Cogir of Brea

Allegation investigated: Staff are not administering resident's medication in a timely manner Staff are not responding to resident's call button in a timely manner

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint investigated by the Department. LPA was greeted and granted entry by the Business Office Director at 8am. LPA met with Executive Director (ED) Susan Allen and explained the purpose of the visit. The facility currently has a census of seventy-six residents. During the investigation LPA reviewed the following documents for Resident #1 (R1). Documents include: Identification and Emergency Information, Physician's Report dated 5/14/2024, Service Plan dated 4/22/2025, Assessments dated 5/8/2024 and 4/22/2025, electronic Medication Administration Records for June and July 2026, Progress Notes and Physician Medication Orders. Resident #1 (R1) moved into the community on 6/30/2024 with a diagnosis of encephalopathy, per Physician's Report dated 5/14/2024, and is non-ambulatory. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) On this date LPA obtained six of six staff training and inservice records, and reviewed the Device Activity Report from 6/1-6/19/2026 and Resident Council Minutes for June 2026. LPA interviewed eight of eight residents, six of six staff members and three of three witnesses during the course of the investigation. It was alleged that Staff are not administering resident's medication in a timely manner. LPA reviewed the electronic Medication Administration Record (eMAR) for Resident #1 (R1) for June through July 2026. Per eMAR, R1 received an as needed (PRN) pain medication at 9:36pm on 6/12/2026. This medication can be given every six hours. Staff interviewed stated that care staff went to the resident after receiving a phone call and relayed to the Medical Technician (Med Tech) that R1 was requesting pain medication. At 10pm, R1 requested additional pain medications. Staff interviewed stated that it was too soon to give additional pain medications and stated they shared this with R1. Staff continue to support R1 since the resident was experiencing a lot of pain. Progress notes from 6/12/2026 stated R1 requested pain medication at 9:30pm and that it was administered and tolerated well and that staff were monitoring R1 frequently. During the PM shift on 6/12/2026 there were two care staff, the Med Tech and the Med Tech trainee. Resident Council minutes from a town hall meeting on 5/28/2026 requested additional medication training for Med Techs for accuracy of medications administered. The facility addressed this issue during the 6/17/2026 Resident Council Meeting stating that an additional MedTech was hired for weekends and that staff have ongoing medication training. LPA reviewed four of six care staff training records documenting continuous medication training. Medication inservices were provided to care staff on 9/17/2025 for Medication Administration, checking dosage against orders and MARs and reading labels. On May 21, 2026 an inservice was provided for Incident reports, Giving Medications, alert and progress charting and shift duties. Five of six staff interviewed denied the allegation. One of six staff members could not confirm, nor deny the allegation. LPA interviewed eight of eight residents Three of eight residents denied the allegation that staff are not administering medications in at timely manner. Two of eight residents confirmed medications are not given in a timely manner Three of eight residents interviewed could not confirm, nor deny if medications were administered timely since they do not use medication services and self administer their own meds. Two of (Continued on LIC 9099-C1) (Continued from LIC 9099-C) three witnesses confirmed the allegation. One of three witnesses could not confirm, nor deny the allegation. It was alleged that Staff are not responding to resident's call button in a timely manner. LPA obtained the June 2026 Device Activity Report for Resident #1 (R1)'s pendant calls. Per report, there were no pendant calls received on June 12, 2026. Eight of eight staff were interviewed and staff reported R1 has a difficult time pressing the pendant due to ongoing skin lesions. Staff stated there was one instance where it was reported to the facility that R1 could not reach the pendant; which was placed on a bedside table. Staff stated they had recently changed R1's shirt and had placed the pendant on the table. Staff then put the pendant on R1's neck. Eight of eight staff denied the allegation. Staff stated on the evening of 6/12/2026 that a phone call was received stating R1 was requesting medications. Care staff stated they responded to the call within ten minutes and notified the Med Tech and the as needed pain medications were provided. Progress notes from 6/12/2026 stated R1 requested pain medication at 9:30pm and that it was administered and tolerated well and that staff were monitoring R1 frequently. Four of eight residents interviewed denied the allegation that staff are not responding to resident's call button in a timely manner. One of eight residents confirmed the allegation. Three of eight residents could not confirm, nor deny the allegation since they do not use pendants. Two of three witnesses confirmed the allegation and one witness could not confirm, nor deny the allegation. Based on LPA interviews, record review and observations, the allegations that Staff are not administering resident's medication in a timely manner and Staff are not responding to resident's call button in a timely manner are Unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director (ED) Susan Allen and a copy of this report and LIC 811 were provided to the facility.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 22-AS-20260615121800

Allegation investigated: Staff interact inappropriately with resident Staff do not provide adequate food service Staff do not ensure facility is clean and sanitary Staff do not ensure resident has clean bedding Staff do not ensure resident's laundry is being done

LIcensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint investigated by the Department. LPA was greeted and granted entry at 10am by the Business Office Director. LPA met with Executive Director (ED) Susan Allen and Assistant Executive Director (AED) Tamera Gant and explained the purpose of the visit. LPA reviewed Resident #1 (R1)'s Physician's Report dated 8/20/2025, and R1's Plan of care, dated 8/11/2025 and Admissions Agreement, signed 8/14/2025, to review R1's services being provided by the facility. Over the course of the investigation LPA interviewed eight of eight staff members, eight of eight residents and one of one witness. The witness could not confirm, nor deny any of the allegations. It was alleged that Staff interact inappropriately with resident. LPA interviewed eight of eight staff members regarding interactions with Resident #1 (R1). Eight of eight staff members stated that R1 is not excluded from activities, and that R1 is not separated from other residents in activities due to odor or other reasons. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) Eight of eight staff stated Resident #1 (R1) chooses to sit away from other residents during activities, such as Bingo and that staff encourage R1 to participate in activities. One of eight staff stated that one day, after Bingo, that the staff member took the stairs which is adjacent to R1's apartment. Staff greeted R1 by their apartment door but did not prevent R1 from going to activities since the activity had just finished and merely was passing by the apartment. Eight of eight staff denied the allegation that they interact inappropriately with the resident. Seven of eight resident also denied the allegation that staff interact inappropriately. LPA investigated the allegation that Staff do not provide adequate food service and asked if food service was delayed for R1 in the dining room. Eight of eight staff interviewed stated that R1 gets served timely and that the Dining Manager goes out of their way to assist with R1. Staff encourage R1 to have meals in the dining room. One of eight staff interviewed shared that, one evening, R1 ordered their meal after the rest of the table had put in their orders. Residents had already been seated at the table and ordered when R1 arrived and thus, the meal did not come out with the rest of the table. Seven of eight residents interviewed confirmed that R1 arrived later and they have not witnessed dining room staff delaying R1's meals. When the residents left the table early, due to completing their meal, R1 remained at the table to eat their meal. Eight of eight staff and seven of eight residents denied the allegation that Staff do not provide adequate food service. LPA investigated the allegation that: Staff do not ensure facility is clean and sanitary. LPA toured the facility on June 19, 2026 and July 2, 2026 and did not detect any odors and the facility was clean and sanitary during all visits. Eight of eight staff interviewed and seven of eight residents stated the facility is clean and that if there is an issue, the staff will come immediately to repair or clean the area. With regards to the allegation that resident did not have clean bedding, it was reported to LPA that there was one week when the assigned staff member to R1's apartment was out of the community. While the staff member was out, a second staff member asked if R1 needed bed linen service and R1 declined and stated they were fine. Per Admissions Agreement bed linen service is provided once a week. Currently there are two and a half housekeepers. The facility recently hired a part-time staff member; as requested by the residents at Resident Council. Eight of eight staff members and seven of eight residents denied residents did not have clean bedding. Eight of eight residents received notification that a staff member would be out for the week and an additional staff member would assist. Seven of eight residents denied the allegation that (Continued on LIC 9099-C1) (Continued from LIC 9099-C) residents did not have clean bedding. It was also alleged that Staff do not ensure resident's laundry is being done. Per Admissions Agreement and Resident Care Plan, Resident #1 (R1) is independent and does not receive personal laundering services and bed linens are laundered once per week. Eight of eight staff and seven of eight residents denied this allegation. Seven of eight residents stated they did not have any issues with laundry services. Based on LPA's document review, observations and interviews the allegations that: Staff interact inappropriately with resident, Staff do not provide adequate food service, Staff do not ensure facility is clean and sanitary, Staff do not ensure resident has clean bedding and Staff do not ensure resident's laundry is being done are Unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Executive Director (ED) Susan Allen and a copy of this report and LIC 811 was provided at time of visit.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 22-AS-20260615144722

Type of visit: Required - 1 Year

LIcensing Program Analysts (LPA) Rose Ruppert and Michael Tea made an unannounced visit to conduct an Annual Required Evaluation. LPAs were greeted and granted entry by the Business Office Director at 8am. LPAs met with Executive Directors (EDs) Susan Allen and Cynthia Figueroa and explained the purpose of the visit. The facility is a two-story building with Assisted Living that occupies the first and second floors and the Memory Care is secured and housed on the second floor. The facility has an approved fire clearance for one hundred ten non-ambulatory residents, of which twelve may be bedridden and is approved for delayed egress. The facility has an approved hospice waiver for twelve residents. Currently there are seventy-eight residents in care with four on hospice and no residents are bedridden. During today’s visit, LPAs and EDs toured the facility and inspected the physical plant. The facility was 72 degrees. LPAs reviewed fire inspection paperwork and twenty fire extinguishers were charged and inspected on June 4, 2026. The fire alarms systems were tested on July 2, 2025 and this year's inspection is scheduled for July 24, 2026. Sprinklers were tested on June 19, 2026. LPAs were also given the monthly Pest Control paperwork and the facility was clean and there were no odors detected. Evacuation chairs were observed on two stairwell exits and both facility elevators were in working order. The facility's last fire drill was conducted on June 10, 2026. The kitchen exhaust cleaning was observed for June 17, 2025 and the kitchen fire extinguisher was also inspected and charged. Resident modified diets were observed in the kitchen and temperature logs for the refrigerator and freezer were completed. (Continued on LIC 809-C) (Continued from LIC 809) LPAs observed there was two days of perishable food and seven-days of non-perishable items. The emergency supplies were also inspected on the second floor with canned food and water. EDs added additional canned goods and water. LPAs visited eight of eight residents apartments and tested the hot water temperatures. The hot water temperatures ranged from 113.5 to 118.4 degrees Fahrenheit. Staff responded to bathroom call test within fifteen minutes. All apartments had the required furnishings and linens and were clean with no safety hazards detected. LPAs tested the delayed egress door in Memory Care, that leads to the street, and the door and alarms were operational. The Memory Care has an enclosed courtyard for residents to walk outdoors and there were no hazards or obstructions in pathways. LPAs observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. LPAs observed residents in the dining room for lunch and participating in activities such as Tai Chi and a group discussion. During the tour LPAs observed all common areas have cameras but they are visual only. LPAs obtained the resident and staff rosters. The Emergency Disaster Form was recently reviewed and updated by ED Susan Allen. LPA Tea reviewed five of five staff training and fingerprint records and reviewed eight of eight resident records. LPAs interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPAs confirmed that administrator has a current administrator certificate which expires on December 10, 2027. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Executive Directors (EDs) Susan Allen and Cynthia Figueroa and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Jul 2, 2026

Allegation investigated: Staff engages in inappropriate physical interactions with resident in care

Licensing Program Analyst (LPA) made an unannounced visit to deliver findings for a complaint investigated by the Department. LPA was greeted and granted entry by the Concierge at 1pm. LPA met with Executive Director (ED) Cynthia Figueroa and explained the purpose of the visit. LPA obtained the current staff roster and there are eighty-two residents in care. LPA reviewed Resident #1 (R1)'s Identification and Emergency Information, Physician's Report dated 8/20/2025, Preplacement Appraisal Information dated 8/11/2025 and R1's Plan of care, dated 8/11/2025, LPA also reviewed the file of Staff #1 (S1) which included: Personnel Record, Criminal Record Statement, Health Screening Report, Corrective Action Form and a written report from S1. S1 recently resigned and no longer is employed by the community. Brea Police Department has also conducted two welfare checks and shared with R1 that there has been no crime and police reports were not filed. (Continued on LIC 9099-C) Substantiated (Continued from LIC 9099) The allegation that: Staff engages in inappropriate physical interactions with resident in care was investigated by the Department. Four of four residents were interviewed. One resident confirmed the allegation and three of four residents could not confirm, nor deny the allegation. Five of five staff members interviewed denied the allegation. LPA reviewed Staff #1 (S1)'s employee file; which included Corrective Action Forms and a written statement by S1. It was brought to management's attention that S1 was offered an item by Resident #1 (R1) that was to be thrown away. The item was in need of repair and R1 did not want it to be thrown out. S1 accepted the item and hoped to refurbish it and would ask R1 questions about the item and things that went with it. Per facility Corrective Action Form, the resident's item was returned to R1 the very next day after management became aware of the situation. R1 also reported to management that S1 left a brown sock in their dresser drawer as a sign that S1 still worked at the facility. R1 stated the staff member asked too many questions and was too comfortable with R1 and gave R1 aggressive hugs. LPA inquired if R1 shared their discomfort with the hugs but R1 did not share this with the staff member. LPA interviewed S1 who stated R1 never gave any indication that S1 was being intrusive and S1 asked R1 if R1 would accept the hug. Although R1 did not reply, S1 felt a closeness to R1 and hugged the resident. Although the resident did not verbally state their discomfort, R1 did not give verbal consent. S1 has since resigned and no longer works at the community. Based on LPA's file review, observations and interviews, A Technical Violation will be given for CCR 87468.2(a)(8) Additional Personal Rights of Residents in Privately Operated Facilities and the allegation above is Substantiated. An exit interview was conducted with Executive Director Cynthia Figueroa, and a copy of this report and LIC 9102-TV was provided to the facility.the state’s words, verbatim · CDSS document, May 14, 2026 · control 22-AS-20260324113805

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct a Case Management Visit. LPA was greeted and granted entry by the Concierge at 1pm. LPA met with Executive Director (ED) Cynthia Figueroa and explained the purpose of the visit. The purpose of the visit is to amend a licensing report (LIC 9099) from April 28, 2026. An exit interview was conducted and a copy of this report and amended report were provided.the state’s words, verbatim · CDSS document, May 14, 2026

Allegation investigated: Staff do not ensure resident is accorded with dignity and respect in their personal relationships with others Staff do not ensure resident is provided personal privacy Staff do not ensure resident is spoken to in an appropriate manner Staff do not ensure resident is served meals in a timely manner as a form of punishment

Licensing Program Analyst (LPA) made an unannounced visit to deliver findings for a complaint investigated by the Department. LPA was greeted and granted entry by the Concierge at 11am. LPA met with Executive Director (ED) Cynthia Figueroa and explained the purpose of the visit. LPA obtained the current staff roster and there are eighty residents in care. LPA reviewed Resident #1 (R1)'s Identification and Emergency Information, Physician's Report dated 8/20/2025, Preplacement Appraisal Information dated 8/11/2025 and R1's Plan of care, dated 8/11/2025, LPA also reviewed the file of Staff #1 (S1) which included: Personnel Record, Criminal Record Statement, Health Screening Report, Corrective Action Form and a written report from S1. S1 recently resigned and no longer is employed by the community. Brea Police Department has also conducted two welfare checks and shared with R1 that there has been no crime and police reports were not filed. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) Per Physician's Report dated 8/20/2025, Resident #1 (R1) has primary diagnoses of osteoporosis and osteoarthritis. R1 does not have mental cognitive impairment but has a history of behavior expression of paranoia. R1 is independent and does not require assistance with mobility/ambulation. Per medical assessment the resident is non-ambulatory due to physical condition diagnoses. R1 is capable of administering their own medications. The pre-appraisal from 8/11/2025 states R1 doesn't prefer to be social but is encouraged to join activities. R1 is capable of doing their own laundry and household tasks. Per R1's Care Plan R1 has a history of occasional anxiety and depression or mood disorder. It was alleged that: Staff do not ensure resident is accorded with dignity and respect in their personal relationships with others. Per LPA staff and resident interviews, R1 usually comes to the dining room for dinner. A comment was made, at the dinner table that female residents stink. Another resident at the table then covered their nose. R1 felt the comment was made towards them. LPA interviewed six of six residents. Three residents at the table were interviewed. One resident confirmed the allegation, a second resident denied the allegation and the third resident moved out of the community and could not be interviewed. Two additional residents were interviewed and denied the allegation. The allegation that Staff do not ensure resident is accorded with dignity and respect in their personal relationships with others is Unsubstantiated. LPA investigated the allegation that Staff do not ensure resident is provided personal privacy. Staff were instructed to conduct a room check for a resident's missing laundry. Two staff members knocked on R1's door and requested entry. The staff stated they were looking for a resident's missing laundry items and requested permission to look in R1's closet and dresser. R1 permitted entry to search for the missing items. R1 does not use laundry services and is able to do their own laundry. Several days later, R1 shared the incident with management, stating they were not afforded privacy and that the staff members entered while R1 was in the bathroom. Staff and management are aware that R1 prefers to be private and so staff will enter the apartment in pairs as needed, to ensure R1 is more at ease with staff. R1 is independent and does not require a lot of services and staff do not enter R1's apartment often. One resident confirmed the allegation and three residents denied the allegation. The allegation that Staff do not ensure resident is provided personal privacy is Unsubstantiated. (Continued on LIC 9099-C1) (Continued from LIC 9099-C) It was also alleged that Staff do not ensure resident is spoken to in an appropriate manner. It was reported to management that two persons entered R1's apartment and were asking questions about R1's medications and medical information. The incident occurred on a Saturday and management was not aware of the incident until Monday. Management interviewed staff and reviewed facility hallway cameras. It was determined the two people visiting were a Physician's Assistant (PA) and Social Worker (SW) from the Primary Care Provider agency; whom R1 permitted entry. R1 also reported that another staff member made inappropriate comments while watching an evening movie. When asked what the comments were, R1 referred to a film the staff member was discussing. The staff member has since resigned and left the community. One resident confirmed the above allegation and three residents denied the allegation; stating staff are always professional and courteous. Five of five staff interviewed all denied the allegation. Thus the allegation that staff do not ensure resident is spoken to in an appropriate manner is Unsubstantiated. LPA investigated the allegation that: Staff do not ensure resident is served meals in a timely manner as a form of punishment. It was reported to LPA that dining staff did not provide a meal at dinner to punish the resident. LPA interviewed five of five staff members who denied the allegation. Three of five residents interviewed also denied the allegation. One resident was unavailable to interview who were present. Staff interviews shared that R1 had eaten an entree and, later, ordered another entree. The server took the second entree order but, as the staff member was walking to the kitchen, was delayed by another table. The order was then placed with the chef. As the residents at R1's table received their initial dinner orders, one of the residents inquired about the second order for R1. The server stated the order was placed but R1 immediately got up from the table and left the dining room. This was brought to management's attention and the chef spoke with R1 about the incident and assured R1 it was not a delay to punish the resident and the order was completed. Thus the allegation that Staff do not ensure resident is served meals in a timely manner as a form of punishment is Unsubstantiated. (Continued on LIC 9099-C2) (Continued from LIC 9099 C1) Based on LPA's file review, observations and interviews the allegations that: Staff do not ensure resident is accorded with dignity and respect in their personal relationships with others, Staff do not ensure resident is provided personal privacy, Staff do not ensure resident is spoken to in an appropriate manner and, Staff do not ensure resident is served meals in a timely manner as a form of punishment are Unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Executive Director (ED) Cynthia Figueroa and a copy of this report,and LIC 811 were provided to the facility. ***This is an amended report.***the state’s words, verbatim · CDSS document, Apr 28, 2026 · control 22-AS-20260324113805

Allegation investigated: Staff do not provide adequate food service Staff do not ensure residents' medication is given in a timely manner

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint that was received in the Regional Office. LPA was greeted and granted entry by the Concierge at 8am. LPA met with Executive Director (ED) Cynthia FIgueroa and explained the purpose of the visit. LPA obtained the resident roster, a care staff schedule for December 2025 and a care staff roster with phone numbers. LPA also requested additional Unusual Incident Reports that were sent to the office on December 15, 2025, Resident room cleaning/linen schedules and Resident laundry schedules. LPA also reviewed three of three resident records and three of three staff records and an In-service manual. It was alleged that Staff do not provide adequate food service. LPA interviewed the Culinary Experience Director and was invited to observe meals. LPA toured Memory Care (MC) at 8:20am and learned the hot box with breakfast items was delivered at 8am. LPA observed eight residents eating breakfast and asked (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) three of three residents if they enjoyed their breakfast. Three of three residents stated the food was good but the food was lukewarm and not hot. LPA inquired if residents would like the food to be hotter and all stated No. LPA also checked the refrigerator in Memory Care that stores snacks overnight for MC residents. Staff are able to contact the kitchen if the refrigerator needs to be stocked and culinary checks the MC refrigerator at 2:30pm. At 6:30pm, prior to the kitchen closing, culinary stocks the MC refrigerator with sandwiches, fruits and drinks for residents to snack on overnight; if they are hungry. LPA did observe snack and drink items in the refrigerator. At 11:50am LPA observed residents eating lunch in Memory Care. The hot box temperature was at 117 degrees and LPA felt inside the box and found it to be hot. LPA again interviewed residents at lunch time and most stated their food was warm, not hot. LPA asked if residents wanted the food to be warmed up and again, all residents stated they were fine. Based on six of six resident interviews and nine of nine staff interviews, the allegation that Staff do not provide adequate food service is Unsubstantiated. It was alleged that Staff do not ensure residents' medication is given in a timely manner. LPA interviewed six of six care staff who denied this allegation. In Memory Care, the Med Tech has the Memory Care Coordinator as a back-up to provide medications in a timely manner. Medications have a one hour window before the medication time is given; as well as a one hour window after the medication is to be given. There have been no incidents where residents in Memory Care are not receiving their meds. One of six residents interviewed stated they do not get medications in a timely manner and has to wait at least two hours. Five of six residents did not have issues with medications. Nine of nine staff interviews also denied this allegation. Thus the allegation that Staff do not ensure residents' medication is given in a timely manner is Unsubstantiated. Based on LPA observations, record review and interviews, although the allegations above 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 that Staff do not provide adequate food service and Staff do not ensure residents' medication is given in a timely manner are Unsubstantiated. An exit interview was conducted with Executive Director, Cynthia Figueroa, and a copy of this report and LIC 811 was provided to the facility.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 22-AS-20251210102834

Allegation investigated: Staff do not ensure that residents' have clean bedding Facility is malodorous Staff do not ensure facility is clean and sanitary Staff mishandled residents resulting in staff dropping residents Staff do not ensure residents are provided a comfortable environment Staff do not ensure hazardous items are inacessible to residents

Licensing Program Analyst (LPA) Rose Ruppert made an uannounced visit to investigate a complaint that was received in the Regional Office. LPA was greeted and granted entry by the Concierge at 8am. LPA met with Executive Director (ED) Cynthia FIgueroa and explained the purpose of the visit. LPA obtained the resident roster, a care staff schedule for December 2025 and a care staff roster with phone numbers. LPA also requested additional Unusual Incident Reports that were sent to the office on December 15, 2025, Resident room cleaning/linen schedules and Resident laundry schedules. LPA also reviewed three of three resident records and three of three staff records and an In-service manual. LPA toured the Memory Care (MC) and conducted a health and safety check. Residents were observed eating breakfast and LPA interviewed three of three MC residents and nine of nine staff members. It was alleged that Staff do not ensure that residents' have clean bedding. LPA entered three of three MC resident rooms and did not detect odors and all beds were clean and made. (Continued on LIC 9099-C) Unfounded (Continued from LIC 9099) LPA also entered three of three resident rooms in Assisted Living (AL). All beds were made and three of three residents interviewed shared they do not sit in soiled linens and that they do not have any issues with laundry services. If there are issues with accidents, care staff call housekeeping and sheets are laundered. Apartments are all cleaned once per week which includes laundering linens Thus this allegation is Unfounded. It was alleged that the Facility is malodorous. LPA toured Assisted Living (AL) and Memory Care (MC) and did not detect any foul odors. LPA randomly checked six of six resident apartments and there were no odors detected. Six of six residents and nine of nine staff all denied the allegation that there were foul odors. It was also alleged that Staff do not ensure facility is clean and sanitary. Upon touring the facility LPA observed bathrooms in common areas being cleaned and the facility was clean and sanitary. Six of six residents and nine of nine staff all denied that the staff do not ensure the facility is clean and sanitary. LPA obtained housekeeping and laundering schedules and all apartments are cleaned once a week. Thus the allegations that the Facility is malodorous and that Staff do not ensure facility is clean and sanitary is Unfounded. It was also alleged that Staff mishandled residents resulting in staff dropping residents. LPA interviewed six of six residents and nine of nine staff members who all denied this allegation. LPA reviewed Unusual Incident Reports submitted to licensing by the facility and there are no occurrences of residents being dropped. Thus, the allegation that Staff mishandled residents resulting in staff dropping residents is Unfounded. LPA investigated the allegation that Staff do not ensure residents are provided a comfortable environment. LPA interviewed six of six residents and nine of nine staff. All residents and staff felt supported by the management and stated staff ensure that residents are provided a comfortable environment. LPA toured the facility and conducted a health and safety check and there were no issues with staff providing a comfortable environment. LPA reviewed three of three staff files and all training of staff are current. Thus, the allegation that Staff do not ensure residents are provided a comfortable environment is Unfounded. Lastly, LPA inquired if Staff do not ensure hazardous items are inaccessible to residents. LPA toured the facility and did not encounter obstacles obstructing pathways, hazardous materials or sharps and knives that (Continued on LIC 9099-C1) (Continued from LIC 9099-C) were accessible to residents in Assisted Living or Memory Care. LPA toured the activities area in Memory Care and noted markers were secured in a box that was inaccessible to residents. Glue sticks are rarely used but are secured in the Lifestyle Enrichment office. LPA interviewed six of six residents and nine of nine staff who all denied this allegation. Thus the allegation that Staff do not ensure hazardous items are inaccessible to residents is Unfounded. Based on LPA's record review, observations and interviews, the allegations that: Staff do not ensure that residents' have clean bedding, Facility is malodorous, Staff do not ensure facility is clean and sanitary, Staff mishandled residents resulting in staff dropping residents, Staff do not ensure residents are provided a comfortable environment and Staff do not ensure hazardous items are inaccessible to residents are Unfounded. The allegations are false, could not have happened, and/or are without a reasonable basis. An exit interview was conducted with Executive Director, Cynthia Figueroa, and a copy of this report and LIC 811 was provided to the facility.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 22-AS-20251210102834

Allegation investigated: Licensee financially abused resident.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an investigation for a complaint received in the Regional Office. LPA was greeted and granted entry at 8am by the Concierge and met with Executive Director (ED) Cynthia Figueroa. LPA requested the following for Resident #1 (R1): Identification and Emergency Information Form, Physician's Report dated 4/9/2025, Omnicare Resident Pharmacy Enrollment form, Resident and Care Agreement, Resident Detail Ledger and email communication with Responsible Party (RP). It is alleged that the Licensee financially abused resident. R1 moved into the facility on April 10, 2025 and had a diagnosis of Atrial Fibrillation, was ambulatory and had Mild Cognitive Impairment. Per Omnicare Resident Pharmacy Enrollment form, the resident was the Financial Responsible Party, which was signed on April 10, 2025. LPA reviewed the Resident Detail Ledger which reports the resident account had a zero balance as of September 18, 2025. (Continued on LIC 9099-C) Unfounded (Continued from LIC 9099) LPA interviewed three of three alert residents regarding their finances and if there were any issues with the facility and financial abuse. Three of three residents denied the allegation and stated there were no problems with billing at this time. LPA interviewed one witness. The witness also denied the allegation and had no knowledge of financial abuse of the residents. LPA interviewed Executive Director (ED) regarding Omnicare medications received for R1 while R1 was out of the community from July 19, 2025. R1 transferred to a higher level of care and medications received for that cycle were destroyed, per community protocol. A new cycle of medications was ordered in September, in anticipation of R1's return to the community, but R1 did not return and passed away on September 18, 2025. Per ED, the September medications were also destroyed. ED will work with Omnicare to handle the medication costs incurred while resident was not in the community. After discussion regarding Long Term Care Insurance, ED reviewed insurance claim filed and found the clerical error for July 12, 2025. ED confirmed the correct date should be July 19, 2025 and that the facility will resubmit the claim to insurance. ED will provide written documentation to the Responsible Party regarding the financial issues reported to the Licensee to ensure all parties are on the same page. ED also provided this documentation to the LPA via email Based on LPA's record review and interview, the allegation that Licensee financially abused resident is Unfounded. The allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Executive Director (ED), Cynthia Figueroa, and a copy of this report and LIC 811 was provided to the facility.the state’s words, verbatim · CDSS document, Nov 21, 2025 · control 22-AS-20251114134103

Allegation investigated: Staff are under the influence of alcohol while caring and supervising residents.

Licensing Program Analyst (LPA) Rose Ruppert made an unannouced visit at 1pm to investigate a complaint received in our Regional Office. LPA was greeted and granted entry by Concierge and met with Executive Director (ED) Cynthia Figueroa and explained the purpose of the visit. It was alleged that: Staff are under the influence of alcohol while caring and supervising residents. LPA interviewed four of four residents and ten of ten staff. Four of four residents denied observing a staff under the influence and two of ten staff confirmed the allegation. LPA conducted a health and safety check on residents in care and toured the facility. LPA reviewed five of five staff files regarding training and spoke to ED regarding the facility Drug and Alcohol Policy. ED reviewed this policy at the All-Staff meeting regarding the procedure on reporting and documenting any drug or alcohol use in the workplace. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with ED Figueroa and a copy of this report was provided to the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 25, 2025 · control 22-AS-20250910183027

Allegation investigated: Staff does not ensure facility is clean and sanitized. Staff does not ensure kitchen appliances are free of mold. Staff do not properly store food. Staff do not ensure food is properly cooked. Staff does not ensure facility is free of pests.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in the Regional Office. LPA was greeted and granted entry by Concierge and met with Executive Director (ED) Cynthia Figueroa and explained the purpose of the visit. On September 16, 2025 LPA toured the kitchen, interviewed five of five staff members and obtained copies of five of five staff member files. LPA returned on September 23rd and 25th to interview five of five additional staff members and four of four residents. Ten of ten staff members interviewed denied the above allegations. Four of four resident interviews also denied the above allegations. LPA observed staff cleaning the kitchen on the afternoon of September 16, 2025. LPA observed sanitation buckets were in various areas of the kitchen and being used, during the inspection. Four of four staff stated the ice machine was cleaned daily and was free of mold. (Continued on LIC 9099-C) Unfounded (Continued from LIC 9099) LPA spoke with line staff regarding proper storage of food and if food was properly cooked. Kitchen staffwalked LPA and ED throughout the kitchen where LPA observed food was properly stored and labeled. LPA inquired how oatmeal was cooked and kitchen staff stated oatmeal is boiled on the stove and not made in the steam well. LPA observed refrigerator and freezer logs were kept in binders in the Director's office. While touring the facility LPA did not observe any pest infestations. LPA asked the kitchen staff if there were issues with ants and four of four kitchen staff stated it happened one day where ants were near the maple syrup bottle on the counter. Staff immediately cleaned the syrup bottle and ants have not been observed since that day. Four of four residents to not have any issues with ants. Based on LPA file review, interviews and observations the allegations that: Staff does not ensure facility is clean and sanitized, Staff does not ensure kitchen appliances are free of mold, Staff do not properly store food, Staff do not ensure food is properly cooked and Staff does not ensure facility is free of pests are Unfounded. The allegations are false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with ED Figueroa and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 22-AS-20250910183027

Allegation investigated: Staff did not ensure the residents emergency pull and button was properly operating Staff did not ensure the resident's outlets were properly operating Staff mishandled a resident's medication

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint investigation conducted by the Department. LPA was greeted and granted entry and met with Cynthia Figueroa, Executive Director (ED). It was alleged Staff did not ensure the resident's emergency pull button was properly operating and Staff did not ensure the resident’s outlets were properly operating due to Resident #1 (R1)’s pull cord and outlets not working. R1 moved into the facility on December 15, 2024. Upon moving into the facility, interviews conducted with R1’s family reported outlets were observed to be in working order but the call button and emergency pull cord was not working. The issue was brought to the facility maintenance director’s attention and R1 was offered to move rooms due to the emergency pull cord and call button not working. R1 was not moved into another room until January 4, 2025 which was eleven days later. (Continued on LIC 9099-C) Substantiated (Continued from LIC 9099) Based on LPA observations, record review and interviews the allegations that alleged Staff did not ensure the residents emergency pull button was properly operating and staff did not ensure the resident’s outlets were properly operating are Substantiated. It was alleged that Staff mishandled a resident's medication. Facility progress notes from January 5, 2025 at 8:54pm document that a personal caregiver showered R1 and found three medication patches on R1’s right side; one on the shoulder and two on the bottom. This was reported to the Health and Wellness Director (HWD). Personal caregiver notified family of the three patches found on R1. HWD notified hospice and on January 10, 2025 a new patch was applied and former patches removed. A photo was submitted to the Department of multiple patches on R1. Per physician’s report dated December 12, 2024 one medication patch was to be applied daily. Therefore, the allegation that Staff mishandled a resident's medication is Substantiated. This was cited on June 18, 2025 for Control # 22-AS-20250416144122 with the allegation that: Staff are mismanaging residents medications. The Plan of Correction documentation was submitted to the Department that the staff received medication storage and destruction trainings on June 24th and June 30, 2025. Based on LPA's observations, interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations: Staff did not ensure the residents emergency pull and button was properly operating, Staff did not ensure the resident's outlets were properly operating and Staff mishandled a resident's medication are found to be Substantiated. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Cynthia Figueroa, Executive Director (ED) and a copy of this report was given to the facility along with a copy of the LIC 811, LIC 859; LIC 9099-D and Appeal Rights.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 22-AS-20250310123459

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i) · Plan of correction due date: Aug 22, 2025

87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more...shall have a signal system which shall: (A) Operate from each resident's unit. (B) Transmit a visual and/or auditory (cont.) signal to a central staffed location or produce an auditory signal... loud enough to summon staff. (C) Identify the specific resident living unit. This requirement was not met as evidenced by: Resident call button was not in working order which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: Executive Director and LPA toured Memory Care and tested the signal system. The signal system was in working order. The Plan of Correction wil be cleared by the visit today on August 21, 2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Aug 22, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (cont.) This requirement was not met as evidenced by: Resident outlets were not in working order. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: Executive Director and LPA toured Memory Care and tested outlets in resident room. Outlets were tested and in working order. The Plan of Correction will be cleared by the visit today on August 21, 2025.

Allegation investigated: Staff did not properly maintain a resident's bathroom while in care

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint investigation conducted by the Department. LPA was greeted and granted entry and met with Cynthia Figueroa, Executive Director (ED). It was alleged that Staff did not properly maintain a resident's bathroom while in care due to Resident #1 (R1)’s toilet having traces of feces along the exterior of the toilet. Per photographs obtained dated December 26, 2024 & December 31, 2024, traces of feces appear to be observed along the outer edge of the toilet seat lid and rim. On January 01, 2025, photographs obtained show urine on the upper tank of R1’s toilet. Witness interviewed reported R1’s bathroom floor was sticky and appeared to have R1’s footprint on the tile. Per R1’s admission agreement dated December 9, 2024 R1’s room is to be cleaned once a week. LPA interviewed two of two facility housekeepers who reported resident rooms are cleaned once a week, however, they will clean the rooms as needed if accidents occur and are reported to them. Interviews with (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) housekeepers, care staff, and med techs report R1’s behaviors of urinating and having bowel movements were frequent. Facility progress notes documented that on December 16, 2024 R1 had a bowel movement (BM) in the dining area and R1 spread BM on table and floor. It is charted that staff cleaned R1 and the cleaning area that was soiled. On December 17, 2024 R1 was assisted to the toilet and seated by staff but R1 stood up and wandered away while urinating on the floor. Staff interviews report accidents were not small and during one incident, it took the housekeeper over an hour to clean the area. R1’s behavior was also charted on December 21, December 30, January 4, January 5, 2025. Staff stated accidents were always cleaned up but the frequency of R1’s behavior and the areas where incidents occurred, such as R1’s room, carpet, bathroom, and common areas, may have not been attended to. Staff stated they constantly redirected the resident to the toilet but R1 was combative with staff or refused to go. It is unclear when the feces and urine incidents occurred in R1's bathroom, and when staff would come to clean the area. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation that Staff did not properly maintain a resident's bathroom while in care is Unsubstantiated. A Technical Violation will be given. An exit interview was conducted with Cynthia Figueroa, Executive Director (ED) and a copy of the report, the LIC 9102-TV and files reviewed LIC 859 and LIC 811 were given at the time of the visit.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 22-AS-20250310123459

Allegation investigated: Staff did not meet a resident's incontinence needs Staff did not have planned activities for the residents Staff mishandled a resident's personal belongings Resident sustained an unexplained injury while in care Staff did not properly report incidents involving a resident Staff did not ensure a resident was properly fed while in care Staff did not have adequate record keeping of a resident

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility to deliver findings from a complaint received in the Regional Office. LPA was greeted and granted entry and met with Cynthia Figueroa, Executive Director (ED) and explained the purpose of the visit. Resident 1 (R1) moved into the facility on December 15, 2024. Per Physician’s Report dated December 12, 2024, R1 has a diagnosis of Alzheimer’s Disease. R1 is frequently disoriented and required repeated verbal prompts and redirection. R1 also received hospice services upon admission. On January 11, 2025, R1 was sent out to the hospital, due to a fall, and never returned to the community. Family removed belongings on January 11, 2025. It was alleged that Staff did not meet a resident’s incontinence needs. Per physician’s report dated December 12, 2024 it is noted R1 has bladder and bowel impairment and wears pull-ups. R1 is unable to care for own toileting needs. LPA reviewed the initial Needs and Services plan dated December 16, (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) 2024. Needs and Services Plan noted R1 had Moderate toileting needs and required stand-by assistance for toileting tasks. The hospice nurse documented on January 3, 2025 that resident was incontinent with a strong urine odor. Antibiotics were prescribed for a Urinary Tract Infection. On January 5, 2025 the Needs and Services Plan was updated by the Health and Wellness Director (HWD). Toileting needs changed from Moderate to Extensive, stating R1 required hands-on assistance from one person and the resident is incontinent. HWD spoke with hospice and family that a personal caregiver would help with R1s behaviors. Facility progress notes, beginning on December 16, 2024 report R1 was resistant to being directed to the toilet, would remove pull up and frequently urinated or had bowel movements in common areas. Facility staff worked with hospice to find ways to mitigate these behaviors. The allegation that Staff did not meet a resident’s incontinence needs is Unsubstantiated. It was alleged that Staff did not have planned activities for the residents. LPA obtained Activities Calendar for Assisted Living (AL) and Memory Care (MC), also known as Revere, with Daily Activities detail by the hour for February and March 2025. LPA observed there were six to seven scheduled activities per day. LPA toured Revere on March 18, 2025 and observed four residents painting shamrocks that were continued from a St. Patrick’s Day activity on March 17, 2025. LPA interviewed two of two Activities staff regarding the implementation of activities. One staff member works Sunday through Thursday and the other works Tuesday through Saturday. There are only three days where both activities staff are present. Of the three days when both are present, one staff member usually drives residents for scheduled appointments as needed. Interviews shared that if an activities staff member needs to drive, the staff member will start the activity and leave instructions for care staff to complete with residents. Four of the seven days per week there is only one activities person on-site. (Continued on LIC 9099C1) (Continued from LIC 9099C) Both activities staff reported that, if residents are uninterested in participating in Activities, that they do not force them and will pivot to try to engage the residents in another way. LPA interviewed four of four residents in Revere. One of the four residents participated in activities. Three of four residents did not show interest in participating. Due to staffing shortages activities staff were pulled to assist with non-care needs; such as serving food or answering calls. Staffing shortages were cited on May 13, 2025 Control number 22-AS-20250509094345. Thus, although activities were always planned, staffing dictated if they could be implemented. Therefore the allegation that: Staff did not have planned activities for the residents is Unsubstantiated. It was alleged that Staff mishandled a resident’s personal belongings due to R1’s soiled clothing being thrown out. LPA interviewed two of two housekeepers who reported they are responsible for cleaning resident rooms, once per week, or as needed. Per interviews with two of two housekeepers, care staff are responsible for laundering resident personal belongings. LPA interviewed four of four med technicians and three of three care staff. Interviews with three of three Revere care staff stated that when a resident’s clothing is soiled, most times staff discover the resident throws the clothing away in trash cans, attempts to flush soiled clothing in toilet, hides soiled clothing in furniture or places item in another resident’s room. Care staff denied tossing R1’s clothing and that staff make the effort to clean the resident and launder the clothing. Facility progress notes on December 20, 2024 documented R1 was aggressive towards staff and another resident and was removing and taking their belongings. When staff were asked for three items of R1’s clothing that were missing, the staff member who stated the soiled clothing was thrown away denied the allegation. Thus, the allegation that: Staff mishandled a resident’s belongings is Unsubstantiated. (Continued on LIC 9099C2) (Continued from LIC 9099C1) It was alleged that a Resident sustained an unexplained injury while in care. Photo evidence was submitted to the Department of the bruise under the chin. Facility progress notes dated January 7, 2025 at 7:49am reported the Med Tech (MT) had changed R1 and had given morning medications when MT noticed bruising on the bottom of R1’s jaw. It was reported to the Health and Wellness Director and hospice. Hospice notes dated January 8, 2025 documented that nurse reported the bruise under R1’s chin and the skin was intact. Family was notified by facility of the bruise. Med Tech was unaware of how R1 received the bruise and there were no falls reported. The unexplained bruise was immediately identified and reported to the Health and Wellness Director, Hospice nurse and family. Thus the allegation that a resident sustained an unexplained injury while in care is Unsubstantiated. It was alleged that Staff did not properly report incidents involving a resident. Review of facility progress notes from January 11, 2025 stated R1 had a fall in the dining area during lunch time and was witnessed by care staff. The fall happened approximately at 11:15 am and Med Tech (MT) charted at 1:37:02 pm that the spouse was called twice but MT was unable to leave a voicemail due to the voicemail box being full. On the third try MT texted information to spouse’s cell phone. Charting notes stated the daughter was also called and was unable to get a hold of her, but an incident report was made. MT also notified hospice and spoke to the nurse. MT spoke to Manager on Duty (MOD) that MT attempted to contact family. At 12:23pm MOD left a voicemail for family to call the community. The voicemail also references other items to address with family but does not state that R1 was sent out per facility policy. R1 was transported via ambulance to a local hospital for further evaluation. On January 11, 2025 at 9:30pm progress notes stated resident moved out this evening and meds were signed out and given to family. The allegation that Staff did not properly report incidents involving a resident is Unsubstantiated. (Continued on LIC 9099C3) (Continued from LIC 9099C2) It was alleged Staff did not ensure a resident was properly fed while in care due to R1 not being fed at the scheduled meal times. Per R1’s physician report dated December 12, 2024, R1 was diagnosed with Alzheimer’s disease and is able to feed themselves. Per R1’s initial Needs and Services Plan dated December 16, 2024 , R1 required minimal assistance and that R1 could feed self, chew and swallow food, however needs reminding/ cueing to maintain adequate intake. LPA conducted interviews with six of six staff who reported their priority is assisting residents who require feeding. Staff interviewed reported R1 often would remain in their bed due to being awake most of the night. Due to staffing needs, they had to first assist with residents who were present in the dining area and required feedings. Staff frequently checked on R1 and would attempt to coax R1 to eat. Per Pre-Appraisal dated December 15, 2024 food allergies were noted, R1 does not eat lunch and eats small portions. Review of facility progress notes reported R1 often would remain in their bed during scheduled meal times. Med Tech charted on December 16, 2024 that R1 stated they were not hungry. R1 was given water and propel powder provided by family. Family was aware R1 did not always eat. Notes report on December 18, 2024 R1 refused dinner and chose to eat two cookies. On December 22, 2024 R1 ate with family member but only at three to four spoonfuls of dinner. It is noted that spouse said this was the normal eating pattern. Family stated that if R1 refuses to eat, to provide Ensure or pudding. On December 24, 2024 R1 refused to eat and spouse was made aware. On December 30, 2024 R1 ate 100 percent of dinner. On January 6, 2025 R1 ate 80 percent of dinner. Hospice notes reviewed dated December 15, 2024, documents R1's wandering behavior, separating themselves from others; and refusing eating and medications. On December 20, 2024, Hospice notated that R1 continued to have a decline in appetite. On December 30, 2024 Hospice noted a weight loss of eight pounds. Hospice nurse met with HWD and MT to discuss ways to increase R1’s appetite. (Continued on LIC 9099C4) (Continued from LIC 9099C3) Based on record review and interviews staff continued to coax R1 to eat and charted Food and Nutrition in the progress notes. Staff communicated with hospice nurse that R1 did not like to eat and that they always attempted to feed R1 or offer Ensure. Staff did frequent checks on R1 due to behaviors. R1 continued to refuse to eat and hospice and family were aware. Thus the allegation that Staff did not ensure a resident was properly fed while in care is Unsubstantiated. It was alleged staff did not have adequate recording keeping of a resident due to facility not documenting R1’s weight daily. Per R1’s hospice weight records reviewed, R1 was weighed on December 15, 2024, to weigh 116 lbs. R1’s physician report dated December 12, 2024 further corroborated R1’s weight at 116 lbs. LPA conducted interviews with three of three staff that facility policy is to weigh residents once per month or as prescribed by physician's order. On December 20, 2024, R1’s hospice notated R1 continued to have a decline in appetite. On December 30, 2024, hospice weighed R1, and notated their weight to be 108 lbs, a decline of 8 lbs over a period of approximately two weeks. Facility frequently communicated with hospice regarding R1’s loss of appetite. R1 exhibited behaviors and hospice continued to try different medications to help R1 sleep through the night and help with the behaviors. R1 would often refuse to eat and spit out medication. On January 3, 2025 R1 also was diagnosed with a Urinary Tract Infection and hospice notes report resident was nauseous and felt like vomiting. Both facility and hospice monitored the food and nutrition for R1. Interview with Executive Director stated when residents move into the community, the weight is taken from the Physician’s Report. The facility’s policy is to weigh residents monthly or as prescribed by physician's order.. R1 came to the facility on December 15, 2024 and was weighed on December 30, 2024 when concerns were relayed to hospice. Thus the allegation that staff did not have adequate record keeping of a resident is Unsubstantiated. 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 that: Staff did not meet a resident's incontinence needs, Staff did not have planned activities for the residents, Staff mishandled (Continued on LIC 9099C5) (Continued from LIC 9099C4) a resident's personal belongings, Resident sustained an unexplained injury while in care,Staff did not properly report incidents involving a resident, Staff did not ensure a resident was properly fed while in care and Staff did not have adequate record keeping of a resident are Unsubstantiated. An exit interview was conducted with Executive Director, Cynthia Figueroa and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 22-AS-20250310123459

Allegation investigated: Resident is getting sick due to staff not cooking food thoroughly

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint received in our Regional Office. LPA met with Cynthia Figueroa, Executive Director and explained the purpose of the visit. The Department conducted a ten day visit on August 5, 2024 regarding the allegation that residents were getting sick due to staff not cooking food thoroughly. Three of three residents were interviewed at that time who all denied the allegation. On August 6, 2025, LPA Ruppert interviewed three of three residents during breakfast regarding food quality, if the food was cooked thoroughly and if residents got sick from food. LPA asked if food was served hot or if vegetables were hard. Three of three current residents denied the allegation. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) LPA interviewed two of two staff regarding the procedure for cooking chicken and how staff determine the chicken is cooked. Dining Service Director/ Chef stated chicken is considered cooked when the food thermometer measures the temperature at 165 degrees for fifteen seconds. LPA toured the kitchen and observed line staff checking temperatures of food items being cooked. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation that the: Resident is getting sick due to staff not cooking food thoroughly is Unsubstantiated. An exit interview was conducted with Cynthia Figueroa, Executive Director, and a copy of this report and LIC 811 was provided to the facility.the state’s words, verbatim · CDSS document, Aug 6, 2025 · control 22-AS-20240625101021

Allegation investigated: Staff handled resident in a rough manner Staff are not providing adequate food service to residents Staff inappropriately attended a resident council meeting Staff are not providing activities for residents

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate and deliver findings from a complaint received in the Regional Office. LPA met with Executive Director (ED) Cynthia Figueroa and explained the purpose of the visit. LPA obtained the following documents: Resident #1 (R1)'s: Identification and Emergency Form, Physician's Report, Appraisal and Needs and Services Plans. LPA also requested a resident roster and obtained the August 2025 Memory Care "Revere" Calendar. LPA interviewed three of three residents regarding the allegations listed above and attempted to contact their respective responsible parties. The Department also interviewed six of six staff members. Based on record review, observations and interviews the Department has determined the following: (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) For the allegation that: Staff handled resident in a rough manner, the Reporting Party (RP) was not able to recall who the staff member was who treated the resident in a rough manner. Three of three residents interviewed could not recall if they were mistreated and six of six staff denied this allegation. For the allegation that: Staff are not providing adequate food service to residents, LPA toured the Memory Care unit and observed what residents were eating for lunch. LPA surveyed the ten residents eating lunch and all residents were fine with their meal. LPA observed three staff members providing meal and beverage service, the entrees were hot and the beverages were cold. Three of three residents and six of six staff denied this allegation. On June 13, 2024 the Department interviewed former Executive Director (ED) Kara Kneedy-Cayem regarding the allegation that: Staff inappropriately attended a resident council meeting. ED Kneedy-Cayem stated she was invited to the meeting by the resident council and attended for ten minutes to read "Residents' Rights" and then excused herself from the meeting. Additional staff interviews corroborated this statement. Six of six staff denied this allegation. For the allegation that: Staff are not providing activities for residents, LPA interviewed the Life Enrichment Director (LED) and Resident Lifestyle Assistant (RLA) regarding activities provided for Memory Care. The LED had been hired on June 1, 2024 and was providing activities as well as the assistant. There were three days where both activities personnel overlapped and on some of those days, the RLA would provide transportation to residents for appointments. On those days, the RLA would begin an activity and the care staff in Memory Care would try to complete the activity. Activities were always planned but due to staff shortages during that time, activity staff would have to pivot. Two of two Activities staff denied the allegation. LPA obtained the Activities Calendar for August 2025 and noted there are nine to ten activities scheduled daily in Memory Care. Based on LPA observations, record review and interviews, although the allegations above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, there the allegations that: Staff handled resident in a rough manner, Staff are not providing adequate (Continued on LIC 9099-C1) (Continued from LIC 9099-C) food service to residents, Staff inappropriately attended a resident council meeting and Staff are not providing activities for residents are Unsubstantiated. An exit interview was conducted with Cynthia Figueroa, Executive Director (ED) and a copy of this report and LIC 811 were provided to the facility.the state’s words, verbatim · CDSS document, Aug 6, 2025 · control 22-AS-20240603152039

Allegation investigated: Facility fails to provide a safe environment for its residents Facility staff is not following dietary orders Alcohol is being served to residents with a dementia diagnosis Facility staff does not safeguard the residents' personal information Climate control is not operational Facility is admitting residents requiring a higher level of care and supervision Transportation services included in the admission agreement are not being provided to the residents

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility regarding a complaint received in the Regional Office. LPA was greeted and granted entry by the concierge and met with Executive Director (ED) Cynthia Figueroa and explained the purpose of the visit. LPA reviewed the following documents: Resident roster from October 2024, Personnel Report (LIC 500) dated October 15, 2024, and Kitchen Staff Schedule from 10/7-10/27/2024. LPA reviewed seven of seven resident files which include: Resident Dietary Orders/Food Preferences Form, Identification and Emergency Information, Physician's Report, and Admissions Agreement. Additional documents obtained and reviewed were: October 2024 Activities Calendar, October 2024 Transportation Calendar, and Bus Repair invoice. The Department interviewed thirteen of thirteen staff members, which include the former Chef and the current Chef at the facility. LPA also interviewed four of four alert residents. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) The Department conducted a ten day visit on October 15, 2024 and observed approximately forty residents in the dining room for dinner. Due to staff shortages in Memory Care, Memory Care residents were brought to dinner in the dining room. Three of four resident interviews denied the allegation that:Facility fails to provide a safe environment for its residents. Thus is allegation is Unsubstantiated. LPA obtained standing modified diets from the kitchen and spoke to the Chef about resident allergies and preferences. Chef shared the line staff know resident preferences and they are posted in the kitchen. During the time the complaint was received, Chef was not an employee but currently, modified diets are followed. Three of four residents interviewed stated they did not have issues with food at this time. Seven of seven resident Physician Reports and modified diets were reviewed and were being followed. None of the residents reported having allergies or becoming ill from food. Thus the allegation that: Facility staff is not following dietary orders is Unsubstantiated. LPA reviewed seven of seven Physician's Reports (LIC 602A) and spoke with ED Figueroa regarding alcohol policy for Memory Care. Currently two residents are allowed alcohol per LIC 602A but the majority of residents in Memory Care get a non-alcoholic alternative during Happy Hours. Thus, the allegation that: Alcohol is being served to residents with a dementia diagnosis is Unsubstantiated. Four of four residents were asked if the facility safeguards their personal information. Three of four residents felt personal health information was safeguarded. One of four residents felt staff spoke about other residents' health issues. Nine of nine staff denied that resident personal information was improperly shared with others. Based on resident and staff interviews, the allegation that Facility staff does not safeguard the residents' personal information is Unsubstantiated. Upon touring the facility. LPAs visited resident rooms and took temperatures in common areas. The temperature ranged between 72.3 - 74.1 degrees Fahrenheit. Three of four residents did not have any issues with temperature in their apartments and one of four residents received a partial refund due to an AC unit in disrepair. Thus the allegation that: Climate control is not operational is Unsubstantiated. (Continued on LIC 9099C1) (Continued fro LIC 9099C) LPA reviewed resident files and spoke to former ED regarding residents being admitted that need a higher level of care. Former ED stated on May 12, 2025 that Title 22 Regulations are clear about what diagnoses can or cannot be accepted. Residents who have a change of condition, such as falls, are reassessed with a new Needs and Services Plan, an updated Physician's Report and a care plan meeting. The allegation that: Facility is admitting residents requiring a higher level of care and supervision is Unsubstantiated. LPA spoke with nine of nine staff, the ED and Life Enrichment Director regarding transportation services. LPA reviewed the October 2024 Activities Calendar, the Concierge and Transportation Log and obtained a Bus Repair Invoice. The community bus' wheelchair lift was not operable and had been inspected and then repaired. Both the Life Enrichment Director and Assistant were designated drivers during this time and the Transportation log does show residents were taken to appointments in the month of October 2024. Thus the allegation that: Transportation services included in the admission agreement are not being provided to the residents is Unsubstantiated. 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 that: Facility fails to provide a safe environment for its residents, Facility staff is not following dietary orders, Alcohol is being served to residents with a dementia diagnosis, Facility staff does not safeguard the residents' personal information, Climate control is not operational, Facility is admitting residents requiring a higher level of care and supervision and Transportation services included in the admission agreement are not being provided to the residents are Unsubstantiated. An exit interview was conducted with Cynthia Figueroa, Executive Director and a copy of the report and files reviewed (LIC 811) were given at the time of the visit. ****This is an amended report.****the state’s words, verbatim · CDSS document, Jul 31, 2025 · control 22-AS-20241011144206

Allegation investigated: Facility staff is insufficient to provide care and supervision to memory care residents Kitchen staff is insufficient to provide meal services Food service is insufficient in both quantity and quality

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility regarding a complaint received in the Regional Office. LPA was greeted and granted entry by the concierge and met with Executive Director (ED) Cynthia Figueroa and explained the purpose of the visit. LPA reviewed the following documents: Resident roster from October 2024, Personnel Report (LIC 500) dated October 15, 2024, and Kitchen Staff Schedule from 10/7-10/27/2024. LPA reviewed seven of seven resident files which include: Resident Dietary Orders/Food Preferences Form, Identification and Emergency Information, Physician's Report, and Admissions Agreement. Additional documents obtained and reviewed were: October 2024 Activities Calendar, October 2024 Transportation Calendar, and Bus Repair invoice. The allegation that: Facility staff is insufficient to provide care and supervision to memory care residents was Substantiated on May 13, 2025 with Complaint Control Number:22-AS-20250509094345. (Continued on LIC 9099-C) Substantiated (Continued from LIC 9099) The Department interviewed thirteen of thirteen staff members, which include the former Chef and the current Chef at the facility. LPA also interviewed four of four alert residents. Seven of thirteen staff confirmed that on October 9, 2024 the dining room staff walked off the premises during dinner service. Six of the thirteen staff members interviewed were not employees of the community during October 2024. None of the staff members denied that the incident occurred. Three of the four residents interviewed recalled the incident when dining room staff walked out and that management voluntarily returned to the community to serve dinner and a family member also brought meals to the community. One of four residents did not reside in the community during this time. The allegation that: Kitchen staff is insufficient to provide meal services is Substantiated. This allegation was addressed on May 13, 2025 with the allegation that: Facility is understaffed to provide services necessary to meet resident needs with Complaint Control Number:22-AS-20250509094345. The Department conducted a ten day visit on October 15, 2024. LPAs interviewed the former Chef and spoke with three of three staff members. The Chef's interview stated the residents have access to food and that desserts, fruits and snacks are found in the bistro. LPAs took a photo of the bistro case and there observed three apples and six mini cakes in the glass casing. Three of the four residents LPA interviewed had various food issues and felt the food was not always accessible. In October 2024 there was a week between the former Chef leaving the community and the current Chef being cleared to work where food was not of adequate quantity or quality. This was primarily due to staffing shortages. Thus, the allegation that: Food service is insufficient in both quantity and quality is Substantiated. Based on LPAs observations, document review and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations: Facility staff is insufficient to provide care and supervision to memory care residents, Kitchen staff is insufficient to provide meal services and Food service is insufficient in both quantity and quality are Substantiated. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Cynthia Figueroa, Executive Director and a copy of this report was given to the facility along with a copy of the LIC 811, LIC 9099-D and Appeal Rights.the state’s words, verbatim · CDSS document, Jul 31, 2025 · control 22-AS-20241011144206

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(5) · Plan of correction due date: Aug 21, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents. Based on LPA observations, and interviews, this requirement is not met as evidence by: Three of four residents stated food was not always accessible, low quantity, per photos taken 10/15/24, and quality. This poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Facility will ensure there is adequate culinary line and server staff. Chef will submit menus to LPA by August 14, 2025 to provide documentation of food quality and minutes from the August Food Forum.

Allegation investigated: Facility left resident unattended for an extended period of time Facility did not provide care and supervision resulting in multiple falls

LIcensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in our Regional Office. LPA met with Cynthia Figueroa, Executive Director (ED) and explained the purpose of the visit. LPA came to investigate the allegations that: Facility left resident unattended for an extended period of time and Facility did not provide care and supervision resulting in multiple falls. LPA obtained and reviewed the following: Resident Roster, Care Staff schedule from 6/29-7/31/2025, Copy of Unusual Incident Report faxed to Regional Office on July 19, 2025 and facility policy for Alert Charting. LPA obtained the following from Resident #1's file: Identification and Emergency Information Form, Preappraisal Information, Physician's Report dated 2/06/2025 and Appraisal and Service Plans from 5/13/2025 and Admissions Agreement. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) LPA toured the facility and was permitted entry in Resident #1 (R1's) apartment by Care Staff. LPA conducted six of six staff interviews, three of three witness interviews and interviewed the Executive Director (ED regarding the incident that occurred on Saturday, July 19, 2025. LPA reviewed documents and noted on the Appraisal, Services Plan and Physician's Report that Resident #1 (R1) is independent and only requires assistance with medication. Although R1 does not receive alert charting care for two hour checks, staff continually check on R1; especially if R1 strays from the normal routine. R1 keeps to self and felt the frequent checks were not necessary and wears a bracelet call button. R1 is able to toilet and bathe independently and when staff inquire if R1 needs assistance, R1 does not request assistance. R1 rarely presses the bracelet pendant and was not wearing it at time of fall. On the date of the unwitnessed fall, R1 was found by AM Medical Technician (Med Tech) when entering the apartment to give medications at 8:30am. Responsible Party and Emergency Medical Services (EMS) were immediately called and R1 was transported to a local hospital for evaluation. R1 was admitted to the hospital for further observation. It was reported by AM Med Tech to EMS that R1 received meds at 8pm. ED also observed R1 the day before and did not note anything unusual and observed R1 playing Bingo. PM Med Tech did not notate any changes in condition in charting. Photo documentation was obtained and staff members on-site, at the time of the incident, noted the urine and feces were fresh and that R1 had not been left for an extended period of time. Record review did not show that Resident #1 (R1) has had any falls since admission on April 10, 2025. The incident on July 19, 2025 was the first fall for the resident in the community. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations that: Facility left resident unattended for an extended period of time and Facility did not provide care and supervision resulting in multiple falls are Unsubstantiated. An exit interview was conducted with Executive Director (ED) Cynthia Figueroa and a copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 22, 2025 · control 22-AS-20250721114004

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to amend a report from a complaint visit on June 18, 2025. LPA was greeted and granted entry by the Concierge. LPA met with Cynthia Figueroa, Executive Director (ED) and explained the purpose of the visit. LPA amended the resident identifier from R3, on the second page of the report, to R6; to match the correct resident from the Confidential List of Names (LIC 811) provided to the facility on June 18, 2025. An exit interview was conducted with ED Figueroa and a copy of the amended report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 30, 2025

Allegation investigated: Staff are mismanaging residents medications

Licensing Program Analysts (LPAs) Hanna Gough and Rose Ruppert conducted an unannounced visit to deliver findings. LPAs met with Executive Director (ED), Cynthia Figueroa. It was alleged staff are mismanaging residents medications due to Resident #6’ (R6)s narcotics not being destroyed in a timely manner and that destruction protocols were not being followed. Furthermore, it was reported residents bubble packed medications were stored and mixed together. During LPA’s visit on April 24, 2025, LPA Ruppert reviewed facility medications which appeared to be in order meaning bubble packed medications were not being stored and mixed together and Narcotics were logged and initialed on facility narcotics logs. Narcotic logs were obtained for all facility narcotics dated March 27, 2025, through April 24, 2025. Interviews conducted with four of four facility med techs confirmed that bubble packed medications may (Continued on LIC 9099-C) Substantiated (Continued from LIC 9099) get mixed on occasion and are audited by the facility Memory Care Director (MCD) for accuracy. Per facility surveillance camera footage obtained, facility Executive Director Dyan Summerell found narcotics from a deceased resident (R6) in facility Memory Care Director's desk. Per facility records, R6 passed away on March 24, 2025. Narcotics were discovered by ED Summerell on May 07, 2025. Per facility medication destruction protocol, medications are to be destroyed or returned to dispensing pharmacy upon a resident passing. An interview with interim Health and Wellness Director (HWD) stated the medications are destroyed immediately, upon a resident's passing, with a designated staff member and another adult witness who is not a resident. HWD and ED Summerell destroyed medications upon discovery in MCD's office on May 12, 2025. Facility Memory Care Director was placed on leave effective May 05, 2025, unrelated to the undestroyed medications incident. Following discovery of the undestroyed medications, facility Memory Care Director was terminated from the facility. Based on LPAs' observations, interviews and record reviews, the preponderance of evidence standard has been met, therefore the allegation that Staff are mismanaging resident medications is found to be Substantiated California Code of Regulations (Title 22, Division 6 Chapter 8) are being cited on the attached LIC 9099-D. An exit interview was conducted with ED Figueroa and a copy of this report, the LIC 9099-D, LIC 811 Confidential Names and Appeal Rights were given at time of visit. ****This is an amended report.**** (Continued from LIC 90990-C) ****THIS IS AN AMENDED REPORT**** This page was incorrectly placed under the Substantiated LIC 9099)the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 22-AS-20250416144122

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Jul 3, 2025

87465(i) Incidental Medical and Dental Care: Prescription medications which are not taken with the resident upon termination of services... disposed of... .shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years. This requirement has not been met as evidenced by: LPAs observations show resident passed on 3/24/2025 and meds were not destroyed until 5/12/2025. A signed record was not found. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2025

Plan of correction: ED stated they will provide an in-service to all staff on medication storage and destruction and will send documentation of in-service to LPA by POC due date. Medications were disposed of on May 12, 2025.

Allegation investigated: Staff are not following infectious protocols for residents Staff are not meeting residents showering needs Staff are falsifying residents LIC 602's Staff are not providing a comfortable environment

Licensing Program Analysts (LPAs) Hanna Gough and Rose Ruppert conducted an unannounced visit to deliver findings. LPAs met with Executive Director (ED), Cynthia Figueroa. It was alleged staff are not following infectious protocols for residents due to resident 1 (R1) not being quarantined after being diagnosed with scabies. On April 14, 2025, R1 was seen by Physician due to R1 having an itchy rash. The After Visit Summary stated the following, “We did not see scabies mites when we scraped some of the skin flakes…however given scabies is fairly common and easy to treat we will go ahead and treat presumptively for scabies…” Interviews with ten of ten staff reported the facility follows infection control protocols and that R1 was placed in isolation and their clothing and linens were cleaned separate from other residents to avoid spreading. LPA interviewed two facility housekeepers who confirmed R1’s room was deep cleaned after R1 was cleared from isolation. On April 23, 2025 R1 was assessed by facility nurse after nine days of treatment and R1 did not have scabies. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) It was alleged staff are not meeting residents showering needs due to resident 2 (R2) not receiving showers. LPA conducted interviews with ten of ten staff who reported R2 is independent in showering needs and does not require shower assistance. LPA interviewed four of four residents who did not report any concerns of body odors or smells from R2. LPA Hanna Gough interviewed R2 and stated to LPA that he does showers himself and nobody helps him. Per R2’s physician report dated June 10, 2023. R2’s needs and assessment dated March 20, 2025, R2 is independent in showering and does not require assistance. LPAs Ruppert and Gough spoke with ED Cynthia Figueroa and HWD regarding R2’s showering needs and will set-up a care plan meeting with family. It was alleged staff are falsifying residents LIC 602's due to Executive Director changing residents LIC602’s when a resident complains or questions director in an effort to move residents to facility memory care. It was reported LIC602’s were changed for Residents #3, #4 and #5 (R3; R4; R5). Per R3’s physician report dated February 24, 2025, R3 has a diagnosis of hepatic encephalopathy. The report was signed by MD Woo who was treating R3 for less than one month. Due to R3’s confusion, wandering and sundowning behavior at time of admission, R3 was re-evaluated on March 01, 2025, and was diagnosed with mild cognitive impairment and placed on hospice services. R3 moved into Assisted Living on February 28, 2025. On March 2 2025 R3 was transferred to Memory Care which was the appropriate placement. Per physician report dated March 05, 2025, R4 has a diagnosis of dementia. Physician report was completed by R4’s primary care physician who treated R4 for the past five years prior to moving into the facility. A new Physician’s Report for R4, dated May 12, 2025, was conducted and an assessment is being obtained Family communicated with ED Figueroa to have R4 to transfer to Assisted Living but R4 currently resides in Memory Care. Resident #5 recently passed away and was never a candidate to move into Memory Care. LPA interviewed R5’s Power of Attorney (POA) who stated R5 was residing in facility assisted living unit and had no intentions to move resident to memory care unit. Per POA, there were no concerns of R5’s LIC602 being re-evaluated and/or changed improperly. LPA interviewed ten of ten staff who denied the allegation. (Continued on LIC 9099-C1) (Continued from LIC 90990-C) It was alleged Staff are not providing a comfortable environment due to being told not to speak to Community Care Licensing and hide information. LPA interviewed seven of seven staff who denied the allegation. LPA interviewed five of five residents who denied ever being told to not speak to licensing or hide information. LPA reviewed ten of ten staff member training records and observed mandatory reporter training is current and up to date. LPA observed required PUB475 posted in a prominent place notifying residents of the right to report concerns to Community Care Licensing. 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 that: Staff are not following infectious protocols for residents, Staff are not meeting residents showering needs, Staff are falsifying residents LIC 602's and Staff are not providing a comfortable environment are Unsubstantiated. An exit interview was conducted with ED Figueroa and a copy of this report and LIC 811 Confidential Names were provided to the facility.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 22-AS-20250416144122

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Rose Ruppert and Hanna Gough arrived at the facility to conduct the required annual inspection and was greeted and granted entry by staff. LPAs met with Administrator (AD) Cynthia Figueroa and explained the purpose of the visit. The facility currently has fifty four residents in care. The facility is a two-story building with a memory care unit, resident apartments, kitchen, great room, activity room, dining room, lobby, staff offices, medication room and an outdoor shaded seating area for resident use. LPAs observed the kitchen to be clean and free of vermin. LPAs observed the seven day non-perishable and two day perishable food supply on hand. LPAs observed the emergency food and water supply in a storage room. LPAs observed all resident apartments had the required components and furnishings. LPAs observed the water in resident bathrooms to be tested between 112.6-117.3 degrees Fahrenheit. LPAs observed the knives to be stored in the locked chef office when not in use making them inaccessible to residents in care. LPAs observed the centrally stored medication to be in the locked medication rooms made inaccessible to residents in care. LPAs observed toxins and chemicals to be locked and stored in the housekeeping rooms located on each floor and made inaccessible to residents in care. LPAs observed the outdoor space to be free of obstructions. LPAs observed the delayed egress in the memory care unit to be operational. LPAs observed an outdoor shaded space for resident use in the memory care unit. LPAs observed residents engaged in bingo and a resident council meeting during the course of the visit. LPAs observed the last fire drill conducted on June 4, 2025. LPA observed the last fire inspection done on October 16, 2024 for the entire facilities fire and sprinkler systems. LPAs observed resident medication and no discrepancies were observed. Continue on LIC 809-C (Continued from LIC 809) LPA reviewed XXX of XXX staff training and fingerprint records. [Insert any relevant details]. LPA reviewed XXX of XXX resident records. (OR) LPA conducted a complete review of resident and staff records. Client P&I records were reviewed and were accurate. LPA interviewed alert clients/residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on XXX LPAs reviewed resident files and no discrepancies were observed. LPAs reviewed staff files and observed that the ED that has been overseeing the facility for three weeks is updating the files to completion. A technical advisory was given at the time of inspection. Based on today's inspection no citations are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with ED Cynthia Figueroa and a copy of this report was left at the facility at the time of inspection.the state’s words, verbatim · CDSS document, Jun 18, 2025

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

Allegation investigated: Staff did not conduct proper appraisal to place residents in memory care Staff does not have job training or experience in the job assigned to them

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint filed in our Regional Office on May 9, 2025. It was alleged staff did not conduct proper appraisals to place residents in memory care due to facility moving Resident #1 (R1) and Resident #2 (R2) to facility memory care. Per R1’s physician report dated April 04, 2025, R1 has a diagnosis of dementia. Per interviews conducted with facility staff, five of five staff reported R1 was refusing showers causing concerns for R1’s hygiene. In addition, staff reported concerns that R1 would leave the facility without informing anyone and on one occasion accidently ran over their dog using their motorized scooter. Based on R1’s changing behaviors, the facility conducted a re-assessment on May 15, 2025. Based on needs and service plan reviewed, R1 was assessed to have occasional disorientation to person place time or situation. In addition, it was determined R1 requires redirection and reminding from others. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) A care plan meeting was held with facility representatives and R1’s family on May 20, 2025 and the decision was made not to move R1 to the facility memory care unit at this time and to remove R1’s motorized vehicle. R2’s physician report dated December 08, 2024, lists R2’s diagnosis as Mild Cognitive Impairment and intermittent bladder incontinence. Furthermore, the physician report states R2 is not able to care for their own toileting needs. Interviews conducted with five of five facility staff and six of six residents reported concerns that R2 was exhibiting incontinence issues in the facility creating sanitary issues in facility common areas. On April 15, 2025, the facility conducted a re-assessment of R2 and determined R2 required extensive 1:1 hands on assistance with incontinence care. Per interview with Executive Director, the facility had a care plan meeting on April 15, 2025 with R2’s family and assessed not to move R2 to the facility memory care unit at this time. Following the re-assessment of R2 interviews with residents reported the sanitary concerns had improved. It was alleged staff does not have job training or experience in the job assigned to them due to facility Chef overseeing the facility care floor. During LPA’s interview with Executive Director it was reported the facility Health and Wellness Director and Memory Care Director were not actively working at the facility beginning approximately May 8, 2025. Due to staffing shortages, the facility requested the facility Chef to assist with manager oversight over facility care floor staff. LPA conducted interview with Executive Director and facility Chef who both reported Chef’s role in overseeing the facility care floor was to provide managerial support to facility care staff. Both denied Chef was providing any direct care to facility residents and/or giving directions to facility care staff regarding care to residents. LPA reviewed facility training records for Chef. Per records reviewed facility Chef has current updated training in all mandatory training topics including but not limited to Dementia, Ladder Safety, Fire Safety, Customer Service, Home Health, Sexual Harassment, Diversity, Spiritual Aging, Hiring, Active Shooter, and Hospitality. Interviews with eight of ten staff reported no concerns with Chef’s oversights. Two of ten staff reported concerns with the Chef’s oversight of facility care floor as he needed to remain in his area of expertise. Interviews with nine of nine residents reported no concerns. Per interviews with facility Executive Director the facility is actively hiring for the facility Health and Wellness Director position as well as Memory Care Coordinator. Effective May 13, 2025, the Facility Regional Nurse is on site providing oversight to facility care (Continued on LIC 9099-C1) (Continued from LIC 9099C) floor. The facility has created a managerial schedule to ensure a manager is on site every day including weekends. Based on LPA's observation, interviews and record 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 violation(s) did or did not occur. Therefore, the allegations that the: Staff did not conduct proper appraisals to place residents in memory care and Staff does not have job training or experience in the job assigned to them are Unsubstantiated. An exit interview was conducted with Erin Hernandez, Community Relations Director and verbally read to Executive Director Cynthia Figueroa, and a copy of the report andthe List of Confidential Names (LIC 811) was provided to the facility.the state’s words, verbatim · CDSS document, Jun 10, 2025 · control 22-AS-20250509094345

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit regarding a report received in our Regional Office. LPA was greeted and granted entry by Concierge. LPA met with Cynthia Figueroa, Executive Director (ED) and explained the purpose of the visit. The purpose of the visit is to follow-up on a Death Report received in our office on May 22, 2025. LPA spoke with ED and obtained copies of Resident #1 (R1)'s: Identification Form, Physician Orders for Life Sustaining Treatment (POLST), Physician's Report, Needs and Services Plan/ Appraisal, Discharge paperwork from hospital and follow-up orders. LPA interviewed the Resident Services Director (RSD) from a sister facility; who was on-site with the MedTech, who were called to R1's apartment on May 22, 2025. Both Med Tech and RSD did not detect a pulse. 911 was called and RSD grabbed POLST paperwork and noted R1 was DNR. LPA spoke with ED about the chronological order of events; as well as with the Power of Attorney (POA). POA shared palliative care was being considered with Primary Care Physician (PCP) on the day prior to R1's passing. POLST documentation states Do Not Resuscitate (DNR) but the box was also checked for Full Treatment. At time of incident, RSD showed police department (PD) the POLST and verbally stated R1 was DNR and pointed at the checked DNR box. PD felt a faint pulse and initiated CPR and pointed to the POLST form box that was selected for Full Treatment. Paramedics arrived on scene and were told R1 was DNR and contacted POA, who also confirmed R1 was DNR. The Fire Department (FD) spoke with ED Figueroa regarding the communication between the facility, PD and FD and will provide an in-service for facility staff (Continued on LIC 809-C) (Continued from LIC 809)\ regarding clear and preferred communication for first responders. Based on LPA's file review, interviews and observations, the facility is in complaince with Title 22 California Code of Regulatiosn and no deficiences will be cited on this date An exit interview was conducted with Cynthia Figueroa, ED and a copy of this report and LIC 811 was provided at exit.the state’s words, verbatim · CDSS document, May 28, 2025

Allegation investigated: Facility is understaffed to provide services necessary to meet resident needs

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to continue an investigation of a complaint received in our Regional Office. LPA was greeted and granted entry and met with Regional Vice President of Operations (RVPO) Whitney Blake. At 8:15am on May 12, 2025, LPA toured the facility and visited Memory Care. LPA observed one caregiver for Memory Care (MC) with nine residents, one Med Tech covering both Assisted Living (AL) and MC and one caregiver designated for AL with forty-three residents for the morning shift. One caregiver was assisting the culinary department. LPA interviewed seven residents and nineteen staff members. All nineteen of nineteen staff members, from various departments, confirmed the care department was short-staffed. LPA obtained a copy of the resident and staff rosters, the April and May care staff schedules, and payroll documentation from March 21 through May 12, 2025. (Continued on LIC 9099-C) Substantiated (Continued from LIC 9099) Based on LPA's observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation that the: Facility is understaffed to provide services necessary to meet resident needs is Substantiated. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with Whitney Blake, Regional Vice President of Operations, and a copy of this report, 9099-D, and Appeal Rights were provided to the facility.the state’s words, verbatim · CDSS document, May 13, 2025 · control 22-AS-20250509094345

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 14, 2025

Personnel Requirements - General 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care...The licensing agency may require any facility to provide additional staff whenever it determines...that the needs of the particular residents, the extent of services provided... require such additional staff for the provision of adequate services.the state’s words, verbatim · CDSS document, May 13, 2025

Plan of correction: This requirement is not met as evidenced by: Based on LPA observation and interviews of residents and staff on May 12-13, 2025, facility is understaffed to provide services necessary to meet resident needs. This poses an immediate health and safety risk to residents in care. Regional Vice President of Operations pulled care staff from another department to have adequate staffing on May 12, 2025. National Clinical Nurse, Regional Nurse and Health and Wellness Nurse from the sister community provided additional staff support on May 13, 2025.

Allegation investigated: -Resident files do not have the required documentation -Staff files do not have the required documentation -Staff do not have criminal record clearance -Staff do not have the required qualifications -Staff do not respond to residents' calls for assistance in a timely manner -Facility staff are not providing adequate food service

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA arrive at facility was greeted and granted entry by receptionist. LPA spoke with Phil Altman, SVP of Operations and explained the purpose of the visit. Findings are based upon this investigation which included resident file review, staff file review, tour of the physical plant of the facility and interviews conducted. It is alleged resident files do not have the required documentation. LPA Martinez reviewed 10% of the resident census files. Files reviewed reflected that it was observed the records reviewed had all required documentation on file per title 22 requirements. Continued on LIC9099-C Unsubstantiated It is alleged staff files do not have the required documentation. Staff files are kept electronically and were made available to LPA. LPA reviewed 10% of hired staff at the facility and observed that all required documentation was in the files per title 22 requirements. It is alleged staff do not have criminal record clearance. LPA obtained an employee roster for the facility. LPA reviewed staff files, and it was observed a Criminal Record Clearances was in staff files. LPA cross checked the roster to the Guardian background check system and observed all hired onboard staff were associated to the facility and cleared. It is alleged staff do not have the required qualification. LPA reviewed 10% of the onboard hired staff files and observed that all required qualifications were met such as a medical assessment and training. It was observed that records reviewed reflected this paperwork and kept in the files per title 22 requirements. It is alleged staff do not respond to residents’ calls for assistance in a timely manner. LPA conducted a facility visit on January 21, 2025, and toured the physical plant of the facility. Upon the tour LPA entered several resident apartments, common spaces, and restrooms and tested the pull cord system. LPA observed that facility utilizes a pull cord system as well as pendants. LPA observed that the response time for staff to respond to calls were between 2 minutes and 15 minutes throughout the various times call system was pulled. On today’s visit LPA toured the facility and observed residents being assisted by caregivers. Records review for call system for assistance logs reflect all alerts and reflect that the response time is anywhere between 50 seconds to average response time of 16 minutes 28 seconds. It is alleged that facility staff are not providing adequate food service. LPA conducted a site visit on January 21, 2025, and on today’s visit. LPA toured the facility kitchen and bistro; it was observed that there was sufficient amount of quality and quantity of perishables and nonperishable food for residents. At the time of visits LPA observed food being prepped and staff preparing the food for resident meals. LPA obtained a copy of the facility weekly menu for review, and the always available menu and observed the food service to be well balanced with variety of choices. LPA conducted interviews with the facility Executive Chef and stated that food delivery is twice a week, and Saturdays as needed. Residents have the choice to modify the menu Continued on LIC9099-C to their liking as well as food being modified based on resident needs. Dining room services is from 7:00am to 7:00pm and after 7:00pm the bistro will be stocked with food and will be available to residents at all times of the day. Interview with facility residents 7 of 7 indicated that they didn’t have an issue with the food served and they have always been able to request food or request for something out of the menu and the bistro always has food for them. Tour of the dining room LPA observed food being served, menu posted, and always available menu posted. Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with facility representative and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Mar 20, 2025 · control 22-AS-20250115150043

Allegation investigated: Staff did not provide adequate supervision, resulting in a resident sustaining multiple injuries.

LPA Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegation listed above. LPA met with Phil Altman, Senior Vice President of Operations and Lakeisha Phillips, Regional Director of Health and Wellness During the course of the investigation, Department staff inspected the facility, interviewed AD, witnesses, and staff, and obtained and reviewed records, including resident roster, staff roster, staff schedule, Resident 1’s (R1) physician’s report dated August 15, 2023, R1’s facility initial assessment dated August 23, 2023, R1’s Admission Agreement dated August 25, 2023, R1’s service plan dated August 29, 2023, R1’s Medication Administration Record (MAR) for R1 for April 2024, R1’s facility assessment dated May 2, 2024, R1’s service plan dated May 2, 2024, R1’s facility progress notes dated February 25, 2024 to May 15, 2024, R1’s incident reports from April 25, 2024 and April 29, 2024, R1’s Kaiser Permanente records dated April 29, 2024, R1’s Home Health request completed by Kaiser Permanente dated May 3, 2024. R1’s Hospice order dated February 7, 2024, R1’s Hospice notes dated February 7, 2024. R1’s Providence St. Jude Hospital records dated April 25, 2024. Substantiated The investigation revealed the following: It was alleged, staff did not provide adequate supervision, resulting in a resident sustaining multiple injuries. Resident 1 (R1) moved to the facility on September 2, 2023. R1 was diagnosed with a major neurocognitive disorder, osteoporosis, kidney disease, hypertension, and depression. R1’s physician’s report dated August 15, 2023, has R1 listed as ambulatory. R1 was able to ambulate and transfer independently at the time of move in. In December of 2023 R1 had a fall that resulted in a hip fracture. Witnesses interviewed reported that R1 began to decline after this fall and became a fall risk. The facility assessment for R1 dated August 23, 2023, states R1 does not have a history of falls and is not a fall risk. The facility assessment for R1 dated May 2, 2024, shows R1 requires a walker and wheelchair and is a fall risk. Hospital records from April 25, 2024, show R1 is a fall risk. R1 was admitted to Hospice on February 7, 2024. A review of R1’s care notes show, R1 suffered falls on April 3, 5, 25, 29, and 30 of 2024. Two of the falls resulted in R1 being transferred to local hospitals. On April 25, 2024, Staff found R1 on the floor with a bump on the head along with bruising on the right side of their face. R1 was transported to St. Jude Medical Center. R1 was diagnosed with a closed head injury and a closed fracture of the nasal bone. R1 was treated and released back to the facility the same day. On April 29, 2024, R1 fell and was found on the floor by staff. R1 was transported to Kaiser Permanente Hospital. R1 was diagnosed with a head injury and a left knee contusion. On April 29, 2024, R1 was admitted to Home Health due to the head injury and the left knee contusion. Resident returned to the facility the same day. Staff interviewed reported that R1 had a wheelchair and a walker but would still attempt to walk without the use of assistive devices. The Health and Wellness Director reported that the facility implemented a fall intervention plan which included increased checks on R1 to once an hour, a lower bed and a fall mat placed next to the bed. R1’s Responsible Party verified this information. Five out of eight staff members interviewed reported that R1 had increased checks after the May 2, 2024, assessment was completed. Staff reported that all interventions they placed on R1 to prevent falls did not work. There is no documented evidence of a specific fall prevention plan. R1’s Primary Care Physician (PCP) reported the facility never consulted with them regarding R1’s falls to determine the best level of care for R1. R1’s Hospice Doctor reported the facility never consulted with them regarding R1’s care. A review of R1’s service plans from August 23, 2023, and May 2, 2024, shows an increase in service regarding mobility/ambulation. The Health and Wellness Director reported that they offered R1’s responsible party a one-on-one care companion at the end of March 2024 or early April 2024, but they declined the offer. The Health and Wellness Director reported they suggested a different facility which could provide a higher level of care, but the responsible party declined. R1’s responsible party only verified the recommendation for a one-on-one care companion. The service plan for R1 was updated on May 2, 2024, after R1 had 5 falls. There is no record of R1 falling after April 30, 2024. On May 1, 2024, Hospice, Facility staff and R1’s Responsible Party had a meeting to discuss R1’s change in condition and need for one-on-one care. The Responsible Party declined one-on-one care due to financial reasons. On May 2 the Hospice provider and R1’s Responsible Party had a meeting and Hospice recommended R1 be placed in a higher level of care, but the Responsible Party declined, so the facility placed R1 in another room which allowed for closer supervision. Facility staff acknowledged that R1 continued to fall despite their fall intervention plan and the facility retained R1 knowing they did not have adequate and supervision to meet R1’s needs. R1 remained at the facility until they passed away on June 3, 2024, cause of death was respiratory arrest and senile degeneration of brain not elsewhere classified. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation that staff did not provide adequate supervision, resulting in a resident sustaining multiple injuries. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Mar 20, 2025 · control 22-AS-20240502115044

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Mar 21, 2025

Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure R1 received care and supervision, as a result R1 suffered multiple injuries because of falls suffered on April 25 , 2024 and April 29, 2024, which poses an immediate health and safety risk to persons in care. CIVIL PENALITY ASSESSED.the state’s words, verbatim · CDSS document, Mar 20, 2025

Plan of correction: Licensee agrees to train care staff on CCR 87464 and to submit proof of training to LPA.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced case management visit. LPA met with Phil Altman Senior Vice President of Operations and explained the reason for the visit. During the investigation of complaint 22-AS-20240502115044 it was discovered through a review of Resident 1’s (R1) care notes that R1 suffered falls on; April 3, 5, 25, 29, and 30 of 2024. A review of the special incident reports (LIC 624) received from the facility for April (5) and May (8) of 2024 show the facility only reported the falls on April 25, 2024, and April 29, 2024, to the Agency. The facility failed to report the falls on April 3 , 5 and 30 to the Agency as required by California Code of Regulations (CCR) Title 22, Division 6, 87211. Based on the information discovered during the course of the complaint investigation the facility is being cited per Title 22 Division 6 of the California Code of Regulations (LIC 809D for details). An exit interview was conducted and a copy of the report along with appeal rights was provided.the state’s words, verbatim · CDSS document, Mar 20, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Apr 3, 2025

Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by, The facility failed to report the falls of R! on April 3, 5, and 30 to the Agency, which poses a potential health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2025

Plan of correction: Licensee agrees to train all staff on CCR 87211 and to submit proof of training to the LPA by the POC due date.

Allegation investigated: Facility is not in good repair Facility is understaffed

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Executive Director Kara Kneedy-Cayem and explained the reason for the visit. The Department received a complaint on 01/31/2025 and LPA Mendivil conducted the initial 10 day visit on 02/10/2025. LPA Mendivil obtained copies of pertinent documents such as staff schedule and service documentation. LPA also interviewed staff and residents. Regarding the allegations, facility is not in good repair and facility is understaffed, the investigation revealed the following: It was alleged an elevator in the facility was not operational. Based on interviews with Executive Director Kara , it was reported that the facility has 2 elevators. The first elevator is located in the front of the building near the mail room and the second elevator is located in the back of the bulding. It was reported the second elevator was non operational. Unsubstantiated It was reported by ED Kara that the elevator did work but made a noise that was concerning. ED reported the elevator was "down" for 2 weeks until a technician could check the elevator. ED stated on 2/7/2025 a technician came to the facility to fix the noise issue in the elevator. Per review of work order Schindler Elevator Corporation "lubed rails" and elevator was opened back up for use by 1:50pm on 2/7/2025. Regarding the allegation facility is understaffed. Per review of caregivers/med-tech schedule there are 5 staff members in the AM shift which is 6am-2:15pm, 4 staff members in the PM shift which is 2pm-10:15 and 2 staff members during NOC shift which is 10pm to 6:30 am for Assisted Living. Per interviews with 4 out of 4 residents state they feel all their needs are met and they have enough staff. Therefore based on the preponderance of evidence through records review and interviews the allegations that facility is not in good repair and facility is understaffed are determined to be UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Feb 10, 2025 · control 22-AS-20250131142108

Allegation investigated: Facility did not safeguard resident's personal belongings. Facility has surveillance cameras in the resident's room. Facility is not in good repair.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegations listed above. LPA was greeted and granted entry by front desk after introducing himself and stating the purpose of the visit. Executive Director Kara Kneedy-Cayem was notified via telephone as she was doing an assessment in the community and later returned to assist. Facility Marketing Director Denise Renella was present to assist. During the initial complaint investigation visit, LPA requested and obtained the current resident census. LPA accompanied by tour conducted a tour of the two levels of the facility including the facility's memory care. LPA conducted three staff interviews including maintenance staff and reviewed resident records for five past or current residents. Additional documentation of a call to Brea Police for suspected theft and maintenance logs were also provided. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Regarding the allegation that Facility did not safeguard resident's personal belongings, the following has been concluded: Based on interviews and records reviewed, multiple incidents of theft or loss are alleged to have occurred on the premises. Most of the incidents came to be known to facility staff knowledge after being mentioned during the facility's residents council. Reports were made to local law enforcement and did not result in additional investigation after an officer was initially dispatched. Records review also confirmed that no cash amounts were placed into the facility's safeguarding authority. Additionally, facility staff provided LPA with a file where all theft and loss incidents were logged including: a description of the article, its estimated value, the date and time the theft or loss was discovered, if determinable, the date and time the loss or theft occurred as well as the action taken. The facility's theft and loss policy is also posted on the premises as required. All elements of the required theft and loss policy are therefore present. Regarding the allegation that Facility has surveillance cameras in the resident's room, the following has been concluded: Based on a tour of the physical plant, LPA was able to confirm the presence of a video surveillance system operated by the licensee, restricted to the facility's common areas. A review of multiple residents' admission agreements show the following clause which implies approval prior to admission: "For security purposes, there are video cameras in some of the common areas of Cogir of Brea. These cameras are not monitored by staff. By signing this Agreement, you consent to the use of video surveillance in the common areas. In order to protect the dignity and privacy of our residents, we do not permit the use of nanny cams or other video surveillance devices in resident apartments without written approval." Individual agreements for both residents observed to have video cameras in the room reviewed and signed by respective responsible parties. No additional cameras found during a tour of a total of thirteen randomly selected units throughout the facility. Regarding the allegation that Facility is not in good repair, the following has been concluded: Based on two tours of the facility physical plant and observation of a total of thirteen units on both levels in addition to the common areas, no outstanding items of disrepair were observed by LPA and/or facility staff. Additionally, maintenance working orders were reviewed and residents interviews conducted. No outstanding items of maintenance were identified at the time of the present visit. Based on the evidence gathered, all three allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jan 22, 2025 · control 22-AS-20241023160037

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with the Health Services Director Miriam Im and explained the reason for the visit. The facility is a two-story building with 82 resident rooms. The building has a central courtyard with outdoor shaded seating area. The facility has 2 dining rooms, a theater, fitness room and an activity room. Facility has a capacity of 110 non-ambulatory of which 12 may be bedridden and a hospice waiver for 12. LPA and the Health Services Director toured the facility. LPA observed the See Something Say Something poster posted next to the main entry door of the facility. There are 2 stairways which are both outside. LPA observed an evacuation chair at the top of each stairway. LPA observed the kitchen is clean and organized. The refrigerator and freezer are maintained at the required temperatures. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The fire extinguishers in the kitchen are fully charged. LPA observed carbon monoxide detectors on each floor of the facility. All of the carbon monoxide detectors tested operational. The facility's fire protection equipment was inspected on November 21, 2023, no deficiencies noted. The delayed egress exit doors on the first floor are operational. LPA and Health Services Director toured the resident rooms. LPA observed that all the rooms inspected (6) had the required furnishings and bed linens. Hot water measured from 114.9 to 117.6 degrees Fahrenheit in all 6 six rooms. No obstacles or hazards observed inside or outside of the facility. The activity room has games and puzzles for residents. The theater has a large screen TV for residents to watch movies or TV. LPA reviewed 6 resident files and medications, no discrepancies observed. LPA reviewed 5 staff files. All staff members interviewed and encountered were background cleared and associated to the facility. LPA observed Staff 1 did not have the required initial training of 20 hours in their first 4 weeks of employment. Deficiencies are being cited per Title 22 division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.the state’s words, verbatim · CDSS document, Jul 22, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced case management visit. LPA met with the Health and Wellness Director Miriam Im and explained the reason for the visit. During the required 10-day visit to begin the investigation into complaint # 22-AS-20240502115044, LPA observed that the See Something, Say Something poster (PUB 475) was not posted in the main entry way of the facility. The PUB 475 poster was posted in the hallway adjacent to the main entry way of the facility next to the mail boxes and elevator. LPA informed the Health and Wellness Director that the PUB 475 poster must be posted in the main entry way of the facility. The Health and Wellness Director stated she understood. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, May 2, 2024

Allegation investigated: Staff do not ensure that client is adequately fed Staff do not ensure that client's hygiene needs are met Staff do not keep client's room clean or sanitary

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility and to deliver the findings. LPA De Perio explained the purpose of today's visit, and was greeted by Community Relations Director – Charles Luetto. During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that staff do not ensure that client is adequately fed. 4 out of the 4 resident interviews conducted, did not corroborate with the allegation. 3 out of the 4 resident interviews specified that if a resident does not come down to eat, then staff will knock on their door to remind them, or will bring food to their room. 3 out of the 3 staff interviews conducted, also did not corroborate with the allegation by stating that staff will remind and encourage residents to go to the dining room to eat, however, if a resident refuses in wanting to eat, then staff will not force the resident to do so. Unsubstantiated Per documentation review, facility offers three meals a day and two snack times, and that the facility dining room hours have an “All Day Dining” from 7:00am-7:00pm. Meal times goes as follows: breakfast (7:00am-10:00am), snack (10:00am), lunch (11:30am-1:00pm), snack (2:00pm) and dinner (4:30pm-6:30pm). It was alleged that staff do not ensure that client's hygiene needs are met. 3 out of the 4 resident interviews did not corroborate with the allegation by stating that hygiene needs are met. 3 out of the 3 staff interviews conducted, did not corroborate with the allegation by stating that if a resident requires assistance per physician report, there will be a caregiver assigned to that resident to assist with bathing on a weekly basis. 3 out of the 3 staff interviews also stated that if a resident refuses staff assistance, or refuses to bathe, then staff will document the resident refusal. Per physician report of resident 1 (R1), R1 is able to bathe, dress, and groom self. R1 verified via interview that R1 will shower on their own, and does not need assistance. It was alleged that staff do not keep client's room clean or sanitary. 4 out of the 4 resident interviews did not corroborate with the allegation by stating that the staff do a good job at ensuring rooms are clean and sanitized. 3 out of the 3 staff interviews conducted, did not corroborate with the allegation by stating that housekeeping and maintenance are regularly scheduled for each resident to conduct cleaning, sanitizing, repairs, and laundry, however if a resident refuses, then staff will document it. LPA conducted a tour of R1’s room and observed that the room was clean, no hazards observed, and had clean furniture and bed sheets. LPA also did not observe any stench in room, or rotten food. R1 also specified that housekeeping cleaned on 1/29/24 and will come often to assist R1 with any cleaning and laundry that needs to be completed. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, these allegation are deemed UNSUBSTANTIATED. An exit interview was conducted with Community Relations Director – Charles Luetto. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Jan 30, 2024 · control 22-AS-20240124122534