LPA Gonzalez may return to gather additional information. Exit interview was conducted. A copy of this report was provided to Business Office Director Debbie Valdez.the state’s words, verbatim · CDSS document, May 8, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual visit. LPA was greeted by staff and the purpose of the visit was explained. Executive Director Michele Johnson and Maintenance Director Rene Sandoval assisted with the tour. The facility is licensed to serve age range 60 and over, 148 non-ambulatory of which six (6) may be bedridden. Bedridden is approved for all first and second floors. The facility has a hospice waiver for 10. Approved for delayed egress. The facility is a two-story building located in a residential area of Glendora operating as an RCFE with a Memory Support unit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Operational Requirements: Facility is operating within the limitations of their license. They have 10 residents under hospice and 1 bedridden resident. LPA observed current liability insurance. Physical Plant/Environmental Safety: During facility's tour, LPA observed all common areas in good repair. Carbon monoxide and smoke detectors are located in every resident room. A total of 8 residents' rooms for assisted living, and memory support were selected at random for inspection. Each room contained the required furnishing, with sufficient lighting, and bedding supplies. Linens were observed to be clean and in good repair. continued on LIC809C Water temperature was tested in each resident bathroom and measured between 113°F - 122 ° F, which is not within the required 105-120 degrees F. Bathrooms were observed with grab bars and non-slip mats or flooring. Disinfectants, cleaning solutions, and sharps are locked and not left unattended. Passageways, hallways, stairways are clear of debris and obstructions. Auditory signal/pendant buttons were tested for 3 residents and staff responded less than 4 minutes. Facility has a fire sprinkler system throughout. Fire extinguishers were observed throughout the facility. Delay egress exit doors were tested and in working condition. Elevators were observed working. There are no pools or large bodies of water. Resident Rights/Information: License, Let us Know (PUB 475), Ombudsman, and personal rights posters were posted in the hallway. Food Services: LPA toured the commercial kitchen and observed good quality/commercial food supplies for at least 2 days of perishables and 7 days of non-perishables. Kitchen was observed clean and free of pest. Cleaning supplies were observed stored away from food supplies. Staff were observed practicing hygiene and infection prevention. A list for residents with modified diets was observed. Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in medication carts in each medication room. LPA reviewed medication for 5 residents. Facility uses EMAR and medications are dispensed as prescribed. Resident Records/Incident Reports: LPA reviewed 8 residents files. Files were available electronically and each contained admission agreement, medical assessment, TB clearance, a current needs and care appraisal, pre-appraisal. Disaster Preparedness: LPA obtained a copy of and reviewed emergency disaster plan LIC 610E. Evacuation chairs were observed in staircase. Emergency drills are conducted quarterly; last emergency drill was conducted on 01/22/2026. continued on LIC 809C page 3 Staffing: Administrator certificate was reviewed for Michele Johnson. Documents were submitted in 2023 to licensing for change of Administrator. During today's visit, LPA received documents to review for the change of Administrator. CPR/First aid training was observed for staff. Personnel Records/Staff Training: LPA reviewed 8 staff files. Files included; TB clearance, health screening, background clearance, personnel record, and training. Planned Activities: Facility has an Lifestyle Director to coordinate activities provided at the facility. LPAs observed various rooms throughout the facility with puzzles, reading areas, music, crafts, activities and movies. Residents with Special Health Needs: Facility is serving 1 bedridden resident and 11 residents on hospice. Memory Support unit residents do not have access to knives/sharps, chemicals or medications, unless the physician allows them to have access to any. A delay egress system was observed and tested in the Memory Support unit. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were cited during today’s visit. Exit interview was conducted with Michele Johnson and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 29, 2026

Allegation investigated: Licensee does not ensure an adequate supply of PPE is provided for staff. Licensee did not ensure infection control measures were properly implemented. Staff did not maintain documentation of the resident’s medical history and current health status.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit regarding the above stated allegations. LPA met with Michele Johnson, Executive Director and explained the purpose of the visit. The investigation consisted of the following: On 12/23/2025, LPA toured the facility, inspected PPE supplies, obtained/reviewed copies of the staff and resident rosters, Invoices for PPE supplies (last 3 months), and Resident #1 (R1) - Resident #3 (R3) files. LPA also interviewed Staff #1 (S1) - Staff #5 (S5). LPA also requested the Executive Director/House Services Director to email additional documents pertinent to the investigation. During today's visit, LPA obtained resident & staff rosters, additional documents related to the investigation such as Hospice nurse noted and interviewed Witness #1 (W1) and Resident #1 (R1) - Resident #10 (R10) from Memory Care and Assisted Living units. *****CONTINUED ON LIC 9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: "Licensee does not ensure an adequate supply of PPE is provided for staff." It is alleged that facility has inadequate supply of PPE for staff to use while providing care to the resident, and prior to entering the resident rooms and no PPE for staff to use the first 2 days. (5) of (6) staff interviewed stated that PPE supplies are adequate and available for staff to use. Some staff indicated that they conduct weekly audits of their supplies such as gloves, masks, med cups, hand sanitizers and replenish them as needed. S2 stated that their PPE supplies are ordered through Amazon which offers expedited delivery, often with same-day delivery. (1) of (6) staff interviewed stated that although they don't know where to get the PPE supplies, they get it from their supervisor if they ask. (10) of (10) residents interviewed denied the allegation and stated that the facility always have masks or sanitizers available. During the visit on 12/23/2025, LPA observed sufficient stocks of PPE supplies in cabinets in the med room, storage room and in the office of the House Services Director. Therefore there was insufficient evidence to corroborate with this allegation. In regards to the allegation: "Licensee did not ensure infection control measures were properly implemented." It is alleged that on 12/16/2025, staff learned that R1-R3 have different kinds of infections and found out of their infections during shift change since the administrator did not inform them of this. Staff interviewed stated that the hospice nurse for R1 visited R1 on 12/15/2025 and ordered a new antibiotic medicine because there was a high probability that R1's illness was contagious. However, some staff stated that they still followed the infection control guidelines, although there was no confirmed diagnosis that R1 has an infectious disease. Some staff stated that they were using gloves and masks when providing care to R1. S6 stated that PPE supplies such as gowns, masks, and gloves were placed outside the residents’ rooms on the same day they learned about the infection. On the evening of 12/16/2025, S6 also stated that they texted the care team with the preventative measures and instructions. Documents reviewed revealed that staff were trained on infection control measures and the facility has implemented guidelines. Therefore, there was insufficient evidence to corroborate with this allegation. In regards to the allegation: "Staff did not maintain documentation of the resident’s medical history and current health status." It is alleged that on 12/16/2025, R1-R3 have infections but the administrator did not tell any of the direct staff about any of the residents infections. Additionally, when R1 was admitted to the facility, this recurring infection information was never noted in their chart history. Some staff stated that they were not aware of R1's pre existing condition as they were not listed on R1's medical history nor the current physicians report. Some staff interviewed stated that when they notified R1'sfamily about the infection flare up, the family said that they were aware of R1's condition a long time ago, but forgot to mention it to the facility staff when R1 was pre-appraised. (10) out of (10) residents interviewed stated that the staff maintain a record of their medical history as well as their current health status. Based on documentation reviewed by LPA, the staff failed to communicate and flag R1-R3's complex or changing health needs to the care team, however, the facility maintain a timely chart documentation of R1-R3's care plan and medical records. Additionally, facility conducts staff training on documentation. Therefore there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 28-AS-20251218103514

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Executive Director Michele Johnson at approximately 8:00 AM and explained reason for visit. The facility is a two-story building with a memory care unit, operating as a Residential Care Facility for the Elderly. It is licensed to serve (148) older adults, ages 60 and over. There is a fire clearance approved for (148) non-ambulatory residents, of which (6) may be bedridden, and includes bedridden rooms approved on both first and second floors and delayed egress. There are currently (10) residents receiving hospice care. It has an approved Dementia Care Plan and a Hospice Waiver approved for (10) residents. LPA observed random resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. Resident bathrooms and shower rooms are equipped with required grab bars and non-skid mats. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility has a commercial kitchen. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. The call system was tested in resident bedrooms and were operational. The facility is equipped with surveillance cameras in common areas. One water fountain was observed in the center of the assisted living side, courtyard; however, it contained a small amount water. There is a shaded seating area for the residents located. Passageways and exits are free of obstruction. SEE LIC 809c Seven (7) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Ten (10) residents files were reviewed and included physicians report, TB clearance, and appraisal needs and service plan. Last fire/earthquake drill was conducted in February of 2025. Infectious control plan was reviewed. Three (3) staff and six (6) residents were interviewed. Random resident medications were reviewed. Medications are centrally stored and locked MAR log is used. LPA observed R11 medication missing Deficiency cited. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 28, 2025

Allegation investigated: Staff did not prevent residents from sustaining multiple falls. Staff did not prevent residents from sustaining injuries while in care. Staff left residents in soiled depends for a long period of time.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegations. LPA met with Claudia Bauer, Business Office Director and Andrea Barraza, Memory Support Director and explained the purpose of the visit. The investigation consisted of: LPA toured the facility (Assisted Living and Memory Care Unit) and obtained the following documents: Staff and Resident rosters, Memory care staff schedule list, Fall reduction program/policy, Staff In-service training log (dementia care, fall risk, documentation, status checks and changing schedule) and Resident #1 (R1) - Resident #3 (R3)'s file such as: Identification and Emergency Information, Admission Agreement, Physician's Report, Resident Appraisal, Appraisal /Needs and Services Plan, Medication Record/list, Medication Administration Records (Dec. 2024-Jan. 2025), Incident reports (Oct. 2024-Jan. 2025), Daily care/progress notes (Nov. 2024-Jan. 2025), Incontinence change schedule (Nov. 2024-Jan. 2025) and Body check (post falls) documentation (Nov. 2024-Jan. 2025). LPA interviewed Staff #1 (S1) - Staff #4 (S4), Resident #4 (R4) - Resident #12 (R12) and telephonically interviewed Staff #5 (S5). LPA attempted to interview Resident #1 (R1) - Resident #3 (R3) but unsuccessful due to their cognitive abilities.*****CONTINUED ON LIC9099-C***** Unsubstantiated In regards to the allegation: "Staff left residents in soiled depends for a long period of time." It is alleged that staff observed multiple residents left in their feces and urine for a few hours last week. (4) out of (5) staff interviewed denied the allegation and stated that they have adequate staffing at this time. S1 stated that they do staffing based on acuity and there are 4-5 staff assigned per shift. Staff stated that they conduct rounds every 2 hours per shift or as needed, not only to change undergarments for incontinent residents, but to check if residents are doing well or need other assistance. Interviewed residents denied the allegation. (5) incontinent residents who were interviewed stated that staff assist them all the time in toileting, changing and never left them in soiled undergarments. Therefore there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with staff, residents, review of residents' files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Andrea Barraza, Memory Support Director. The investigation revealed the following: In regards to the allegation: "Staff did not prevent residents from sustaining multiple falls." It is alleged that most of the residents are falling out of their beds and staff are not doing anything to prevent the falls. And recently, a resident who is a fall risk, fell when getting out of bed. 4 out of 5 staff interviewed denied the allegation and stated they have adequate staffing. Staff interviewed stated that they have completed training regarding fall risk, dementia care and documentation. S1 stated that majority of the residents do not have one-on-one care. S1 stated that the facility has a fall reduction program and staff are aware of the protocol to prevent residents from falling. Interviewed staff indicated that they use different intervention techniques to prevent them from falling like providing fall mats, bed rails for hospice residents, do strength and balance exercises to improve their balance, encouraging residents to stay in the common areas, and/or attend activities for extra supervision. Interviews with residents stated that staff do all the best they can to prevent the residents from falling. Some interviewed residents who experienced a fall stated that the staff conducted body checks, assessed and provided first aid on them. Interviewed residents stated that staff are supportive and conduct routine checks daily. LPA observed enough staff members working and assisting residents during the visit. Therefore there was insufficient evidence to corroborate with this allegation. In regards to the allegation:"Staff did not prevent residents from sustaining injuries while in care." It is alleged that there have been multiple falls at the facility and residents have sustained black eyes and “busted faces” due to these falls. Additionally, a resident fell and hit her face on the night stand, resulting in a cut on her face close to her eyebrow. Interviewed staff denied the allegation. S1 stated that she was aware that R2 who is receiving hospice care experienced an unwitnessed fall and when it occurred, R2 was promptly attended to, evaluated and underwent a body check by the staff. S1 stated that R2 did not have a one-on-one care and that R2 had a minor cut above her eyebrow, but there was no apparent trauma. Nonetheless, 911 was called to assess R2 and the paramedics suggested transporting R2 to the hospital. R2 was not hospitalized and did not sustain major injury. Interviewed staff indicated that they use different intervention techniques to prevent residents from falling and sustaining injuries like providing fall mats, bed rails for hospice residents and encouraging residents to stay in the common areas, and/or attend activities for extra set of eyes. Interviews with residents stated that staff do all the best they can to prevent residents from sustaining injuries. Interviewed residents stated that staff assist them with their needs and monitors them regularly. LPA observed enough staff members working and assisting residents during the visit. Therefore there was insufficient evidence to corroborate with this allegation.the state’s words, verbatim · CDSS document, Feb 4, 2025 · control 28-AS-20250131095225

Allegation investigated: Licensee does not ensure facility is adequately staffed to meed resident's needs Staff are not providing adequate laundry services for resident's Staff leave resident's in urine soaked clothing for an extended period of time Staff are not dispensing medications as prescribed Licensee does not ensure enough staff are present to prevent inappropriate interaction between resident's Facility did not report unwitnessed falls to authorized representatives

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Business Director Claudia Bauer and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 11/19/2024, LPA interviewed Staff #2 - Staff #9, Resident #1 - Resident #10, and toured the facility. LPA obtained copies of the following documents: staff roster, resident roster, SIR reports for unwitnessed falls, laundry schedule, receipts, and emails for dryer purchase. LPA obtained Individual service plan, progress notes and physician report for R6. During todays visit LPA Gutierrez checked medication and delivered findings. SEE 9099C Unsubstantiated In regard to the allegation “Licensee does not ensure facility is adequately staffed to meet resident's needs”, it is alleged that due to the lack of staffing residents are not being changed timely when they use the restroom leading to UTI and that residents requiring 2/3 people assist are not being helped due to staffing issues. During interviews with staff eight (8) out of nine (9) staff stated that they have enough staff members. S5 stated “We are always fully staffed. If we ever feel like we are busy our MedTech step in to and help”. S6 stated “Yea we usually have three to four care partners per shift. I feel there is enough most of Assisted living are independent”. During interviews with residents seven (7) out of ten (10) residents feel there is enough staff to meet their needs. R5 did feel there is not enough staff and response time is to slow when pendants are pushed. In regard to the allegations “Staff are not providing adequate laundry services for resident's and “Staff leave residents in urine-soaked clothing for an extended period of time” it is alleged that due to lack of staffing residents’ laundry is not being completed and resident are being left in urine-soaked clothing for extended periods of time. During interviews with staff eight (8) out of nine (9) staff stated that they have a laundry schedule they follow, and they do a diaper check every two hours. S4 stated that if the needs and service plan indicate there is an incontinence problem they check more often. During interviews with residents nine (9) out of ten (10) residents felt that their laundry always gets done in a timely manner and have never been left or witnessed any resident in a urine-soaked clothing. R9 did state that he/she witnessed a resident in a wheelchair asking staff to be changed. During visit LPA observed multiple washers and dryers in both the memory care unit and assisted living unit. LPA did a walkthrough of several rooms and did not witness any urine-soaked laundry. In regard to the allegation “Staff are not dispensing medications as prescribed”, it is alleged that staff is not disposing medication as required. During interviews with staff six (6) out of nine (9) staff stated that all medication is given as prescribed. S6 and S7 had no knowledge of how medication is dispensed. S4 stated “Sometimes we have pharmacy medication on hold for insurance reasons if it’s not covered”. During interviews with residents eight (8) out of ten (10) residents stated they are getting there medication as prescribed. R5 expressed the only problem was at noon time for eye drops. R6 stated only when they are away at mass that there not given medication and marked as a refusal. LPA checked medication for memory care unit and assisted living unit and no discrepancies were found. SEE 9099C In regard to the allegation “Licensee does not ensure enough staff are present to prevent inappropriate interaction between resident's”, it is alleged that R4 who resides in the assisted loving side constantly tries to enter the memory care unit and that R4 has been caught kissing another resident and walking resident to assisted living side without staff knowledge. During interviews with staff eight (8) out of nine (9) staff stated there are no inappropriate interaction between residents. Staff indicated that they are aware when anyone enters the memory care unit as they need to be let in. S4 stated” We don’t prohibit residents from interacting with each other unless there is a specific order for that”. During interviews with residents ten (10) out of ten (10) state there was nothing inappropriate going on between residents. R3 stated “No, they are very careful they know our names”. R4 stated “staff is aware and said I can go to the common areas just not the rooms. I understand that it is a safety concern”. In regard to the allegation “Facility did not report unwitnessed falls to authorized representatives”, it is alleged that the facility has had several unreported falls and are not reported due to “too much paperwork”. During interviews eight (8) out of nine (9) staff indicated they always report falls. S8 stated “We report everything. I have never heard that”. Staff provided LPA with incident report for unwitnessed falls. During interviews with residents nine (9) out of nine (9) residents were unaware if staff reports falls. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Business Director Claudia Bauer.the state’s words, verbatim · CDSS document, Dec 6, 2024 · control 28-AS-20241112145228

Allegation investigated: Staff did not prevent the resident from attacking another resident resulting in injuries. Staff did not prevent residents from disturbing other residents.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent visit regarding the above allegations. LPA met with Michele Johnson and explained the reason for the visit. The investigation consisted of the following: On 11/7/23 LPA Galarza conducted an unannounced health and safety visit at the facility no deficiencies were noted during that visit. Documents were collected: resident #1-#3 (R1 - R3) file documents, incident reports, maintenance work orders, cycle meal menus from July to October 2023, special diet list, food handling certificates, kitchen server "to do list", dietician services agreement, resident roster, and LIC 500 Personnel Report.On 11/7/23 Investigation Bureau of the Department(IB), Investigator Laura Garcia was assigned to conducted interviews with staff, family members, and obtained medical records for R1 and R2. On 3/25/24 LPA Flores interviewed 3 staff over the phone. On 4/23/24 LPA Flores interviewed 3 additional staff and 7 residents, toured the memory care unit observed 7 random rooms and delivered findings. (CONTINUED ON LIC 9099C) Substantiated The investigation revealed the following: regarding allegations: Staff did not prevent the resident from attacking another resident resulting in injuries and Staff did not prevent residents from disturbing other residents. It is alleged R2 is wandering and randomly going into residents’ rooms and on 10/30/23 R2 went into R1’s room, punched R1 in the face, stomach, leg and pulled R1 off the bed, and R1’s roommate was attacked as well. On 10/30/23 facility staff called 911 and requested services due to an assault at the facility. Upon arrival of police officer and paramedics. Police officer observed R1 was being treated by fire department paramedics with blood dripping from the left side of the head. R1 stated at that time to have been pulled of the bed and pushed by a resident causing R1 to fall and getting hurt. Staff assisting R1 stated that R2 had also attacked Resident #4(R4), R1’s roommate. R1 was taken to the hospital and was treated for a head contusion and laceration on the left side of the head. Interviews conducted revealed that 5 out of 5 staff interviewed by IB investigator stated to be aware of R2’s aggressive and wandering behaviors. A staff stated R2 had shown aggressive behavior towards two staff providing care, one of those two staff was injured. Staff also stated that R2 had punched R3 in the past. However, no changes to R2’s care were provided. R2’s nurse practitioner stated also to be aware of the incidents and R2’s behavior. Document review revealed, on 10/27/23, R2’s needs and service plan was updated noting R2 needs 2-3 caregivers to assist with R2’s care and nurse practitioner noted an adjustment for medication due to behaviors. Based on investigation conducted R1 was seriously injured at the facility by R2. The facility was aware of R2’s behaviors and no additional supervision was provided during shifts or shift changes to prevent R2 from entering other resident’s rooms and/or prevent aggressive behavior towards other residents. Based on interviews and review of documentation regarding the allegation, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to Resident #1 sustaining a laceration to the head due to lack of supervision of Resident #2 while in care. Refer to LIC 421IM*** The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the injury of the resident is due to neglect. Exit interview was conducted with Michele Johnson and a copy of this report, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegation: Staff not providing resident with meal(s). It is alleged the cooks do not send food over to the memory care side and meals are not being provided to resident during mealtimes. Interviews conducted revealed 6 out of 7 residents interviewed stated to receive 2-3 meals a day, residents have not missed a meal, and meals are timely every day. 1 out of 7 residents interviewed stated the food can be late hours. Interviews with staff revealed food is serve timely, food is provided to memory care unit before it is provided to the assisted living section, and food is brought to the memory care unit by the servers. LPA observed memory care unit’s kitchen which provides an area to maintain meals warm and be able to serve residents in the dining area. Per documents review the facility has a menu designed to accommodate the needs of the residents and the staff are qualified to prepare and provide meals. 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, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Resident’s toilet is in disrepair. It is alleged on multiple occasions toilet in resident’s room has been overfilled to the “brim” with urine and feces. Interviews conducted revealed, 7 out of 7 residents interviewed stated that the toilet is always in working condition. Interviews conducted with staff revealed, facility has a system in which work orders are added for maintenance department to response. Per staff, maintenance department responds right away, even thought they have 36 hours to respond and repair anything in the work order. If a toilet is clogged the maintenance department responds even faster and in addition plungers can be found in the maintenance closets accessible to any staff to assist with unclogging the toilets if needed. LPA Flores observed 7 rooms in the memory care unit and each room had a working toilet at the time of the visit. Documents reviewed revealed three work orders for the following dates: 7/25/23, 8/25/23, and 9/28/23 for clogged/overflowing toilet in room #123 in which one of the reports shows it took 30 minutes to resolve and each was place in the evening after 4:45pm and set as completed by the next day before 11:10am. 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, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Michele Johnson and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 23, 2024 · control 28-AS-20231031163231

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 24, 2024

87468.2 Additional Personal Rights of Residents...: (a)... shall...: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on document review and interviews licensee did not ensure R2 was provided with supervision due to aggressive behaviors to prevent R1 obtaining laceration to the head which poses an immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Apr 23, 2024

Plan of correction: Administrator will certify in writing and create a plan which will address the steps to take when a circustance of wandering and aggressive behaviors are observed in a resident to the department by POC due date 4/24/24. ***An immediate Civil Penalty of $500.00 is being issued today, due to Resident #2 sustaining a laceration to the head due to lack of supervision of Resident #1 while in care. Refer to LIC 421IM***

Allegation investigated: Staff did not prevent a resident from biting another resident in care. Staff did not provide adequate supervision to a resident in care. Staff did not properly conduct a urine test for a resident in care. Facility illegally evicted a resident in care. Staff did not ensure that resident was fed. Staff did not ensure that resident's hygiene needs were being met.

**Please note: This report will supersede the report dated 11/30/23 to change information previously noted. However, the findings to all allegations will remain the same: Unsubstantiated.** Licensing Program Analyst (LPA) V. Maldonado made a subsequent, unannounced, complaint visit to the facility, for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Executive Director, Michele Johnson, and explained the purpose for the visit. On 11/21/23, LPA Maldonado made an initial complaint visit, to investigate the above-mentioned allegations. During the visit, LPA Maldonado obtained a copy of the resident and staff roster, and obtained the following documents for Residents# 1-3 (R1-R3): Facesheet, Physician's Report, Needs and Services Plan, and incicent reports for the months of September-Novemeber 2023. LPA also obtained Medical Records and Shower charts for R1, and Hospital Discharge documents for R2. Interviews were conducted with Staff# 1-3 (S1-S3) and Residents# 3-6 (R3-R6). Telephone interviews were attempted with Staff# 4-6 (S4-S6), however S6 did not answer or call back. Interviews with R1 and R2 were not possible during the visit, due to residents no longer residing at the facility. (Report Continued on LIC9099-C...) Unsubstantiated LPA also attempted to conduct a telephone interview with R1's physician, but was unsuccessful. On 11/30/23, LPA Maldonado conducted a subsequent visit to the facility for the purpose of continuing the investigation. LPA conducted an interview with Staff# 6 (S6). The investigation revealed the following: Regarding allegation: Staff did not prevent a resident from biting another resident in care. It is alleged that on 10/30/23, at about 11:00PM, an incident occurred where R1 wandered into another resident's room and R1 had a bite mark on R1's arm, as R1 was not being monitored properly. Per staff interviews, (5) of (6) staff stated that R3 had pressed R3's pendant for assistance. Upon arrival, staff discovered R3 holding down R1. R1 had bitten R3 and R3 bit R1 back to try to get R1 off from R3. Staff were able to separate the residents and law enforcement was called to file a report. (6) of (6) staff stated they were aware that R1 was a wanderer and had attempted to enter other resident's rooms prior to this incident. However, R1 was redirected when observed attempting to enter other rooms and staff did not have concerns prior to the incident. Per R1's Physician's Report, dated 9/07/23, it was noted that R1 had a history of aggressive behaviors. Per resident interviews, R3 admitted to biting R1 due to R1 entering R3's room while R3 was sleeping and attempting to pull R3 off R3's bed. R3 stated staff took quick action and were able to remove R1 from R3's bedroom. Per incident report dated 10/30/23, the facility reported the incident of R1 biting R3 and R3 biting R1 in return. Regarding allegation: Staff did not provide adequate supervision to a resident in care. It is alleged that facility staff were not aware that R1 was often attempting to enter other resident's rooms and taking their personal possessions, and were not aware of R1's whereabouts. Per staff interviews, (6) of (6) staff stated they were aware that R1 was a wanderer and had attempted to enter other resident's rooms prior to this incident. However, R1 was easy to redirect when observed attempting to enter other rooms and staff were aware of resident's whereabouts as R1 was always walking the halls, where staff could see R1. (6) of (6) staff stated that no complaints from other residents, or suspicion, that R1 was taking others' personal possessions, was reported. (4) of (6) residents interviewed could not corroborate the allegation. Regarding allegation: Staff did not properly conduct a urine test for a resident in care. It is alleged that an LVN at the facility did not properly store or handle a urine sample obtained for R1, as the test results were found to be invalid upon testing, by R1's physician. LPA attempted several times to conduct an interview with R1's physician regarding the allegation, but was unsuccessful. Per staff interviews, (5) of (6) staff could not corroborate the allegation. S1 stated that a urine sample was collected for R1 and results were provided by the lab company. S1 could not recall the exact dates. Per R1's medical records, on 10/03/23, the facility received a physician's order to collect a urine sample. A "Final Report" from the lab company, dated 10/20/23, indicate that a urine sample was collected and received for R1 on 10/18/23 and results regarding the sample were provided to the facility on 10/20/23. (Report continued on LIC9099-C... (4) of (6) residents interviewed could not corroborate the allegation. Regarding allegation: Facility illegally evicted a resident in care. It is alleged that on 11/02/23, R1 was informed that R1 needed to leave the facility immediately, without any prior or proper notice. S1 stated that on 11/02/23, R1's responsible party took R1 to the hospital. S1 stated to have contacted R1's responsible party to inquire on R1's return date, which was the following day. S1 was notified shortly after by other facility staff that R1's responsible party had came to pick up R1's furniture and left without notice. Per S6, R1 did not give proper notice prior to moving out. S6 stated that R1's responsible party contacted S6 to inform S6 that R1 was living elsewhere and would not be returning to this facility. S6 denied evicting R1. (6) of (6) staff interviewed stated to not know the reason for R1 moving out of the facility. (4) of (6) residents interviewed could not corroborate the allegation. Regarding allegation: Staff did not ensure that resident was fed. It is alleged that staff were not making sure that R1 was eating R1's dinner for the first month that R1 resided at the facility. Per staff interviews, (6) of (6) staff denied the allegation and stated that they would report any issues/concerns of residents refusing meals or not eating. Per R1's Needs and Services Plan, R1 required notice of mealtimes. (6) of (6) staff stated that upon admission to the facility, it was noted that R1 was active and could not sit for a proper meal. However, staff ensured R1 was eating meals by providing more finger foods due to R1 always "on-the-move". Per S1, R1's physician was notified of this. Per R1's medical records, the facility received a physician's order dated 9/29/23, indicating "ok to do finger food". (4) of (6) residents could not corroborate the allegation. Regarding allegation: Staff did not ensure that resident's hygiene needs were being met. It is alleged that R1 was combative and facility staff were unable to bathe the resident for three weeks. Per Skin Integrity Monitoring forms, it was discovered that on 9/16/23, it was documented that R1 refused a skin integrity check, and on 10/10/23, it was documented that R1 refused a shower. Per R1's Physician's Report, it was noted that R1 required assistance with baths. Per staff interviews, (6) of (6) staff denied the allegation. Staff stated that R1 was combative, however they made all attempts to bathe resident as needed and ensured hygiene needs were met. (4) of (6) residents interviewed could not corroborate the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore the allegations are Unsubstantiated. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Executive Director, Michele Johnson, and copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 19, 2024 · control 28-AS-20231115094705

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Executive Director (ED), Michele Johnson, and explained the purpose for the visit. During today's visit, LPA Maldonado conducted a tour of the physical plant with ED Michele, observed the facility food supplies, reviewed (5) resident medications, (5) resident files, (5) staff files. The facility is a two-story building with a memory care unit, operating as a Residential Care Facility for the Elderly. It is licensed to serve (148) older adults, ages 60 and over. There is a fire clearance approved for (148) non-ambulatory residents, of which (6) may be bedridden, and includes bedridden rooms approved on both first and second floors and delayed egress. There are currently (2) residents receiving hospice care. It has an approved Dementia Care Plan and a Hospice Waiver approved for (10) residents. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file, as required. LPA observed random resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. Resident bathrooms and shower rooms are equipped with required grab bars and non-skid mats. The hot water was tested and measured at 105*F-108*F, which is in compliance. The facility has a commercial kitchen. Food supplies was observed and was sufficient as required. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. The last fire drill was conducted on 01/19/2024. The call system was tested in resident bedrooms and were operational. The facility is equipped with surveillance cameras in common areas. (5) resident files and (5) staff files were reviewed and observed to be complete with all required documentation. (5) resident medications were reviewed and were observed to be documented properly and given as prescribed. No deficiencies were observed or cited, during today's visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 16, 2024

Allegation investigated: Staff did not prevent a resident from biting another resident in care. Staff did not provide adequate supervision to a resident in care. Staff did not properly conduct a urine test for a resident in care. Facility illegally evicted a resident in care. Staff did not ensure that resident was fed. Staff did not ensure that resident's hygiene needs were being met.

Licensing Program Analyst (LPA) V. Maldonado made a subsequent, unannounced, complaint visit to the facility, for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Executive Director, Michele Johnson, and explained the purpose for the visit. On 11/21/23, LPA Maldonado made an initial complaint visit, to investigate the above-mentioned allegations. During the visit, LPA Maldonado obtained a copy of the resident and staff roster, and obtained the following documents for Residents# 1-3 (R1-R3): Facesheet, Physician's Report, Needs and Services Plan, and incicent reports for the months of September-Novemeber 2023. LPA also obtained Medical Records and Shower charts for R1, and Hospital Discharge documents for R2. Interviews were conducted with Staff# 1-3 (S1-S3) and Residents# 3-6 (R3-R6). Telephone interviews were attempted with Staff# 4-6 (S4-S6), however S6 did not answer or call back. Interviews with R1 and R2 were not pissible during today's visit, due to residents no longer residing at the facility. LPA also attempted to conduct a telephone interview with R1's physician, but was unsuccessful. (Report Continued on LIC9099-C...) Unsubstantiated During today's visit, LPA Maldonado conducted an interview with Staff# 6 (S6). The investigation revealed the following: Regarding allegation: Staff did not prevent a resident from biting another resident in care. It is alleged that on 10/30/23, at about 11:00PM, an incident occurred where R1 wandered into another resident's room and R1 had a bite mark on R1's arm, as R1 was not being monitored properly. Per staff interviews, (5) of (6) staff stated that R3 had pressed R3's pendant for assistance. Upon arrival, staff discovered R3 holding down R1. R1 had bitten R3 and R3 bit R1 back to try to get R1 off from R3. Staff were able to separate the residents and law enforcement was called to file a report. (6) of (6) staff stated they were aware that R1 was a wanderer and had attempted to enter other resident's rooms prior to this incident. However, R1 was redirected when observed attempting to enter other rooms and did not have concerns prior to the incident. Nor was it noted that R1 had a history of aggressive behavior prior to admission. Per resident interviews, R3 admitted to biting R1 due to R1 entering R3's room while R3 was sleeping and attempting to pull R3 off R3's bed. R3 stated staff took quick action and were able to remove R1 from R3's bedroom. Per incident report dated 10/30/23, the facility reported the incident of R1 biting R3 and R3 biting R1 in return. Regarding allegation: Staff did not provide adequate supervision to a resident in care. It is alleged that facility staff were not aware that R1 was often attempting to enter other resident's rooms and taking their personal possessions, and were not aware of R1's whereabouts. Per staff interviews, (6) of (6) staff stated they were aware that R1 was a wanderer and had attempted to enter other resident's rooms prior to this incident. However, R1 was easy to redirect when observed attempting to enter other rooms and staff were aware of resident's whereabouts as R1 was always walking the halls, where staff could see R1. (6) of (6) staff stated that no complaints from other residents, or suspicion, that R1 was taking others' personal possessions, was reported. (4) of (6) residents interviewed could not corroborate the allegation. Regarding allegation: Staff did not properly conduct a urine test for a resident in care. It is alleged that an LVN at the facility did not properly store or handle a urine sample obtained for R1, as the test results were found to be invalid upon testing, by R1's physician. LPA attempted several times to conduct an interview with R1's physician regarding the allegation, but was unsuccessful. Per staff interviews, (5) of (6) staff could not corroborate the allegation. S1 stated that a urine sample was collected for R1 and results were provided by the lab company. S1 could not recall the exact dates. Per R1's medical records, on 10/03/23, the facility received a physician's order to collect a urine sample. A "Final Report" from the lab company, dated 10/20/23, indicate that a urine sample was collected and received for R1 on 10/18/23 and results regarding the sample were provided to the facility on 10/20/23. (4) of (6) residents interviewed could not corroborate the allegation. (Report continued on LIC9099-C... Regarding allegation: Facility illegally evicted a resident in care. It is alleged that on 11/02/23, R1 was informed that R1 needed to leave the facility immediately, without any prior or proper notice. S1 stated that on 11/02/23, R1's responsible party took R1 to the hospital. S1 stated to have contacted R1's responsible party to inquire on R1's return date, which was the following day. S1 was notified shortly after by other facility staff that R1's responsible party had came to pick up R1's furniture and left without notice. Per S6, R1 did not give proper notice prior to moving out. S6 stated that R1's responsible party contacted S6 to inform S6 that R1 was living elsewhere and would not be returning to this facility. S6 denied evicting R1. (6) of (6) staff interviewed stated to not know the reason for R1 moving out of the facility. (4) of (6) residents interviewed could not corroborate the allegation. Regarding allegation: Staff did not ensure that resident was fed. It is alleged that staff were not making sure that R1 was eating R1's dinner for the first month that R1 resided at the facility. Per staff interviews, (6) of (6) staff denied the allegation and stated that they would report any issues/concerns of residents refusing meals or not eating. Per R1's Needs and Services Plan, R1 required notice of mealtimes. (6) of (6) staff stated that upon admission to the facility, it was noted that R1 was active and could not sit for a proper meal. However, staff ensured R1 was eating meals by providing more finger foods due to R1 always "on-the-move". Per S1, R1's physician was notified of this. Per R1's medical records, the facility received a physician's order dated 9/29/23, indicating "ok to do finger food". (4) of (6) residents could not corroborate the allegation. Regarding allegation: Staff did not ensure that resident's hygiene needs were being met. It is alleged that R1 was combative and facility staff were unable to bathe the resident for three weeks. Per Skin Integrity Monitoring forms, it was discovered that on 9/16/23, it was documented that R1 refused a skin integrity check, and on 10/10/23, it was documented that R1 refused a shower. Per R1's Physician's Report, it was noted that R1 required assistance with baths. Per staff interviews, (6) of (6) staff denied the allegation. Staff stated that R1 was combative, however they made all attempts to bathe resident as needed and ensured hygiene needs were met. (4) of (6) residents interviewed could not corroborate the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore the allegations are Unsubstantiated. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Executive Director, Michele Johnson, and copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 28-AS-20231115094705