Cloisters of the Valley

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced case management visit to cite a deficiency observed during a case management visit that was unrelated. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Candi Laird. During the visit, it was revealed that two(2) staff members (S1 and S2) were previously working at the facility without a criminal background clearance. [Executive Director was provided with an LIC811 Confidential Names List to identify S1 and S2]. Interviews with the Executive Director revealed that S1 and S2 had been working at the facility for more than 5 calendar days. During the time of the visit, both staff were no longer working at the facility. One deficiency was cited for staff without criminal background clearance and noted on the attached LIC809-D pages. Additionally, two(2) civil penalties in the amount of $500 was assessed for two staff members without a criminal background clearance and noted on the attached LIC421BG form. The plan of correction was cleared during the visit due to staff no longer working at the facility. An exit interview was conducted with Executive Director Candi Laird, whose signature below confirms receipt of a copy of this report, the LIC811, the LIC809-D, the LIC421BG and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Sep 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Sep 15, 2026

87355 (e) All individuals subject to a criminal record review pursuant to Health ... (1) Obtain a California clearance or a criminal record exemption as required by the Department… This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above in that S1 and S2 were working at the facility for at least 5 calendar days and did not have a criminal background clearance, which poses an immediate safety risk to x out of x residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Executive director(ED) stated that the two employees were dismissed once it was known that they were not cleared. ED stated that they will continue to review staff records to verify that staff have valid fingerprint clearance and association.

Type of visit: Case Management - Incident

Licensing Program Analyst(LPA) Janet Ngallo conducted an unannounced case management visit in response to a self-reported incident. LPA introduced themselves, and was greeted by Executive Director Candi Laird, to discuss the purpose of the visit. The department received an incident report on 09/08/2026 regarding R1 presumably consuming a poisonous substance. R1 stated they consumed the substance, but there are no witnesses. The substance was left in R1's bathroom. The incident report stated R1 was sent to the hospital with no adverse reactions. During today's visit, LPA conducted interviews and reviewed records. No deficiencies were cited during today's visit. LPA provided Technical Assistance (TA) to Licensee regarding change of condition procedures and observation of the resident in RCFE's. An exit interview was conducted with Executive Director Candi Laird, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Sep 15, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst(LPA) Janet Ngallo conducted an unannounced Case Management - Deficiencies Visit. LPA was greeted by, introduced themselves to, and discussed the purpose of the visit with Executive Director Candi Laird. LPA was at the facility regarding unrelated complaints and during the facility visit, LPA received information from a staff member(S1) indicating that a false claim was made regarding another complaint case [08-AS-20260803145557]. S1 reported that administration had instructed them to provide inaccurate information to licensing. S1 stated they had not been scheduled to work during the time in question and reported receiving text message and verbal instructions from administration directing them to state that they had left the facility and later returned, when in actuality, S1 was not scheduled for the afternoon shift, resulting in delayed medication administration. A review of the staffing schedule for the week of August 2, 2026 through August 8, 2026 revealed that on August 2, 2026, the PM shift (2:00 PM-10:30 PM) medication technician assignment listed one medication technician assigned and one unfilled slot, S1 was not listed for the shift. Review of text message correspondence between S1 and administration showed messages in which administration directed S1 to report to licensing that they had left the facility for two hours and returned. One deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A plan of correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Candi Laird and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, Aug 25, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Aug 25, 2026

87207 No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by: Based on interviews and records review, the licensee provided false and misleading statements to the licensing agency regarding the staffing schedule for who was on shift to provide medications for residents. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 25, 2026

Plan of correction: Licensee self-certifies their understanding of this requirement, and has signed the attestation for self-correction under penalty of perjury. Licensee stated they will comply with this regulation throughout the duration of facility operation. The previous Executive Director that was operating the facility during the false claim is no longer employed by the facility.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced quarterly Case Management/Legal Non-Compliance visit. LPA was granted entry by and disclosed the purpose of the visit to Executive Director Tia Suuronen-Goodwin. On May 19th, 2026, the Licensee agreed on a compliance plan for the following 24 months through May 19th, of 2028. During today’s visit, LPA conducted a general overall inspection of the facility, interviewed staff, reviewed records, and evaluated licensee’s ongoing compliance with the requirements described in the LIC9111. During the visit, the facility was clean, safe, and in good repair. Records reviewed were current and complete. There were no immediate health or safety concerns. Based upon today’s observation and interviews, the facility was operating consistent with the terms of the compliance conference. No deficiencies were observed or issued as part of this compliance visit. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 16, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Tia Suuronen-Goodwin. According to the facility’s license, the facility has a maximum capacity of seventy (70) residents, of whom seventy (70) may be non-ambulatory and nine (9) may be bedridden. During today’s inspection, there were a total of sixty-eight(68) residents in care. This facility features delayed egress doors. LPA, accompanied by Tia Suuronen-Goodwin toured the interior and exterior of the facility. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to clients were compliant. There was at least 2 days supply of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters observed available to residents. Medications were labeled, as required, and stored in locked areas. (Cont. on LIC 809-C) (Cont. from LIC 809) No pools or bodies of water were observed on the premises. Per Tia Suuronen-Goodwin, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 16, 2026

Allegation investigated: Staff are not adequately supervising a resident in care. Staff made an inappropriate comment to a resident in care.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above mentioned allegations. LPA identified themselves and met with Executive Director Tia Suuronen-Goodwin to discuss the purpose of the visit and elements of the complaint. On 05/19/2026, it was alleged that staff are not adequately supervising a resident in care, and that staff made an inappropriate comment to a resident in care. The department's investigation consisted of interviews and records review. Regarding the allegation that staff are not adequately supervising a resident in care, interviews consistently reported that the facility currently has two residents(R2 and R3) who exhibit wandering behaviors. Staff consistently reported that wandering residents are redirected throughout the day, guided to activities, or escorted back to their rooms as needed. [Cont. on LIC 9099-C)] Unsubstantiated [Cont. from LIC 9099] Staff acknowledged that one wandering resident (R2) recently moved into the community and occasionally enters other residents’ rooms, however, staff stated that these incidents are brief and that redirection occurs immediately when observed or when the incident is brought to their attention by other residents. Interviews further reported that caregivers, med techs, and supervisory staff are present in the hallways throughout the day, conduct frequent checks, and work together to monitor residents who wander. Regarding the allegation that staff made an inappropriate comment to a resident in care, interviews consistently denied witnessing any staff member speak to a resident in an inappropriate or dismissive manner. Interviews reported that when other residents express frustration about wandering behaviors or other residents entering their rooms, staff respond by redirecting the wandering resident and addressing concerns respectfully, and staff denied ever responding to such complaints in a rude, dismissive, or unprofessional way. LPA attempted to interview the resident in question (R1), who was reportedly involved in a room-entry incident, but R1 was not available during the visit due to being out in the community and multiple attempts to interview by telephone were unsuccessful. Additional resident interviews reported that they have witnessed R2 wander into their rooms, however staff redirect R2 immediately, and it does not happen often. Records review of the behavioral service plan for R2, initiated on 05/11/2026, documented that R2 requires redirection, engagement in calming activities, and verbal support when wandering or searching for individuals not present. The service plan noted that the resident responds to reorientation and redirection. The physician’s report further showed that the resident does not utilize a walker or wheelchair and requires special observation due to wandering. Based on interviews and records review, the preponderance of evidence standard has not been met, therefore the above allegations are found to be unsubstantiated. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, May 27, 2026 · control 08-AS-20260519093841

Allegation investigated: Staff did not ensure residents records were kept safely secured. Staff mismanaged residents records. Licensee does not ensure staff are adequately trained.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced subsequent visit to deliver findings regarding the above mentioned allegations. LPA identified themselves and met with Executive Director Tia Suuronen-Goodwin to discuss the purpose of the visit and elements of the complaint. On 04/09/2026, it was alleged that staff did not ensure residents records were kept safely secured, staff mismanaged residents records, and that the licensee does not ensure staff are adequately trained. The department's investigation consisted of interviews, observations, and records review. Regarding the allegation that staff did not ensure residents records were kept safely secured, interviews reported that resident records are kept in locked cabinets at the front desk or in designated administrative offices. Staff stated they were trained on securing documents, including storing files when stepping away and minimizing electronic screens. Staff reported they have not witnessed any unsecured records left out in common areas. (Cont. on LIC 9099-C) Unsubstantiated (Cont. on LIC 9099) Records review of facility employee training materials revealed instruction on confidentiality and safeguarding resident information. Facility manuals contained procedures for faxing, scanning, and securing physical and electronic records. Records review of staff job descriptions emphasized confidentiality requirements in all matters including but not limited to resident and employee information. LPA observed the front desk area clean and organized, with no records left out. Staff demonstrated accessing locked cabinets with a key, and resident files were observed stored and organized inside the secured cabinets. Regarding the allegation that staff mismanaged residents’ records, interviews reported consistent procedures for receiving, alphabetizing, scanning, uploading, and filing resident documents. Staff denied sending records to incorrect providers or mishandling resident information. Staff indicated that if any errors occurred, they were incoming documents from external senders, not errors caused by facility staff. Regarding the allegation that the licensee does not ensure staff are adequately trained, interviews reported receiving training through a third party training portal, hands-on instruction, and shadowing by former experienced staff. Administrative staff stated that new hires receive job-specific training and ongoing guidance. Staff reported having access to manuals and training materials for front desk procedures and record handling. LPA review of training records showed completion of HIPAA, confidentiality, and job-specific modules and front desk manuals included step-by-step instructions for administrative tasks. The Department has investigated the above-mentioned allegations and based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, May 6, 2026 · control 08-AS-20260409110000

Allegation investigated: Facility staff are not ensuring that facility is free of pests.

Licensing Program Analyst(LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above-mentioned complaint allegation. LPA introduced themselves and disclosed the purpose of the visit and elements of the complaint to Executive Director Tia Suuronen-Goodwin. On 04/08/2026, it was alleged that facility staff are not ensuring that facility is free of pests. The department's investigation consisted of interviews and records review. Regarding the allegation, staff interviews reported that an incident with a rodent entering the facility has occurred. Staff additionally reported that they have seen occasional cockroaches, and pests inside resident rooms. Maintenance staff confirmed recent rodent and cockroach activity inside the building. Staff consistently stated that pest control is contacted when pests are observed, but acknowledged that pests continue to appear intermittently. Resident interviews further reported that pests have been present in some rooms. (Cont. on LIC 9099-C) Substantiated (Cont. from LIC 9099) Records review revealed pest control service invoices from February and March 2026 documenting treatment for crawling insects and rodents at the facility. Based on interviews 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, is being cited on the attached LIC 9099D. A plan of correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents. (Cont. from LIC 9099) LPA observed the facility to be clean, and free of pests, hazards or debris during the visit. LPA also observed housekeeping staff actively performing cleaning duties throughout common areas. A records review of the facility’s housekeeping logs for December 2025 showed detailed daily cleaning tasks, including routine cleaning of resident rooms and common areas. Although housekeeping documentation was later discontinued due to workload, available records support that structured cleaning practices were in place. Based on staff and resident interviews, direct observations, and records review, there is insufficient evidence to support that the facility is not kept clean. Therefore, the allegation is found to be unsubstantiated. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, Apr 13, 2026 · control 08-AS-20260408125632

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 1, 2026

87303 Maintenance and Operation: “(a) The facility shall be clean, safe, sanitary…at all times.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure the facility was clean and sanitary at all times. This posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 13, 2026

Plan of correction: The licensee agreed to provide additional training for housekeeping staff on proper sanitation procedures and best practices for preventing pest infestations. Documentation of staff training will be submitted to the LPA via email by the POC due date. In addition, the licensee agreed to continue maintaining monthly pest control services.

Allegation investigated: Staff did not ensure resident's hygiene needs were met. Staff communicate in an inappropriate manner to residents in care.

Licensing Program Analyst(LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above-mentioned complaint allegations. LPA introduced themselves and disclosed the purpose of the visit and elements of the complaint to Resident Service Director Marquette Corbett. On 03/30/2026, it was alleged that staff did not ensure resident's hygiene needs were met and that staff communicate in an inappropriate manner to residents in care. The department's investigation consisted of interviews and records review. (Cont. on LIC 9099-C) Substantiated (Cont. from LIC 9099) Regarding staff not ensuring residents’ hygiene needs were met, interviews with residents and staff consistently reported that scheduled showers were frequently missed within the last month, largely due to ongoing staffing shortages and limited availability of caregivers to complete bathing tasks. Resident interviews reported going more than a week without receiving their scheduled showers. Staff interviews acknowledged that they were unable to provide showers when the facility was short-staffed or lacked necessary supplies. Staff further stated that the facility does not have a system in place to document missed showers, only refusals. Records review revealed that the facility maintained a standard shower schedule for all residents however, no documentation existed to show whether scheduled showers were completed or missed. Regarding the allegation that staff communicate in an inappropriate manner to residents in care, interviews with both residents and staff consistently reported that certain staff spoke to residents in a rude, harsh, or otherwise inappropriate manner. Resident interviews reported that some caregivers used unpleasant or short tones when interacting with them, and one resident stated they had personally observed disrespectful communication from management staff. Staff interviews further corroborated these accounts, with multiple caregivers confirming they had witnessed or were aware of staff raising their voices, speaking unpleasantly to residents, or making inappropriate comments. Management interviews also confirmed at least one prior incident involving an inappropriate comment made to a resident. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California code of Regulations, Title 22, is being cited on the attached LIC 9099D. An exit interview was conducted with Resident Service Director Marquette Corbett and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, Apr 8, 2026 · control 08-AS-20260330161726

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 24, 2026

(a)In addition to the rights... personal rights: (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers.. needs. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure staff was sufficient in numbers for residents to receive scheduled showers/bathing needs, which posed a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: The licensee agreed to maintain staffing levels sufficient to meet resident hygiene needs and to provide outside vendor training on resident hygiene and care plan requirements. The licensee will also implement and maintain a tracking system to document completed and missed resident showers. Licensee will send proof of training and documentation to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 13, 2026

(a)"Residents in all residential care facilities for the elderly shall.. personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons." This requirement was not met, as evidenced by: Based on interviews, the facility did not communicate with residents in an appropriate manner. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: Licensee will conduct resident personal rights outside vendor training to review resident personal rights and etiquette for all staff with sign-in sheet and training topic clearly noted by POC due date.

Allegation investigated: Illegal Eviction.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced subsequent visit to deliver findings regarding the above mentioned allegation. LPA identified themselves and met with Resident Services Director Marquette Corbett to discuss the purpose of the visit and elements of the complaint. On 02/23/2026, it was alleged that Resident 1(R1) was illegally evicted from the facility. The department's investigation consisted of interviews and records review. (Cont. on LIC 9099-C) Substantiated (Cont. from LIC 9099) Interviews and records review revealed that on 02/12/2026, R1 was sent out to the hospital and admitted for treatment of behaviors. R1 was medically cleared for discharge the next day, on 02/13/2026. Following R1’s clearance for discharge from the hospital, Staff 1 (S1) informed LPA that the facility needed to assess R1 prior to accepting R1 back into the facility. However, S1 stated that no staff were available to conduct the assessment. Review of R1’s progress notes dated 02/17/2026 revealed that the facility was actively seeking alternative placement for R1 rather than arranging for R1’s return at that time. Additional records review revealed that as of 03/02/2026, R1 had been transferred to a Skilled Nursing Facility and still had not returned to the facility, with interviews indicating that the transfer occurred because the facility would not accept R1 back. Licensee did not allow R1 to return to the facility or provide R1 with a 30 day written eviction. R1 was illegally evicted. Based on interviews 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, is being cited on the attached LIC 9099D. A plan of correction was jointly developed with the licensee. An exit interview was conducted with Resident Services Director Marquette Corbett and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, Mar 27, 2026 · control 08-AS-20260223111455

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(4) · Plan of correction due date: Apr 17, 2026

(4)"The licensee may evict a resident for one or more of the reasons listed in…Thirty (30) days written notice to the resident is required…the reappraisal believe that the facility is not appropriate for the resident." This requirement was not met, as evidenced by: Based on records and interviews: Licensee evicted 1 out of 63 residents(R1) based on inability to meet their needs, without issuing them 30 days written notice. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: Licensee will conduct eviction procedure training for all administrative staff. Documentation of the training will include a sign-in sheet with participant names and the training topic clearly noted. Proof of completion due by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced Case Management - Deficiencies visit. LPA identified herself and discussed the purpose of the visit with Executive Director Tia Suuronen-Goodwin. LPA was at the facility for a complaint investigation, when a violation was found after an interview with staff. LPA requested a records review of the incident report that occurred for R1, who was sent out to the hospital on 02/12/2026 for behaviors, however, interviews revealed that no incident report was written for R1. Records review revealed that R1's incident report was not reported to the department until 03/05/2026. The facility did not submit a written incident report to the department within the required seven (7) days of the occurrence. One deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). A previous citation was issued on 02/04/2026 for the same deficiency. Since the deficiency is a repeat violation within the last twelve (12) months, a Repeat Violation Civil Penalty of $250 was also assessed/charged to Licensee (refer to the LIC421-FC page). An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director Tia Suuronen-Goodwin whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Mar 27, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Apr 10, 2026

(a) (1)A written report shall be submitted to the licensing agency..within seven days of the occurrence..(D) Any incident which threatens the welfare, safety or health.. any resident This requirement was not met, as evidenced by: Based on records review and interviews, licensee did not follow the facility Reporting requirements for 1 out of 66 residents. This posed a potential health and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: The Licensee will conduct outside vendor reporting requirements training and provide a sign-in sheet with signatures and training topic clearly noted to LPA via email by POC due date. The licensee will additionally assign a designated staff member to submit timely incident reports when the Resident Service Director is not available.

Allegation investigated: Insufficient staff to meet the residents needs.

Licensing Program Analyst(LPA) Janet Ngallo conducted an unannounced subsequent visit to deliver findings regarding the above-mentioned complaint allegation. LPA introduced themselves and disclosed the purpose of the visit and elements of the complaint to Executive Director Tia Suuronen-Goodwin. On 12/16/2025, it was alleged that there was insufficient staff to meet the resident needs. The department's investigation consisted of interviews and records review. (Cont. on LIC 9099-C) Substantiated (Cont. from LIC 9099) Interviews with staff corroborated the allegation, as staff reported the facility does not have sufficient staffing to meet resident care needs. Staff reported frequent shifts with only two caregivers responsible for more than sixty (60) residents, including multiple residents requiring two-person assistance. Staff also stated that the Resident Services Director and other non-direct care staff would frequently cover caregiver shifts due to shortages. Management acknowledged the use of external staffing agencies to compensate for staffing shortages. Resident interviews further corroborated staffing concerns, with residents reporting long wait times for assistance, delayed responses to call pendants, and challenges receiving timely incontinence care throughout their residence at the facility. Residents interviewed have resided at the facility for over three years and indicated that these delays have been an ongoing issue throughout their stay. A facility records review of staffing schedules confirmed an average of approximately two to three caregivers per shift who were able to provide lifting or physical assistance to over sixty (60) residents. Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation occurred and is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Cont. from LIC-9099A) Regarding the allegation that the facility is in financial distress, specifically related to maintaining hygiene supplies and sufficient food, during unannounced visits, LPA observed an adequate supply of hygiene products as well as sufficient food observed in the dining area. Resident and staff interviews consistently stated that hygiene supplies are regularly provided and accessible. Records review of food supply invoices showed ongoing and consistent purchases across all food groups. Review of invoices for incontinence and hygiene products showed consistent and sufficient purchases of hygiene and incontinence supplies. Regarding the allegation that the facility did not provide residents with sufficient food, residents consistently reported that they receive enough food for their meals. Regarding the allegation that the facility did not have sufficient hygiene items, interviews reported that some staff prefer using briefs over pull-up products because they find them easier to manage, however, pull-up incontinence products were available at the facility. Regarding the allegation that the facility is malodorous, interviews with staff and residents consistently stated that they have not observed any foul or persistent odors in the facility and reported that housekeeping staff clean the facility daily. During multiple unannounced visits, LPA did not observe any malodors in the facility. The Department has investigated the above-mentioned allegations and based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 08-AS-20251216175651

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 20, 2026

(a)Facility personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on interviews and records review, the facility did not provide sufficient staff to meet resident’s care needs. This posed a potential personal rights risk to 65 residents in care.the state’s words, verbatim · CDSS document, Mar 24, 2026

Plan of correction: The licensee agreed to maintain staffing levels sufficient to meet resident needs and to provide in-service training on resident service care plan requirements. The facility will submit a staffing plan and documentation of the training with sign in sheet and training topic clearly noted by the POC due date.

Allegation investigated: Staff did not provide a written incident report to resident's responsible person within seven days. Staff did not dispense medications as prescribed.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above mentioned allegations. LPA identified themselves and met with Executive Director Tia Suuronen-Goodwin to discuss the purpose of the visit and elements of the complaint. On 01/29/2026, it was alleged that staff did not provide a written incident report to resident's responsible person within seven days and that staff did not dispense medications as prescribed. The department's investigation consisted of interviews and records review. (Cont. on LIC 9099-C) Substantiated (Cont. from LIC 9099) Regarding the allegation that staff did not provide a written incident report to the resident's responsible person within seven days, interviews with staff corroborated the allegation. By admission, staff reported that they called Resident 1 (R1)'s responsible party the day R1's incident occurred on 01/10/2026, however they had not sent a written report within seven days. Staff reported that R1's responsible party requested the written incident report and received it on 01/29/2026. Regarding the allegation that staff did not dispense medications as prescribed, interviews with staff corroborated the allegation. Staff #2 (S2) reported that they attempted to administer an as-needed pain medication in a method that was not consistent with the prescribed method, due to R1's condition. S2 stated that hospice staff came to the facility to demonstrate the correct administration technique for R1. By admission, staff also reported that they administered a discontinued medication to R1 on 01/23/2026. R1's Medication Administration Record revealed that the administered medication was placed on hold on 01/23/2026. Records review of R1's discharge paperwork dated 01/22/2026, revealed a discontinuation of three (3) medications, one of which was given to R1 on 01/23/2026. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Resident Service Director Marquette Corbett, whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 08-AS-20260129110454

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Feb 5, 2026

(a) (1) A written report shall be submitted to the licensing agency..within seven days of the occurrence..(D) Any incident which threatens the welfare, safety or health.. any resident This requirement was not met, as evidenced by: Based on records review and interviews, licensee did not follow the facility Reporting requirements for 1 out of 63 residents. This posed a potential health and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: The Licensee will conduct in-service reporting requirements training with management staff and provide a sign-in sheet with signatures and training topic clearly noted to LPA via email by 02/05/2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Feb 4, 2026

(c)(2) If the..licensee shall be permitted to assist the resident with self-administration..requirements are met: (2)Once ordered.. medication is given according to.. directions. This requirement was not met, as evidenced by: Based on interviews the licensee did not administer R1 with PRN medication as prescribed which posed a potential Safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: The licensee provided a sign in sheet dated 01/29/2026 and 02/02/2026 with staff signatures for in-service training for hospice services and medication administration protocols. Therefore, the POC will be cleared today, 02/04/2026.

Allegation investigated: Neglect resulting in delayed medical care.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified self and discussed the purpose of the visit with Executive Director Tia Suuronen-Goodwin. On February 4, 2025, Community Care Licensing (CCL) received a complaint alleging facility staff did not provide medical care to Resident 1 (R1) after it was found that R1 had signs and symptoms of an illness. The Department conducted internal and external interviews and reviewed multiple facility records as well as outside source medical records. According to R1’s Physician Report dated January 12, 2024, R1 is confused and disoriented, requires continuous bed care and is bedridden. R1’s Appraisal, R1 requires maximum assistance with transfers and is frail. (Cont. on LIC 9099-C) Substantiated (Cont. from LIC 9099) During the investigation the Department established the following sequence of events. On January 25, 2025, facility staff reported to family and responsible parties, the facility was having an Influenza A outbreak within its staff and residents. According to an outside source interview, on January 26, 2025, R1 was noticed to have a cough, and such was reported to Staff 1 (S1). Interview with S1 revealed that R1’s Primary Care Provider (PCP) was faxed with details of the symptoms and S1 was later contacted by the PCP via telephone stating that they were unable to provide care to R1 and to contact another provider. Records and interviews collected revealed that on January 27, 2025, an outside sourced medical provider (OS1) visited R1 for other services and noted that R1 was having a cough, OS1 proceeded to report such to S1, S1 informed OS1 that this had already been reported to the medical provider. On January 28, 2025, R1’s responsible party contacted the facility and was informed R1 had not received medical care for symptoms. Responsible party proceeded to contact a medical provider and schedule a video visit with R1 for the next morning, January 29, 2025. During the video appointment, the medical provider advised the responsible party and facility staff to contact emergency medical care immediately. Medical records collected established that after being admitted to the hospital, R1 was diagnosed with Influenza A and acute hypoxic respiratory failure. Further interviews revealed that no staff communicated with the resident, or responsible party regarding response from the first medical provider and did not provide additional medical care to R1 between January 26, 2025, until January 29, 2025, therefore medical care was delayed. Based on interviews conducted, review of records, including outside sources records, a preponderance of evidence exists to support the allegation. Therefore, the allegation is substantiated. A deficiency is cited per the Health and Safety Code (refer to the attached LIC 9099-D). The Department has determined this violation resulted in hospitalization to resident in care. An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421IM. Currently, according to Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin, and a Plan of Correction was jointly developed. A copy of this report, LIC811, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058) were provided to Executive Director Tia Suuronen-Goodwin, signature on this form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 26, 2026 · control 08-AS-20250204132812

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87456(a)(1) · Plan of correction due date: Feb 9, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(1)The licensee shall arrange.. care appropriate to the conditions and needs of residents. This requirement was not met, as evidenced by: Based on interviews and records review, the licensee did not provide medical care to 1 out of 63 residents in care. This posed an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 26, 2026

Plan of correction: Licensee will conduct incidental medical and dental care in-service training for all care staff. Documentation of the training will include a sign-in sheet with participant names and the training topic clearly noted. Proof of completion due by 02/09/2026.

Allegation investigated: Lack of supervision resulted in resident on resident altercation with injury.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above mentioned allegation. LPA identified themselves and met with Executive Director Tia Suuronen-Goodwin to discuss the purpose of the visit and elements of the complaint. Residential Services Director Marquetta Corbett joined the visit shortly after. On January 15th, 2026, it was alleged that lack of supervision resulted in resident on resident altercation with injury. The department's investigation consisted of an unannounced facility visit, LPA observations, interviews with staff and residents, and records review. (Cont. on LIC 9099-C) Unsubstantiated (Cont. from LIC 9099) Regarding the allegation, interviews with staff and residents did not report that a resident on resident altercation with injury occurred. Interviews consistently stated that R1 exhibited increased verbal and physical aggression on January 9, 2026, but behaviors were addressed through redirection. The resident is routinely supervised due to wandering tendencies, with frequent safety checks and staff observation during meals and activities. On January 10, 2026, staff reported that R1 exhibited aggressive behaviors toward other residents for the first time, prompting staff to initiate a 5150 hold due to danger to self and others. Staff reported that none of these altercations caused injury. Residents interviewed reported that they did not witness any altercations. A review of facility records revealed R1's progress notes, which showed no documentation of physical aggression in prior entries except for the dates of the alleged incidents. Records review of the incident report, the resident’s care plan, and the physician’s report were consistent with interviews. The care plan specifies that the resident will be reoriented and redirected when wandering and that frequent checks will be conducted to ensure safety. LPA observed residents throughout the facility, including those identified as potential victims of the allegation. All residents were observed with no visible physical injuries. The environment was clean, organized, and free of hazards. Based on interviews, records review, and LPA observation, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Residential Services Director Marquetta Corbett to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Jan 20, 2026 · control 08-AS-20260115111105

Allegation investigated: Medications not given as prescribed

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and discussed the allegation mentioned above with Resident Service Director, Marquetta Corbett. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff and residents. It was alleged medications were not given as prescribed. It was reported the key to the medication cart was lost, resulting in multiple residents not receiving their medications for two (2) days, 12/04/25 and 12/05/25. The Resident Services Director (RSD) explained that the facility has two (2) medication carts, medication cart #1 and medication cart #2. The lock on medication cart #1 was jammed and they were unable to open the medication cart to dispense resident’s medications. The medication technicians that were interviewed explained the lock on the medication cart was jammed and they contacted Ron’s Pharmacy. However, the individual at Ron’s Pharmacy that was supposed to assist, was unavailable. There were twenty-seven (27) residents that did not receive their medications on 12/04/25. Continued on LIC 9099C. Substantiated The RSD explained on 12/05/25 their Maintenance Director was contacted to break open the medication cart, so they could dispense medications. The maintenance director was able to open the medication cart. However, it was not prior to resident’s first AM dose. Therefore, morning medications were not dispensed on 12/05/25. A review of facility Progress Notes dated 12/04/25 indicated the medication cart was locked and/or staff could not open the cart. The RSD explained once the lock was broken on the cart, the cart was stored in a locked room for safety. Medication technician explained Ron’s Pharmacy came out over the weekend and fixed the lock. The RSD explained the lock was not broken open initially on 12/04/25 to obtain the medications, as the facility did not want to damage Ron’s Pharmacy medication cart. Residents were interviewed and stated they were no adverse reactions to not receiving their medications. LPA was advised by staff that the Executive Director was out of the building today. However, The Executive Director was present but did not meet with LPA regarding the compliant investigation. Towards the end of the visit the Executive Director made LPA aware they were out sick when the incident occurred and it was the responsibility of staff to report the issue. Based on interviews 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 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Resident Service Director whose signature below confirms receipt of these rights. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Resident Service Director whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Dec 23, 2025 · control 08-AS-20251218094408

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 24, 2025

Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure residents received their prescribed medications for 27 out 62 [R1-R27] residents which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: Resident Service Director stated they will conduct In-Service training regarding medication cart checks and reporting issues. The RSD agreed to provide scheduled date of training by POC due date and submit proof of training within 2 weeks.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Deficiencies visit. LPA identified herself and discussed the allegation mentioned above with Resident Service Director, Marquetta Corbett. LPA was at the facility for complaint investigation, when a violation was observed. Upon arrival, there were no staff present at the front desk but staff were observed walking around. The medication room was located near the front desk and opened/unlocked. Medications were made accessible to anyone walking by the medication room. LPA observed ambulatory residents walking around, near the medication room. LPA stood in front of the medication room, waiting for staff to return. A medication technician arrived carrying a pitcher of water. LPA explained the medication room should be locked when staff are not present. The medication technician stated they were aware the medications needed to be locked, and apologized. A deficiency was observed and cited on LIC 809D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Resident Service Director whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Dec 23, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Dec 24, 2025

Incidental Medical and Dental Care. 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 interviews and record review, the licensee did not ensure medications were locked and inaccessible to 62 out of 62 [R1-R62] residents which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: Resident Service Director (RSD) stated they will conduct In-Service training on locking the medication room and ensuring medications are not accessible to residents. The RSD agreed to provide scheduled date of training by POC due date and submit proof of training within 2 weeks.

Allegation investigated: Staff neglect resulted in resident sustaining a fracture.

LPA Janet Ngallo conducted an unannounced visit with the facility to deliver findings. LPA spoke with Executive Director Tia Surronen-Goodwin and explained the purpose of the visit. Regarding the allegation of Staff neglect resulted in resident (R1) sustaining a fracture, R1 had an unwitnessed fall resulting in a fracture of the ankle. During the investigation, staff members were interviewed, and records were reviewed. On 02/15/2024, R1 was taken to the bathroom by staff (S1). R1s Plan of Care states for staff to assist with toileting activities and requires assistance with peri-care. Another staff member (S2) found R1 on the bathroom floor calling out for help, S1 was not around. (Cont. on LIC9099-C) Substantiated (Cont. from LIC 9099) R1s Plan of Care for 09/29/2023 stated staff is to assist with toileting activities and assist with peri-care. This information was verified by RSD who stated what this information means is when a resident calls or pushes their button to be taken to the bathroom the caregiver would have to wait outside the door or close it or have it opened but be there to assist. R1s Plan of Care wasn’t changed until 10/01/2024, which required staff to conduct two-hour rounds to offer and ask R1 if he/she needed to be changed and to assist getting to and from the bathroom. On the new Plan of Care, to mitigate future falls the facility had increased safety checks. The facility staff knew R1 was a risk for falls and what interventions were needed to prevent reoccurrences. The facility was responsible for the neglect/lack of care and supervision causing R1 to have serious bodily injury as the resident was left on the toilet with no supervision which resulted in R1 falling and sustaining a fracture to his/her left ankle. At the time of the complaint inspection on 11/10/2025, executive director was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49. Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D. An immediate Civil Penalty is being charged and assessed as $500 on the LIC421IM. An exit interview was conducted with Executive Director Tia Surronen-Goodwin, and a Plan of Correction was jointly developed. A copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Executive Director Goodwin, signature on this form confirms receipt of documents. (Cont. from LIC9099-A) For the allegation of staff did not adequately assist resident with incontinence care needs in a timely manner, RP alleged that many times R1 is left for hours in soiled diapers because the staff is "too busy" or "understaffed". R1 mentioned that there have been times where he/she sits for hours in soiled diapers and staff does not come and help. RP also said that R1 is not in soiled diapers. On a follow up interview, RP did state that R1 had a dirty brief and a caregiver took a few minutes, before caregiver was able to help. Regarding the allegation of staff did not assist in resident with grooming needs, R1 rarely gets his/her teeth and hair brushed, as well as washing face. R1 said will sit for hours, and no one comes and checks, they don’t brush R1s hair or offer a washcloth. At the same time while the interview was being conducted, a caregiver came in with a washcloth and cleaned R1s face. For the allegation of staff did not assist resident with mobility needs, RP alleged that there isn't always qualified staff members on hand that can get R1 in and out of bed and to the restroom. RSD mentioned that caregivers monitor R1, conduct hourly rounds to ensure R1s safety, and give assistance as needed. Another staff member, S3 mentioned that when he/she takes care of R1, S3 will change R1s diaper every two hours while R1 is in bed, if R1 needs to use the toilet S3 will help R1 to R1s wheelchair take R1 to the restroom. S3 also added that R1 has never gotten out of bed on R1s own, R1 usually uses the pull cord when he/she needs assistance. (Cont. on LIC9099-C pg.2) (Cont. from LIC9099-C pg.1) Regarding the allegation of Staff did not provide assistance for resident to participate in facility activities, RP stated that R1 is left limited to the bed and deprived fresh air or going outside. R1 doesn't get much interaction with other residents or participating in any activities. According to ADM, R1 refuses to join activities. Every morning, the activities team go to rooms and ask residents to join activities. RP shared that R1 doesn’t want to get out of bed and gets anxiety if R1 leaves the room, R1 would rather be on the computer. Based on interviews, observations and records review, the department has determined that 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 with Executive Director Tia Surronen-Goodwin, and a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Executive Director Goodwin, signature on this form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 10, 2025 · control 08-AS-20241231091031

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 1, 2025

87411 Personnel Requirements – General (a)Facility...shall at all times be sufficient in numbers...provide the services necessary to meet resident needs...services. This was not met as evidenced by: Based on interviews and records review, R1 sustained an injury due to R1 being left on the toilet with no supervision which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 10, 2025

Plan of correction: Executive Director will conduct in-service training with Staff in morning, after noon, and NOC shift and sign in sheets with training topic will be emailed to LPA by 12/01/2025.

Allegation investigated: Staff did not issue resident's responsible party a refund

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit regarding the above mentioned allegation. LPA met with Executive Director (ED), Tia Suuronen-Goodwin and Business Office Director (BOD), Susie Dizon. During the investigation, the facility was briefly toured, records reviewed and interviews conducted with staff and outside sources. It was alleged staff did not issue resident's responsible party a refund. It was reported Resident #1 (R1) went to the hospital on 07/02/24 and did not return to the facility. On 07/16/24, R1's belongings were removed from the facility. Outside Source (OS) reported they were made aware of the refunded portion on 10/24/24 with a balance of $2649.64 and unable to obtain the refund. OS also reported the BOD wanted the balance donated back to the facility. OS interview confirmed they did not agree to donate the balance and would like their refund. LPA reviewed an email sent from the BOD to OS indicating the balance amount owed and confirming OS would like to still donate the balance to the facility. Continued on an LIC 9099C. Substantiated The Business Office Director (BOD) explained they suggested the responsible party donate the balance to the facility but it was not required. The BOD stated the facility's policy was to refund the resident or Power of Attorney (POA). R1's responsible party was not the POA. Therefore, they did not refund R1's resident's responsible party. The BOD stated in August of 2025 the facility changed their policy and is now refunding residents responsible party's if even if they are not the POA. The BOD stated they do not have anything in writing stating they can only refund the resident or the Power of Attorney. A review of R1's file reflected a credit statement owed as of 08/01/25 in the amount of $2649.64. A review of R1's Admission Agreement dated 05/03/22, indicated under the Refund Policy that if the agreement is terminated, the resident must vacate and remove their property. R1's agreement was terminated and R1's belongings were removed on 07/16/24, and no refund was issued. The BOD also stated the refund check was approved today and awaiting corporate signatures. The Executive Director (ED) was interviewed but unable to provide facility policy details and referred LPA to the BOD. The ED was unable to provide any details regarding why R1 was not refunded once R1's belongings were removed from the facility. Based on and interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tia Suuronen-Goodwin whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Sep 10, 2025 · control 08-AS-20250902111313

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Oct 1, 2025

Admission Agreements. The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not provide a refund to 1 out of 64 [R1] residents, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 10, 2025

Plan of correction: The Executive Director agreed to refund R1's responsible party by the POC due date.

Allegation investigated: Staff did not ensure facility had hot water.

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced thelf and disclosed the purpose of the visit to Executive Director Tia Suuronen-Goodwin. On April 3, 2025, it was alleged that staff did not ensure facility had hot water. The Department’s investigation consisted of an unannounced facility visit, records review, and staff, resident, and outside source interviews. According to the allegation, the facility did not have hot water for multiple consecutive days and the staff at the facility were aware that hot water was not working properly at the facility. [Continued on LIC9099-C] Substantiated Records review revealed that the facility staff self-reported the hot water outage to residents and residents’ representatives via email communications. Interviews with internal sources revealed that there was an issue with the water heater’s valve and it took a few days to obtain a repair. During the hot water outage, staff were transporting residents to a sister facility to obtain showers, and the facility bought a portable shower. Interviews with internal and external sources and records reviewed corroborated that the facility was without hot water for multiple consecutive days. Based on interviews, and records reviewed, a preponderance of evidence exists to support the allegation. One deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Tia Suuronen-Goodwin, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to. According to the allegations received, staff were seen being physically inappropriate with a wheelchair bound resident by doing wheelies with their wheelchair while the resident was present. It was alleged that staff were unprofessional in the way they spoke to residents and had made a joke about a resident’s incontinence management. It was alleged that Resident #1 (R1)’s pre-operation instructions were not followed by staff and that a physician on-site at the facility tried to enter a resident’s bedroom without permission. It was also alleged that a staff member went through a resident’s purse without permission and that a health insurance program was billed for Resident #2 (R2)’s physician visits at the facility while R2 was not present at the facility. Interviews with internal sources revealed that some wheelchairs bound residents have difficulty raising their feet doing ambulation assistance from staff. Therefore, in the process of aiding residents’ staff may lift the front wheels off of the ground slightly to back up the resident and aid them with foot placements. Interviews with internal and external sources did not reveal a concern for staff being physically abusive nor handling residents inappropriately. Interviews with internal and external sources also did not reveal a concern for unprofessional or verbally abusive staff. Interviews did not reveal a scenario where staff made jokes about a resident’s incontinence management. Per record review, R1 was scheduled for surgery on January 22, 2025, and per the pre-operation instructions, R1 was instructed to receive a hot shower. Interviews and records reviewed revealed that during that time period, the water heater was broken, and the facility did not have hot water. R1 was transferred to a different location by their representative and was provided with a caregiver to shower R1 as instructed. Records reviewed revealed that R1’s representative was compensated by the facility in order to follow the physician’s instructions. Interviews with internal and external sources did not reveal that a physician entered R1’s room without knocking and announcing themselves prior to entering. Interviews revealed that if staff do not get a response from a resident, they will enter to check on the well-being of the residents. [Continued on LIC9099-C] Review of R1’s progress notes dated December 28, 2024 revealed that R1 exhibited an aggressive behavior after stating they did not receive their bedtime medications. Interviews and records reviewed revealed that R1 was asked to check their purse for the bedtime medications, and when the medications were not located, R1 brought the purse over to staff to have them check. Interviews and records reviewed did not reveal that R1’s purse was looked through without R1’s consent. Interviews and records review did not reveal that the licensee is billing for services not provided. Interviews revealed that the physicians that come to the facility are contracted and not employees of the facility. Thus, the billing between the health insurance program and the physician’s visit is not billed through the licensee. Based on interviews and record review, the investigation did not yield a preponderance of evidence to conclude that staff are physically and verbally abusing residents, staff did not follow physician instructions for resident, staff did not accord resident privacy, staff did not safeguard resident’s personal belongings, and the licensee is billing for services not provided. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted Executive Director Tia Suuronen-Goodwin, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 08-AS-20250403163513

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Aug 7, 2025

87303 Maintenance and Operation: "(e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water..." This requirement was not met, as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as the facility did not have hot water for multiple days which posed a potential health and safety risk to sixety-eight (68) of sixety-eight (68) residents in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: Licensee had fixed the hot water heater, and the facility had hot water during LPA's visit. The deficiency was cleared during LPA's visit.

Allegation investigated: Staff did not issue a refund to the resident or authorized representative in a timely manner.

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced self and disclosed the purpose of the visit to Executive Director Tia Suuronen-Goodwin. On May 5, 2025, it was alleged that staff did not issue a refund to the resident or authorized representative in a timely manner. The Department’s investigation consisted of an unannounced facility visit, records review, and staff, resident, and outside source interviews. According to the allegation, Resident #1 (R1) moved out of the facility on April 8, 2025, but did not receive a refund for the remaining days of the month. On May 16, 2025 R1’s representative received a refund, although on May 27, 2025 it was discovered that R1 received such refund as an accidental charge for May and did not receive a refund for April. [Continued on LIC9099-C] Unsubstantiated Interviews revealed that R1 was on automatic payment system and was charged for the month of May 2025, although R1 had moved out of the facility on April 8, 2025. R1’s representative was refunded for the charge of May. Interviews revealed that R1 or R1’s representatives did not give thirty-day notice to terminate their residence. Thus, per the agreement signed and dated on September 3, 2022 by R1’s representative, R1 was responsible for the full monthly fee until the thirty (30) day period had expired. Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude that staff did not issue a refund to the resident or authorized representative in a timely manner. Based on the foregoing, the allegation is unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted Executive Director Tia Suuronen-Goodwin, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 08-AS-20250509152921

Type of visit: Case Management - Other

Licensing Program Analyst, David Roman (LPA D. Roman), conducted an unannounced case management inspection to follow up on circumstances regarding an unknown cause of death to resident 1 (R1). LPA D. Roman identified and introduced himself to Executive Director, Tia Suuronen-Goodwin (ED). LPA D. Roman discussed the purpose of the visit with ED and was provided entry into the facility. During today's visit, LPA D. Roman along side with facility staff conducted a tour of the interior and exterior of the facility. LPA D. Roman observed required postings (facility license, Ombudsman contact information, emergency contacts, etc) at the entrance of the facility. LPA D. Roman observed resident rooms to have required furnishings (bed, drawers, night stands, closets, etc). Residents were observed to have health and safety needs met. LPA D. Roman observed the facility to be clean and clear of hazards. LPA D. Roman completed record reviews, gathered pertinent information, and conducted interviews with staff. This report was discussed with Resident Services Director, River Jon Pagala. A copy of this report along with Licensee/Appeal Rights was provided to them at the conclusion of the visit. Their signature on this form acknowledges the receipt of this report and their rights.the state’s words, verbatim · CDSS document, Jul 18, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Tia Suuronen-Goodwin. According to the facility’s license, the facility has a maximum capacity of seventy (70) residents, of whom seventy (70) may be non-ambulatory of which nine (9) may be bedridden. During today’s inspection, there were a total of sixty two (62) residents in care. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by Tia Suuronen-Goodwin toured the interior and exterior of the facility and viewed a sample of resident rooms. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were compliant. There was at least 2 days supply of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters observed available to clients. Medications were labeled, as required, and stored in locked areas. (CONTINUED ON LIC809-C) (CONTINUED FROM LIC809) No pools or bodies of water were observed on the premises. Per Tia Suuronen-Goodwin, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Confidential records were stored in locked areas. Tia Suuronen-Goodwin also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Tia Suuronen-Goodwin, to whom a copy of this report and the Licensee/AppealRights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jun 12, 2025

Allegation investigated: Facility staff did not address slipping hazard, resulting in resident falling and sustaining a fracture Facility staff did not seek timely medical care for resident

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. Upon arrival, LPA was greeted by Executive Director Tia Suuronen-Goodwin, to whom she identified herself and explained the purpose of the visit. The Department investigated the complaint allegations through a facility inspection, observations, multiple interviews with staff and external sources, and a thorough review of relevant records. On November 14, 2022, Community Care Licensing (CCL) received a complaint alleging that staff failed to address slipping hazards, resulting in resident R1 sustaining a serious injury—a lumbar vertebral (L1) compression fracture. A confidential list (LIC 811) was provided to staff to identify R1. (Continue at LIC9099) Substantiated (Continue from LIC9099) The complaint specifically alleged that R1 experienced an unwitnessed fall in their room on the night of November 8, 2022. R1’s medical and facility records indicated a diagnosis of unspecified dementia and residence in the facility’s memory care section. According to a physician’s report dated January 19, 2022, R1 was ambulatory and able to communicate needs. Interviews with R1 and outside sources consistently reported that R1 slipped due to water on the floor. After the fall, R1 did not report the incident to staff and was able to get up from the floor unassisted and return to bed. The next morning, R1 complained to the staff of lower back pain and requested pain medication. Staff interviews revealed that R1 denied any fall or injury. Interviews with residents, staff, and outside sources confirmed that several rooms, including R1’s, had ceiling leaks for several days due to broken water pipes. Maintenance had placed buckets and towels under leaks to mitigate hazards. Although staff had placed buckets and towels as a temporary measure, it failed to adequately address the hazard. During interviews, it was confirmed that the wet floor condition contributed to R1’s fall. During a visit conducted on November 21, 2022, the ceiling repairs caused by the water leak in R1’s and other residents’ rooms were confirmed by observation. Additional interviews with staff and residents did not yield any other reported injuries caused by the water leaks. It was also alleged that facility staff did not seek timely medical care for R1 to meet their needs. On November 9, due to persistent back pain, the staff ordered a mobile x-ray, which returned unclear results. Despite ongoing back pain complaints, additional medical evaluation was not pursued until November 11, when R1 disclosed the fall to their responsible party. R1 was then immediately transported by R1’s responsible party to the hospital, where a CT scan confirmed an acute L1 vertebral fracture. R1 was subsequently discharged to a skilled nursing facility for rehabilitation. It was confirmed that R1 recovered and was discharged back to the facility from skilled nursing. Although staff did not receive timely notification of the fall, R1 complained of back pain, and medical attention was delayed until November 11, when a hospital CT scan confirmed the injury. The delay in seeking further medical evaluation despite ongoing pain was deemed inadequate care. (continue at LIC9099C) (Continue from LIC9099C) Based on interviews and records review, sufficient evidence supports the allegation that staff negligence in addressing the slipping hazard directly resulted in R1’s fall and injury. It was also substantiated that facility staff did not seek timely medical care for R1. Although the initial x-ray was unclear, staff should have pursued further evaluation when R1 continued to report acute pain. Timely medical attention is a reasonable expectation to ensure residents' health and safety, especially those with dementia. The Department finds the allegations substantiated, meeting the preponderance of evidence standard was met. Deficiencies were cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations, detailed on LIC 9099-D. An immediate $500 civil penalty was assessed, and a plan of correction was jointly formulated with Executive Director Suuronen-Goodwin. Per Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with Executive Director Suuronen-Goodwin, who was provided a copy of this report, the Confidential Names List (LIC 811), LIC 9099D Deficiency Report, and the Licensee Appeal Rights (9058 03/22). (continue from LIC9099A) During a follow-up inspection on November 21, 2022, facility temperatures were measured and found to be within the range required by Title 22 regulations, between 74-75 degrees Fahrenheit. Multiple interviews with residents and staff confirmed that the heater had been nonfunctional for four days in November. However, interviewees consistently reported that the facility’s temperature remained comfortable, and no concerns were raised about rooms being too cold. One resident recalled the heater outage but stated that wearing sweaters and using blankets provided sufficient comfort. Staff and residents also reported receiving no formal complaints regarding the facility’s temperature. Based on the investigation’s findings—including observations and interviews with key staff and residents—there was insufficient evidence to substantiate the allegation. Therefore, this allegation is unsubstantiated. An unsubstantiated finding means that although the alleged violation may have occurred, there is not a preponderance of evidence to confirm it. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin at the conclusion of the visit. She was provided with a copy of this report and the Licensee Appeal Rights (9058 03/22).the state’s words, verbatim · CDSS document, May 30, 2025 · control 08-AS-20221114144958

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303 · Plan of correction due date: Jun 30, 2025

87303(a) Maintenance and Operation The facility shall be clean, safe, ......afety and well-being of residents, employees and visitors. The licensee did not ensure the floors of residents’ rooms were free from slip hazards to ensure the health and safety of the residents while in care. This requirement was not met as evidenced by: Based on observations, records review, and interviews the licensee did not address slipping hazard, to ensure the health and safety of the residents resulting in a resident (R1) falling and sustaining a fracture. This posed an immediate health and safety risk to one (1) of (59) residents in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: Licensee agreed to provide training by a third party provider to staff in the maintenance and operation of the facility to ensure the health and safety of the residents in care. Licensee will submit documentation of training conducted by POC due date of 6/30/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 887466 · Plan of correction due date: Jun 30, 2025

887466 Observation of the Resident The licensee shall ensure that residents are regularly observed ... such observation reveals unmet needs. ...resident's physician ..... Licensee did not seek timely medical attention when a change in condition was observed. This requirement was not met as evidenced by: Based on observations, records review, and interviews with staff and outside sources, the licensee did not seek timely medical care for resident (R1) when a change in condition was observed. This posed an immediate health and safety risk for one (1) of (59) residents in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: Licensee agreed to provide training to staff by a third party provider on the regulations required to conduct observations to monitor changes in conditions of residents and care to ensure timely medical attention to meet residents' needs. Licensee agreed to submit documentation of the training conducted by POC due date 6/30/2025. Licensee agreed to submit documentation of the training conducted by POC due date 6/30/2025.

Allegation investigated: Staff did not seek timely medical care for resident. Staff did not notice change in condition of resident. Staff did not treat resident with dignity. Staff did not ensure resident went to doctor appointments.

Licensing Program Analyst (LPA) Juliana Barfield conducted a subsequent complaint visit via telephone call regarding the above-mentioned allegations. LPA was connected to, identified herself to, and discussed the purpose of the telephone call with Executive Director Tia Suuronen-Goodwin. The Department's investigation consisted of records reviews and interviews with staff and outside sources. It was alleged that the Cloisters of the Valley (facility) staff did not seek timely medical care for Resident one (R1). Based on record review and interviews, R1 complained of stomach pain on 12/12/20 and 12/14/20 and staff scheduled a doctor visit for 12/16/20. When R1 had stomach cramps the following week, nursing staff and former Executive Director visited R1 on the Christmas holiday. R1 complained of stomach cramps on 01/02/21 and the staff gave R1 Tylenol. R1 felt sick on 1/05/21 and facility called 911. Based on records reviews and interviews, there is not substantial evidence to support the allegation that staff did not seek timely medical care for resident, therefore this allegation is unsubstantiated. (Continued on 9099C) Unsubstantiated It was alleged that the staff did not notice change of condition in R1. Progress notes stated R1 had stomach pain on 12/12/20, 12/14/20,12/21/20, and 01/02/21. On 01/03/21, R1 was walking and feeling good. R1 had pain on 01/05/21 and staff sent R1 to the emergency room. According to records reviews and interviews, there is not substantial evidence to support the allegation that staff did not notice a change of condition in R1, therefore the allegation is unsubstantiated. It was alleged that staff did not treat resident with dignity. According to records reviews and interviews, R1 left the facility on 01/05/21 and did not return. R1 was enrolled with a health group that covered a seven day absence from the facility. R1 was responsible to pay for facility rent on 01/12/21 and outside source chose to move R1 out of the facility on 01/11/21. Based on records reviews and interviews, there is not substantial evidence to support the allegation that R1 was not treated with dignity, therefore this allegation is unsubstantiated. It was also alleged that staff did not ensure resident went to doctor appointments. Records reviews and interviews indicated that R1 had doctor visits on 09/30/20, 10/15/20, 11/04/20, 11/20/20, and 12/16/20. Each of these appointments were facilitated by staff. An outside source tried to arrange an in-person appointment with R1 and two consulting doctors during Christmas week 2020. The doctors and facility had limited time, therefore the facility nurse and former executive director evaluated R1 on Christmas day. Staff noted R1 health on 01/05/21, spoke with outside source, and called 911. Based on interviews and record review , there is not substantial evidence to support the allegations that staff did not ensure resident went to doctor appointments, therefore this allegation is unsubstantiated. An exit interview was conducted with Tia Suuronen-Goodwin to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Her signature on this form acknowledges receipt of these rights.the state’s words, verbatim · CDSS document, May 30, 2025 · control 08-AS-20210326122703

Type of visit: Case Management - Other

Licensing Program Manager (LPM) Lizzette Tellez and Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Case Management visit. LPM and LPA met and discussed the purpose of the visit with Executive Director, Tia Suuronen-Goodwin. On November 6, 2024, the Department issued an Order of Immediate Exclusion for S1. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] Per facility staff, the individual was a former employee who was terminated on or about 7/14/2020. During today’s visit, LPM and LPA briefly toured the facility and performed a welfare check on residents in care. LPA verified that S1 was not present or presently employed at the facility. This report was discussed with Ms. Suuronen-Goodwin. A copy of this report, along with Licensee/Appeal Rights, was provided to her at the conclusion of the visit. Her signature on this form acknowledges receipt of these rights.the state’s words, verbatim · CDSS document, Nov 15, 2024

Allegation investigated: Unlawful Eviction. Medications are not locked. Cleaning supplies are accessible to residents. Staff not meeting the needs of a resident. Staff did not treat resident with dignity.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to Business Director Susan Dizon, was granted entrance, and met with Resident Service Director (RSD) River Pagala, and discussed the purpose of the visit. The Department’s investigation consisted of facility, resident, and outside source records reviews, a facility tour, and staff interviews. It was alleged that Resident 1 (R1) was served an unlawful eviction, facility staff were not meeting R1’s needs, and facility staff did not treat R1 with dignity. A resident records review revealed R1 moved into the facility on March 19, 2020, with a Primary diagnosis of Invasive Ductal Carcinoma of the right breast with metastasis. Resident records also revealed R1’s did not have a history of aggressive or inappropriate behaviors, was able to leave unassisted, could communicate needs, and followed instructions. Unsubstantiated Records also revealed at the time of admission R1 was continent and able to manage all their own daily living skills except they required minimal assistance with bathing and grooming reminders. Further review of R1’s resident records revealed less than a month after R1's admission on March 19, 2020, they started to undergo changes in health conditions. In addition, R1 started to display behaviors of concern. A review of facility records dated February 21, 2021, revealed R1’s care needs had increased to requiring a 1 to 2 person assist with ADLs, was non-ambulatory, and required incontinence care. Facility staff conducted a re-appraisal and updated R1's care plan based on new doctor’s orders. However, on March 21, 2021, R1 was given a 30-day eviction notice for several acts of verbal and physical aggressive behaviors toward staff and other residents in care. Records of R1’s behavior outbursts were dated between September 14, 2020, and February 2, 2021, and included yelling profanities during the day and throughout the night scaring and disrupting other resident’s sleep, and conducting inappropriate acts that were sexual in nature. A facility records review revealed it was clearly defined that these behaviors were breaking the rules of facility conduct per contractual agreement. In addition, outside source records revealed on May 12, 2021, R1 was still residing at the facility and R1’s Primary Care Physician (PCP) had submitted an order for R1 to be relocated to a higher level of care, and they were transferred to a post-acute facility. Regarding facility staff not meeting R1’s needs, as mentioned above, R1’s PCP submitted an order for R1 to be transferred due to needing a higher level of care. In addition, a facility records review and interviews conducted with facility staff revealed R1 would refuse assistance by facility staff and would become verbally and physically aggressive. Lastly, it was alleged medications were observed unlocked and cleaning supplies were accessible to residents in care. Staff interviews revealed all medications are kept in locked med-carts, and cleaning supplies were kept in locked storage. During facility tours, LPA observed medications and toxins to be locked and inaccessible to residents in care. (See LIC 811 for confidential name). Due to lack of corroborating evidence, the findings regarding the above allegations were established to be unsubstantiated. This finding means although the allegations may have happened or could be valid, there is not a preponderance of evidence to prove that the alleged violations occurred. LPA Correia conducted an exit interview with RSD Pagala who was advised a copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058) will be provided and signature on this report acknowledges receipt of the rights.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 08-AS-20210514092305

Allegation investigated: Licensee financially abused resident

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate a complaint investigation on the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Business Director Suzie Dizon. On September 26, 2024, Community Care Licensing (CCL) received a complaint alleging licensee financially abused Resident 1 (R1). During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to the allegation, R1 is expected to pay roughly $1398 per month out of pocket but is only receiving $1261 monthly from Social Security Income and the remaining balance of $137 per month is accumulating an ongoing balance for R1. Admissions Agreement reviewed revealed that R1 and responsible party agreed to a total monthly expense of $5,450 per month on October 24, 2023. Unsubstantiated Agreement also revealed that R1 is actively receiving the Assisted Living Waiver (ALW) reducing the required monthly room and board fee to $1324. Records also revealed that the ALW room and board fee increased in January 2024 to $1398 per month. ALW Addendum to Residency Agreement reviewed states the following “If the resident’s total income is less than the required amount of $1324 Resident/Power of Attorney or Responsible Party will need to work with the CCA assigned case manager to increase the income to meet the minimum amount set”. Interview with Business Director corroborated that residents are responsible for paying the full room and board portion directly to the facility. Interview with outside source revealed that this discrepancy may be cleared up by contacting Social Security. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Business Director Suzie Dizon, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 2, 2024 · control 08-AS-20240926070542

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management Visit to cite a deficiency which was identified during a separate complaint investigation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Business Director Suzie Dizon. On today's date, LPA Strong reviewed Resident 1 (R1) Admissions Agreement and found that the Assisted Living Waiver Addendum to Residency Agreement was not signed by R1 or Responsible Party. Based on records reviewed a deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). An exit interview was conducted with Business Director Suzie Dizon. A copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to her during today’s visit.the state’s words, verbatim · CDSS document, Oct 2, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(c) · Plan of correction due date: Oct 9, 2024

87507 (c) Admission agreements shall be signed and dated,...by the resident or the resident’s representative. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement was not met as evidence in: Based on records reviewed the licensee did not have Resident or responsible party sign admissions attachement in one of xxx persons in care (R1) which posed a potential Personal Rights risk to persons in carethe state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: Licensee agrees to review Admissions agreement regulation and train other managements staff on such and provide a written statement of understanding to LPA via email.

Allegation investigated: Staff did not notify responsible party of resident's change in care

On 8/21/24, at about 9:00 AM, Licensing Program Analyst (LPA) Daniel Pena conducted a complaint investigation visit to the facility. After identifying himself, and explaining the purpose of the visit, LPA was allowed inside the facility. LPA discussed the elements of the complaint with Business Office Director, Suzie Dizon. On 07/31/2024, the Department received this complaint which alleged staff did not notify the responsible party of a resident's change in care. The Department's investigation included facility visits, interviews with residents, staff and outside sources and review of pertinent facility and outside agency records. Information obtained showed that staff transferred Resident 1 (See LIC811 to identify R1) from a private room to a shared room on July 22, 2024. Interviews with staff and an outside source revealed that on May 16, (CONTINUED ON LIC9099D) Substantiated (CONTINUED FROM LIC9099) 2024, a care conference was held regarding R1. The interviews revealed that facility staff informed an outside source that R1 was no longer eligible for a private room at the rate they were paying. Staff informed the source that the facility would be transferring R1 to a shared room. All interviews consistently reported that no date was given by the facility as to when R1’s room transfer would occur. Per interviews, no minutes were taken of this meeting. Interviews revealed that R1 was transferred to a shared room on July 22, 2024. When interviewed, staff said they did not present R1’s representative with a 30-day written notice of transfer. When interviewed, staff said they thought the May 16th care conference was all that was necessary. As a result of this investigation, staff expressed an understanding that they should have provided written notice of the transfer as per the resident’s admission agreement. A review of R1’s Residence and Care Agreement reads as follows, “We will provide you with thirty (30) days' written notice before substituting your Apartment.” Based on interviews with residents, staff and outside sources and record reviews, the Department’s investigation yielded sufficient evidence to confirm the allegation that staff did not notify the responsible party of a resident's change in care. The Preponderance of Evidence standard has been met. Therefore, the allegation is Substantiated. California code of Regulations, Title 22, Division 6 & Chapter 1 is being cited on the attached LIC 9099D. LPA investigated a secondary element of this complaint regarding a resident’s payment obligation to the facility. Interviews and record reviews revealed that changes had occurred with the resident’s supplemental funding agency. A review of records and interviews revealed that the issue does not fall within the jurisdiction of CCLD. No additional investigation was conducted into this portion of the complaint nor was a finding made. LPA advised all pertinent parties. An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058 01/16) were provided to Director, Suzie Dizon, whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Aug 21, 2024 · control 08-AS-20240731124908

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2 · Plan of correction due date: Aug 23, 2024

...Residents in Privately Operated Facilities...shall have...the following personal rights:(16) To written notice of any room changes at least 30 days in advance unless a room change...The requirement was not met as evidenced by: Based on interviews and record reviews, the facility did not provide Resident 1 written notice of a room change. This posed a potential Person Rights risk to 1 of 66 residents in care.the state’s words, verbatim · CDSS document, Aug 21, 2024

Plan of correction: Licensee will present proof of vendorized training for all staff and management personnel regarding Personal Rights and provide written evidence to CCLD by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Susie Dizon Office Manager & Tia Suuronen, Executive Director. According to the facility’s license, the facility has a maximum capacity of seventy (70) residents. During today’s inspection, there were a total of Sixty-Seven (67) residents in care. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected the rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident rooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant: Bathroom sinks in the residents rooms ranged from 105.4 degrees -118.8 degrees There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked medication cart. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] There are no pools/ jacuzzi on the premises. Per staff, there are no firearms or ammunition that are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and residents and reviewed multiple staff and resident records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Tia Suuronen, Executive Director to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jun 26, 2024

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

Allegation investigated: Licensee did not provide resident or their representative a comprehensive description and fee schedule for services, as per the admission agreement

Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to initiate a complaint investigation. LPA introduced himself and disclosed the purpose of the visit to Tia Suuronen-Goodwin, Executive Director. Upon completion of the visit and investigation, LPA delivered to Director Suuronen-Goodwin, the findings. On June, 4, 2024, CCLD received this complaint. It was alleged the Licensee did not provide Resident 1 (R1) or their representative a comprehensive description and fee schedule for services, as per the admission agreement. The Department’s investigation consisted of an unannounced facility visit, review of facility and resident records, and interviews with facility staff and outside sources. Staff interviews and record reviews provide evidence that the licensee transmitted, via electronic messaging, transaction records which listed the outstanding fees for R1’s care and services. (CONTINUED ON LIC9099-C) Unfounded Record reviews revealed that the fees for rent and services were recorded in R1’s Admission Agreement. LPAs review of the agreement, indicates that R1's rent and services have not increased and remained consistent with the terms set forth in the contract. Review of the signed Admission Agreement, transaction records, and documented communication between R1’s representative and the Licensee confirms that the Licensee provided billing records that lists the amount being charged to R1. The fees are consistent with the terms and amount agreed upon by the Licensee and R1’s representative. Based on record review and interviews, the allegation that "the Licensee did not provide R1 or their representative a comprehensive description and fee schedule for services, as per the admission agreement" is UNFOUNDED, meaning it was false, could not have happened, and/or is without a reasonable basis. The allegation has therefore been dismissed. An exit interview was conducted with Tia Suuronen-Goodwin, Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 13, 2024 · control 08-AS-20240604153214

Allegation investigated: Medications are not being administered by appropriately skilled professionals Staff are not following physician's orders Residents are not accorded dignity in relationships with staff Staff are not meeting incontinence needs of residents

Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to deliver findings for the aforementioned allegations referenced in this complaint investigation. LPA identified himself and discussed the purpose of the visit with Executive Director, Tia Suuronen-Goodwin. On December 24, 2020, Community Care Licensing (CCL) received a complaint alleging resident medications were not administered by skilled professionals, staff did not follow physician medication orders; did not provide incontinence assistance and did not accord residents dignity. During the investigation, LPA conducted a facility tour, obtained and reviewed copies of resident and staff records and facility documentation and interviewed pertinent staff and outside sources. Three of the four employees named in this complaint no longer work for the facility. Efforts were made to interview the former employees but not all were cooperative. Those providing statements denied participating in or witnessing other staff commit the alleged activities. Outside sources did not provide supporting Unsubstantiated evidence or information to corroborate the allegations. Records reviewed included documented evidence that medication staff received medication training. No staff or outside source provided testimonies to support the allegations that staff was not properly trained to administer medications or did not follow physician medication orders. No interviews provided corroboration to the claim that staff did not provide incontinence care as needed. Interviews also did not provide first hand observation that staff did not treat residents with dignity. The Department has investigated the aforementioned allegations. The preponderance of evidence standard was not met which means, the allegations may have occurred, but insufficient information was obtained to support them. Based on interviews and record reviews, the allegations are Unsubstantiated. An exit interview was conducted with Director, Tia Suuronen-Goodwin, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 27, 2024 · control 08-AS-20201224134935

Allegation investigated: -Unlawful eviction -Facility did not safeguard resident’s belongings -Facility did not respond to communications from resident’s authorized representative

Licensing Program Analyst (LPA), Daniel Pena, conducted an unannounced visit to the facility to initiate a complaint investigation. After introducing and identifying himself, LPA met with Executive Director of Operations, Chad Coleman, and discussed the elements of the complaint. On 03/08/2024, the Department received the following allegations: unlawful eviction of resident, facility did not safeguard a resident’s belongings, and the facility did not respond to communications with a resident’s authorized representative. The Department’s investigation consisted of record reviews, and interviews with facility staff and outside sources. Per facility records, Resident 1 (R1) was admitted to the facility on 12/10/2019. LPA reviewed the Facility Residence and Care Agreement (admission agreement). LPA observed R1’s electronic signature throughout the agreement. LPA also observed a section of the document titled, “Appendix J, Eviction Procedures, 22 CCR 87224(a).” R1’s electronic signature was entered on this section on 12/9/2019. The page reads in part, “the licensee may, upon thirty (30) days written notice to the resident, evict the Unsubstantiated resident for one or more of the following reasons: (1) Nonpayment of the rate for basic services within ten days of the due date.” Interviews with outside sources revealed that R1 had been receiving Medi-Cal funding when they first were admitted to the facility in 2019. This funding paid for R1’s rent at the facility. Outside sources stated that R1 never had to reapply for the funding. However, in early 2024, R1’s Med-Cal coverage stopped and R1 was required to reapply. This caused an interruption of R1’s funding source to pay the required rent payment. In February and March 2024, the facility issued 30-day notices of eviction to R1 due to the lapse of coverage and R1’s outstanding balance due. Interviews with outside sources do not dispute this fact. On or about September 2023, R1’s fanny pack, containing their identification card, credit cards and insurance cards were reported missing by R1’s authorized representative. According to interviews with an outside source, $60.00 cash was also missing. Interviews with outside sources and staff revealed that R1’s fanny pack along with their missing cards were found and returned to R1. The $60.00 cash was not found. On 12/9/2019, R1 electronically signed the admission agreement which reads in part, “IX. Your Property Rights and Obligations C. Damage to your Property. We shall not be responsible for the loss of any personal property belonging to you due to theft, fire or any other cause, unless the loss or damage was caused by our negligence or that of our employees.” This allegation nor the fruits of interviews conducted during this investigation yielded information or evidence to indicate employees or negligence contributed to the alleged loss. As to the allegation, the facility did not respond to communications from R1’s authorized representative, LPA found the following. Facility records, including emails and progress notes, provided substantial documentation to dispute the allegation. LPA observed numerous emails and progress notes generated by staff and directed to outside sources representing R1. An outside source provided a conflicting assessment of this allegation. The outside sources stated that the facility communicated with this party as requested and experienced no problems. The Department has investigated this complaint. Based upon records reviewed and interviews with staff and outside sources, there is insufficient information to corroborate the allegations. The preponderance of evidence standard was not met. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of Licensee's Rights (LIC 9058 3/22) along with a copy of this report was provided to Director, Coleman.the state’s words, verbatim · CDSS document, Mar 15, 2024 · control 08-AS-20240308090955

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Business Office Director Susie Dizon. LPA also spoke with Executive Director Disha Hall via phone during the visit. Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 07/24/2023), involving Resident #1 (R1) and Staff #1 (S1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a brief facility tour and welfare check. LPA reviewed and collected copies of pertinent facility personnel and care records, and reviewed police correspondence. LPA also interviewed relevant facility staff. By the date of LPA’s site visit, R1 had since moved out of the facility, and they could not be reached for interview. However, per R1’s latest LIC602 Physician’s Report (dated 04/28/2022): R1 had no cognitive impairment diagnosis and their doctor determined they were not confused/disoriented, able to follow instructions, able to communicate needs, and able to manage their own cash and economic resources. The LIC603 Preplacement Appraisal (dated 05/10/2022) and the Care Plan (dated 09/15/2022) which licensee performed also showed R1 was able to express themselves and communicate verbally “without difficulty.” Interview of the facility administrator corroborated that R1 was “alert and oriented X4.” [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Records and interviews showed: During July 2023, while R1 resided at the facility, R1 had privately given S1 permission to drive/operate their automobile outside of work for the purpose of finding an alternate residence for R1. On 07/20/2023, R1 first reported to facility management that they had earlier loaned their car to S1, and since lost phone contact with S1 over multiple days, causing R1 distress. Upon learning of the incident, facility management timely suspended R1’s employment, commenced an internal investigation, and reported the incident to the San Diego Police Department (SDPD) and CCLD. On 07/21/2023, R1’s automobile was returned to them (via the care of their responsible person). While SDPD did not pursue criminal charges, Licensee’s internal investigation concluded that S1 had engaged in “misappropriation of resident property.” S1’s employment administratively ended on 08/09/2023. A preponderance of evidence exists to show that during the incident in question, licensee’s staff (S1) used R1’s automobile beyond the scope of their consent/permission, resulting in R1’s temporary loss of control of property, and causing R1 distress. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Dizon. A copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Dizon and Hall during the visit.the state’s words, verbatim · CDSS document, Nov 27, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2 · Plan of correction due date: Nov 28, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents…shall have all of the following personal rights: “(25) To protection of their property from theft or loss…” This requirement was not met, as evidenced by: Based on records and interviews, licensee’s staff (S1) did not ensure that 1 of 62 residents (R1) had their personal property protected from loss of control, which posed an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 27, 2023

Plan of correction: Per personnel records and manager interviews: S1’s employment was suspended on 07/21/2023, and was administratively ended on 08/09/2023. This resolved the immediate risk. Licensee agreed to retrain its remaining facility staff on Resident’s Personal Rights (as articulated in CCLD form LIC613C-2), and to E-mail LPA a copy of the training sign-in sheet by 12/27/2023.

Allegation investigated: Neglect to residents resulting in pressure injuries Neglect to residents resulting in urinary tract infections Neglect to residents resulting in skin conditions Neglect to residents resulting in falls Medications are not being administered according to physician's orders Insufficient staffing to meet residents’ needs Facility did not address rodent and roach infestation

On 11/17/2023, at about 9:35 AM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to conclude a complaint. LPA identified himself, presented his department identification and discussed the allegations and findings with Disha Hall, Executive Director. On 6/2/2022, the Department received a complaint, alleging neglect resulted in resident pressure injuries, urinary tract infections, skin conditions and falls. Additionally, it was alleged the facility staff did not administer medications according to physician orders, had insufficient staffing and did not address pest infestations. The Department’s investigation consisted of facility inspection, record reviews, and interviews with staff and outside sources. According to this complaint, an outside source stated that facility staff did not turn a resident as required, resulting in pressure injuries. Per record reviews, the resident had several diagnoses, including Dementia, COPD and hypertension. Records also note that the resident passed away on 06/21/2022. The Unsubstantiated resident’s cause of death was respiratory failure and end stage COPD. The resident’s records indicate that on 06/04/2022, the resident developed a Stage 1 pressure injury on the sacral area. Wound care was requested. On 06/11/2022, records show the resident began receiving hospice care. On 06/17/2022, hospice provider conducted an initial nurse visit with the resident and noted open wound between resident’s glutei. Notes stated wound care was prescribed every time the resident was toileted. The resident was given a gel cushion for sitting. A 06/20/2022, progress note entry stated, the resident “was repositioned every two hours.” The complaint alleged insufficient staffing did not meet residents’ needs. The complaint stated that the facility used "agency" staff that were not trained to provide care and supervision to bedridden residents. Interviews with facility management and a review of records did not provide corroboration for this claim. Staff interviews revealed that unscheduled absences, such as sick leave, cause incidental staff shortages. To address the shortages, the facility utilizes agency staffing. Interviews and records did not reveal support for the allegation that the facility has insufficient staffing. Resident interviews yielded no complaints about lapses in service by staff. It was claimed that staff mismanaged resident medications. A sample of six staff training records and nine resident medication records were reviewed. All staff training records included the completion of medication training. None of the resident’s medication records showed evidence of medication mishandling or errors. It was alleged staff neglect resulted in resident urinary tract infections. It was alleged a resident was left in soiled clothing for extended periods. Records indicate that the resident was nonambulatory due to physical and mental conditions. The resident’s records noted lower extremity cellulitis. Progress notes showed the resident received consistent wound care. The resident’s care plan included dressing changes, weekly debridement as needed and home health nurse visits three times per week to perform dressing changes. Staff interviews did not reveal support for the allegation. Progress notes showed that incoming staff make sure residents receive clothing changes on prior shifts and change clothing as needed. Resident interviews did not reveal complaints about clothing changes. An allegation that the facility had an infestation of rodents and roaches was investigated. Resident interviews offered no information to support the allegation. Staff interviews noted incidental pest sightings but denied the presence of an infestation. Facility management provided LPA with copies of pest control service reports, as current as 6/1/22. The targeted pests were roaches. The 6/1/22 service report showed the facility was inspected for rodent activity as well. The report stated that no evidence of rodent activity was observed. Report stated, “no significant cockroach activity. Four (4) roaches were flushed in dishwashing area.” Another allegation was that neglect resulted in resident falls. Resident records were reviewed and noted numerous falls, mostly unwitnessed. The records did not indicate injuries occurred as a result of the falls. The resident’s documented behavior pattern showed they would become agitated and purposely slide off their bed onto the ground. Strategies such as giving the resident a lower bed, and approved bed rails were implemented to reduce falls. It was alleged that residents sustain body rashes due to neglect. A resident was identified and interviewed regarding this allegation. According to the resident, they developed a fungal infection over various parts of their body. The resident said the community physician provided medicated cream and the condition was just about gone. The resident also received referral to a dermatologist. The resident said the facility was very helpful and responsive. The Department has investigated the aforementioned allegations. Based on interviews and record reviews the investigation yielded insufficient evidence to support the allegations. The preponderance of evidence standard was not met; therefore, the allegations are deemed Unsubstantiated. An exit interview was conducted with Disha Hall, Executive Director, Hall and a copy of this report and Licensee/Appeal Rights (LIC 9058 01/16) were provided to Ms. Hall at the conclusion of the visit.the state’s words, verbatim · CDSS document, Nov 17, 2023 · control 08-AS-20220622093140

Allegation investigated: Staff did not notify the authorized representative that resident had shingles

On 11/15/2023, at about 8:45 AM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to investigate a complaint. LPA identified himself and discussed the allegation mentioned above with River Pagala, Resident Services Director. On 11/9/2023, the Department received a complaint, alleging the licensee did not inform a resident's authorized representative they (the resident) had shingles. The Department’s investigation consisted of facility inspection, record reviews, and interviews with staff and outside sources. According to the complaint, red spots were observed on Resident 1's (R1) body in August 2023. The facility sent a text message to an authorized representative that the facility physician prescribed a medicated ointment to address a rash on R1's body. The staff did not inform the authorized representative that R1 was diagnosed with shingles. According to the complaint, on October 31, 2023, a facility contract physician verbally advised R1's authorized representative that R1 had shingles. LPA reviewed R1's records and found Unsubstantiated progress notes dated as early as 10/12/2023, where "a rash" was observed in R1's upper torso area. A medication was prescribed to address the condition and documented in the same entry. According to interviews with an outside source, they observed red spots on the right side of R1's upper torso. A progress note dated 10/26/2023, indicated that an outside source informed staff that R1 was experiencing a "flare up" of what looked like "shingles." The progress note indicates that staff requested documentation of the diagnosis but were only presented with a prescription that staff faxed to the pharmacy. Another 10/26/2023 progress note entry reads that R1 received their first dose of an antibiotic. Per the Mayo Clinic, the medication named in the progress note is used to treat "the symptoms of chickenpox, shingles..." LPA obtained screen shots of text messages sent by the facility to the authorized representative which noted rashes to R1’s body. The text message stated that the facility contacted R1’s physician who prescribed a medication used to treat shingles. The facility sent the authorized representative photos of the prescribed medication and R1’s skin condition on 8/9/2023. Interviews with an outside source indicated that R1’s red spots improved once the medication was taken. Title 22, Section 87466, Observation of the Resident, requires the licensee to ensure residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes...or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. Evidence obtained indicates that the facility did inform the authorized representative and R1’s physician of a change in R1's skin condition which was documented in facility and outside source records. The Department has investigated the allegation that the licensee did not inform a resident's authorized representative they had shingles. Based on interviews and record reviews the investigation yielded insufficient evidence to support the allegation. The preponderance of evidence standard was not met; therefore, the allegation is deemed Unsubstantiated. An exit interview was conducted with Resident Services Director, Pagala, and a copy of this report and Licensee/Appeal Rights (LIC 9058 01/16) were provided to Mr. Pagala at the conclusion of the visit.the state’s words, verbatim · CDSS document, Nov 15, 2023 · control 08-AS-20231109092101

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Activities Director Jerome Landers. LPA then met and discussed the purpose of the visit with Executive Director Disha Hall. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 10/26/2023). According to the LIC624: on 10/25/2023, Resident #1 (R1) and Resident #2 (R2) both eloped together from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of C1.] Police located R1 and R2 on 10/26/2023, and they were subsequently returned to the facility. During today’s visit, LPA performed a facility tour and welfare check on R1 and R2. LPA also collected copies of pertinent care and hospital records and interviewed multiple relevant staff. According to their latest LIC602 Physician’s Report (dated 03/01/2023), R1 was diagnosed with Dementia and Cerebral Atherosclerosis, and their doctor determined that they were not able to safely leave the facility unassisted. According to their latest LIC602 Physician’s Report (dated 10/03/2023), R2 was diagnosed with Dementia and Alzheimer’s Disease, and their doctor determined that they were not able to safely leave the facility unassisted. Staff interviews, corroborated by date and time stamped records, showed: Between 11:00 AM and 12:05 PM on 10/25/2023, multiple facility staff saw both R1 and R2 present on the facility premises. Camera footage showed that around 12:08 PM, R1 and R2 exited the facility via a perimeter courtyard gate door. This gate door was unlocked but was alarmed to alert staff whenever it was opened. During today’s visit, LPA observed that the alarm on this gate was working and loudly audible. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] During the incident, multiple staff heard the alarm and responded on foot to the gate, but when they arrived, R1 and R2 were not in sight. Staff reset the gate alarm without looking for the person(s) who set off the alarm and without performing an accounting of residents in care. Around 4:10 PM on 10/25/2023, staff first recognized that R1 and R2 were missing. Facility staff performed an unsuccessful search of the facility and surrounding neighborhood, then notified law enforcement and the residents’ respective responsible persons, consistent with timelines described in the facility’s Elopement Policy (i.e., Absentee Notification Plan). The next day, on 10/26/2023, police located R1 by 9:00 AM and located R2 by 11:53 AM. Both residents were transported to the hospital for evaluation, before being returned to the facility. Staff interviews, corroborated by hospital and facility records, showed: While away from the facility, R1 suffered a left distal radius (i.e., left wrist) fracture of unknown origin, and arrived at the hospital with “dehydration,” a urinary tract infection, and an “acute kidney injury.” Due to language barriers and their baseline memory loss, it could not be determined from R1 how their wrist fracture occurred. LPA observed that R1’s left wrist was indeed wrapped/splinted. While away at the facility, R2 suffered blisters to the bottoms of both of their feet. Due to their baseline memory loss, R2 was not able to be qualified as a reliable historian about the incident, but R2 confirmed they suffered feet blisters during the time that they were away from the facility. A preponderance of evidence exists to show that during the incident in question, Licensee’s staff were not trained to competently respond after the above-mentioned gate alarm had sounded. This resulted in staff not timely recognizing that R1 and R2 had exited the facility premises. A preponderance of evidence also exists to show that four (4) full hours had elapsed without Licensee’s staff visually checking on R1 and R2, despite both residents requiring supervision due to their Dementia diagnoses. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). The incident resulted in serious bodily injury to R1, and non-serious bodily injury to R2. Therefore, an immediate civil penalty of $500.00 was assessed (refer to the LIC 421-IM). Since one of the deficiencies is a repeat violation within a 12-month period of time, a civil penalty of $250.00 was also assessed (refer to the LIC 421-FC). Plans of Correction were jointly developed with the licensee. An exit interview was conducted with Hall, to whom a copy of this report, the LIC809-D, the LIC421-IM, LIC421-FC, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Oct 27, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411 · Plan of correction due date: Oct 28, 2023

87411 Personnel Requirements – General: “(a) Facility personnel shall at all times be…competent to provide the services necessary to meet resident needs.” This requirement was not met, as evidenced by: Based on interviews, the licensee did not ensure facility personnel were competent to provide the services necessary to meet the needs of 2 of 63 residents (R1 and R2), which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: Training records showed on 10/26/2023, Licensee retrained its larger direct care staff team on expectations regarding observation of residents, shift change procedures, and how to correctly respond after a door alarm is activated. This resolves the immediate risk. Licensee agreed to run two (2) mock elopement drills with its direct care staff and to submit summaries of each to LPA, by 11/26/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87466 · Plan of correction due date: Nov 26, 2023

87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed…” This requirement was not met, as evidenced by: Based on records and interviews, the licensee did not ensure that 2 of 63 residents (R1 and R2) were regularly observed, which posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: Training records showed on 10/26/2023, Licensee retrained its larger direct care staff team on expectations regarding observation of residents, shift change procedures, and how to correctly respond after a door alarm is activated. This resolves the immediate risk. Licensee agreed to run two (2) mock elopement drills with its direct care staff and to submit summaries of each to LPA, by the POC due date.