Cogir of Folsom

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Angela Hood arrived on September 2, 2026 for an unannounced inspection to follow up on a substantiated allegation of neglect, resulting from a complaint. On February 19, 2026, the Department concluded a complaint investigation regarding the following allegation: Due to neglect and lack of care and supervision, a resident pushed another resident resulting in the resident sustaining fractures. The licensee was cited for California Code of Regulations (CCR) Title 22, § 87464(f)(1) Basic Services. At the time of the complaint visit on February 19, 2026, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by facility staff failing to adequately monitor residents in care, as indicated by an unwitnessed altercation occurring between Resident 1 (R1) and Resident 2 (R2) which resulted in R1’s subsequent fall, requiring emergency medical transportation and hospitalization for multiple rib fractures, including a flail segment involving the 6th-8th ribs. **********************************************Continued LIC809-C**************************************************** Today, September 2, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department determines constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on February 19, 2026, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Sep 2, 2026

Allegation investigated: -Resident sustained injuries due to staff neglect or physical abuse

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Liz Cruz, to deliver complaint investigation findings regarding the above stated allegation. During the course of the investigation, LPA conducted interviews, obtained documentation, and made observations. *********************************************Continued on LIC9099-C*************************************************** Unfounded On April 15, 2026, the facility provided CCLD an Unusual Incident/Injury Report indicating that, on April 13, 2026, resident (R1) was exhibiting verbally and physically aggressive behavioral expressions when staff (S2) was attempting to assist R1 with activities of daily living (ADLs). The Health and Wellness Nurse (HWN), Melanie Cornish, contacted emergency medical services and R1 was transported to the hospital. According to R1's progress notes and facility's internal incident report, the HWN was called to assist S2 as R1 was observed to be grabbing and swinging at S2 while they were attempting to assist with R1's incontinence care. Progress notes and incident report indicated that R1 continued to yell and swing at care staff in addition to kicking and trying to bite care staff. The HWN observed R1 to have a skin tear on their elbow and wrist from their medical emergency bracelet. The HWN called 911 and R1 was sent out via ambulance for further evaluation. According to the Emergency Department Patient Discharge documentation, R1 was admitted for displaying symptoms of neurocognitive decline. R1 was discharged from the hospital on April 14, 2026 with changes to their medications prescribed for agitation and insomnia. R1's diagnosis upon discharge was agitation due to dementia, and there were no notations of injuries sustained. Interviews with staff present during the incident, including HWN, staff (S1), and S2, indicated that R1 was exhibiting aggressive behavioral expressions on the date of the incident. Staff indicated that R1 was receiving assistance with toileting at the time of the incident. HWN indicated that R1 was grabbing staff and hitting the wall next to the toilet. S1 indicated that R1 had their arm linked in the grab bar next to the toilet and would not let go. S2 indicated that R1 was swinging at them when they were assisting in the restroom. Staff indicated that R1 hit their arm on the wall while they were attempting to redirect. Staff indicated that they were able to redirect R1 to their bed where they continued the aggressive behavioral expressions. Staff indicated that emergency medical was contacted. HWN indicated that, upon R1's return to facility on April 14, 2026, there were some changes to R1's medication, which helped with their behavioral expressions. Interview with R1 indicated that staff treat them well and they have not had any trouble with staff. R1 indicated that staff do not neglect or physically abuse them. R1 stated that they are physically okay but their mind wanders a lot. LPA observed the skin on R1's arms, which appeared thin and had reddish purple spots that are commonly caused during the skin's natural aging process. Based on documentation obtained, interviews conducted, and observations, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or are without a reasonable basis. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 59-AS-20260414095727

Allegation investigated: -Facility is in financial distress. -Staff does not treat residents with dignity and respect. -Staff does not ensure residents receive adequate food service.

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Liz Cruz, to deliver complaint investigation findings regarding the above stated allegations. During the course of the investigation, LPA conducted interviews, obtained documentation pertinent to the investigation, and made observations. *******************************************Continued on LIC9099-C***************************************************** Unsubstantiated LPA obtained food delivery service invoices from the facility that indicated food was delivered on March 4, 2026, March 11, 2026, March 25, 2026, April 1, 2026, April 2, 2026, April 8, 2026, April 13, 2026, April 15, 2026, April 16, 2026, and April 22, 2026. During facility visits on April 23, 2026 and June 18, 2026, LPA observed the facility to have the required two-day perishable and seven-day nonperishable food supply on hand. LPA also observed a variety of food options for residents. LPA obtained facility food menus dated March 22, 2026-April 25, 2026. According to the weekly food menus, the facility offers a variety of food options for residents for breakfast, lunch, and dinner. Interviews with staff indicated that, if residents are still hungry during mealtime, residents are offered more food. Interviews with staff also indicated that they provide snacks to residents throughout the day. Interviews with residents (R1, R2, R3, and R4) indicated that they are getting plenty of food to eat. Interviews with residents indicated that there are a variety of food options and that snacks are provided as well. Interviews with staff (S1, S2, and S3) indicated that they have never witnessed staff treating residents with a lack of dignity or respect. Interviews with R1, R2, R3, and R4 indicated that staff treat them well. Interviews with residents indicated that they are being treated with dignity and respect by staff at the care home. Based on interviews conducted, documentation obtained, and observations, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 59-AS-20260324152048

Allegation investigated: -Facility staff did not provide resident's authorized person resident records

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Regional Health and Wellness Director, Karen Silva, to deliver complaint investigation findings regarding the above stated allegation. LPA obtained email correspondence between resident (R1's) responsible party and facility staff. On October 30, 2025, R1's responsible party requested R1's resident records, which included incident reports and any required state notifications or reports made after R1's passing. On October 31, 2025, the facility provided R1's responsible party with R1's resident records. However, the records were missing R1's Death Report LIC624A, which should have also been reported to CCLD within seven (7) days of occurrence. The facility was unable to provide proof that the Death Report was provided to R1's responsible party or to CCLD. Based on records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview conducted. A copy of this report and appeal rights were provided. Substantiated The Final Autopsy Report for resident (R1) indicated that the diagnoses are as follows: edema, electrical cardiac event, and severe emphysema with organizing bronchopneumonia. The Sacramento County Coroner Report indicated that the cause of death was determined to be Citalopram and Memantine Toxicity, as well as hypertension cardiovascular disease and obesity. The report also indicated that “it is unclear how the toxicity occurred. The decedent’s medications were reportedly controlled by the care facility. There were no reports of suicidal ideations. No suspicious circumstances were found. Based on the circumstances and cause of death, the manner will be listed as Undetermined”. The Toxicology Report indicated that R1 had 620 ng/ml of Citalopram/Escitalopram and 380 ng/ml of Memantine. Interview with Sacramento County Coroner’s Office representative indicated that they did not know if the medication toxicity was due to an overdose or R1’s poor metabolism. Interview indicated that R1’s age could have played a role in their body’s ability to metabolize medication. They also noted that R1 had hypertension and obesity, which increased the risk of having a sudden cardiac arrest. Facility staff did not report any changes in R1’s baseline leading to their death. Staff interviews indicated that R1 did not have a history of pocketing medications, and there were no indications of R1 entering the locked medication room and taking medications. Based on documentation obtained and interviews conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 23, 2026 · control 59-AS-20251105134928

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Jul 7, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This requirement is not met as evidenced by: Based on records reviewed, the facility did not ensure that resident (R1's) Death Report was provided to CCLD and R1's responsible party within seven (7) days of occurrence, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 23, 2026

Plan of correction: Facility shall submit a statement of understanding to LPA by the POC due date of 7/7/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced and met with the Executive Director, Liz Cruz, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed six (6) bedrooms, three (3) shower/bathrooms, and common area bathroom. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 115.6 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed four (4) resident files and also reviewed four (4) staff files. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jun 18, 2026

Allegation investigated: -Staff do not ensure medications are dispensed as prescribed

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Liz Cruz, to deliver complaint investigation findings regarding the above stated allegation. During a visit conducted on February 25, 2026, LPA conducted a medication count for residents (R2, R3, R4, & R5), comparing the residents' medication lists on file with medication centrally stored for the residents. LPA observed three (3) medications for R2 that were over the amount documented. R3 had two (2) medications that were over the amount documented. R4 had four (4) medications that were over the amount documented. R5 had two (2) medications that were over the amount documented. Based on a medication count and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents. Substantiated that they have never had any complaints regarding a staff member working under the influence of alcohol. Interviews with S1 and S2 indicated that they have never witnessed staff falsifying documentation regarding medications. S1 indicated that there is a certain way to document medication refusals and explain why. S2 indicated that there are not many medications that are provided during the NOC shift and they ensure all documentation is accurate. S3, S4, and S5 do not handle medication documentation. Based on interviews conducted, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 3, 2026 · control 59-AS-20260223135839

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 6, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication count and records reviewed, the facility did not ensure that residents (R2, R3, R4, & R5) were receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: Facility agrees to provide an in-service training to all med techs regarding job duties to address medication management and submit to LPA by the POC due date of 4/6/26. Facility will also complete bi-weekly audits of all medications for the next two months and submit them to LPA. Facility requested an extension to complete training by 4/8/26.

Allegation investigated: -Staff did not maintain the facility HVAC system in good repair -Staff do not provide appropriate care and supervision for a cognitively impaired resident

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Liz Cruz, to deliver complaint investigation findings regarding the above stated allegations. Allegation: Staff did not maintain the facility HVAC system in good repair On January 14, 2026, LPA and the Local Long-Term Care Ombudsman (LTCO) conducted a joint visit and toured the care home, as well as resident (R1’s) room. The facility has an HVAC system that operates throughout all hallways and common areas and PTAC units in each residents’ room. LPA and LTCO observed all thermostats throughout the facility hallways and common areas, as well as a PTAC on the wall in one hallway. All thermostats appeared to be functioning and the facility temperatures were observed to be within regulatory range. LPA and LTCO observed that the window was open in R1’s room, the PTAC on the wall was not turned on, and the PTAC was plugged in. LPA and LTCO observed that *************************************************Continued on LIC9099-C**************************************************** Unsubstantiated the PTAC in R1’s room was functioning and had a temperature range that could be adjusted between 60-86 degrees F. LPA and LTCO attempted to interview R1, who did not express any concerns regarding the PTAC and indicated that it works. Interviews with the Executive Director (ED) and Maintenance Director (MD) indicated that the PTAC in R1’s room had been replaced as well as the filter. MD also indicated that the PTAC temperatures have a specific range to ensure safety of residents operating the units. Allegation: Staff do not provide appropriate care and supervision for a cognitively impaired resident Interviews with staff (S1 and S2) indicated that they provide care and supervision to residents in R1’s wing of the facility. S1 indicated that R1 opens and closes their window throughout the day. S1 and S2 indicated that staff are notified when a resident opens their window. S2 indicated that if a resident wants their window open and it is the appropriate temperature outside, staff will keep it open. S1 and S2 indicated they will adjust the PTAC, if needed, during resident checks or upon request to ensure residents' rooms remain at a comfortable temperature. S1 and S2 indicated that they believe the facility provides good care and supervision to the residents and that they have enough staff per resident to provide monitoring. S1 indicated that staff will provide checks on residents every two (2) hours. S1 and S2 indicated that most residents will be in the common areas throughout the day. ED indicated that the facility has enough staff on schedule to provide care and supervision for the residents. LPA has been receiving monthly schedules from the facility indicating the facility is fully staffed during all shifts. Based on observations made, interviews conducted, and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 3, 2026 · control 59-AS-20260108215802

Allegation investigated: Staff are not taking steps to prevent the spread of a communicable disease. Staff are not following proper food safety protocols with residents in care.

Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to delivered the findings of the allegations cited above. LPA met with Exceutive Director and explained the purpose of the visit. For the allegation of Staff are not taking steps to prevent the spread of a communicable disease, based on information obtained facility did not have a policy restricting residents from having visitors to prevent the spread of a communicable disease. Interview conducted with Executive Director revealed that staff wears masks to prevent spread, along with complying with proper hand hyigene and cleaning. But residents are not required to if refused. Due to most residents' cognitive impairment, some resident refused isolation. For the allegation of Staff are not following proper food safety protocols with residents in care, based on information obtained, kitchen staff are required to follow proper hand washing protocol. The alleged incident occurred was in reference to a hamburger being undercooked but there are no evidence of the alleged event. Please continue on LIC 9099-C. Unsubstantiated LIC 9099-C Interview conducted with Executive Director revealed that hamburger at the facility may be served a certain way but request of the resident. Interview conducted with resident (R1) revealed that R1 cannot recalled being served undercooked hamburger. With the information obtained, the allegations are unsubstantiated. As a result of this investigation, it was determined the allegations are to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Exit interview and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2026 · control 59-AS-20250623112243

Allegation investigated: -Due to lack of supervision, resident had a physical altercation with another resident resulting in resident falling

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Liz Cruz, to deliver complaint investigation findings regarding the above stated allegation. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. Interviews with staff present at the time of the incident involving residents (R1 and R2) on November 16, 2025, indicated that the only witness to the incident was staff (S2). Interview with S2 indicated that, as they were assisting another resident in the common area, they witnessed an incident between R1 and R2. S2 stated that R1 and R2 had their hands linked together and, when R1 and R2 let go of each other’s hands, R1 lost their balance and fell. Facility had R1 sent to the hospital for evaluation. Incident Report provided by the facility indicated the same information as the witness’s statement. Interviews with staff **********************************************Continued on LIC9099-C************************************************** Unsubstantiated indicated that the other caregivers on duty at the time of the incident were assisting other residents and the med tech was in the medication room. Interviews with staff indicated that they were not short staffed and there was no lack in care or supervision at the facility. According to the staff schedule, the facility was fully staffed on the date of the incident. R1’s After Visit Summary and Progress Notes indicated that R1 returned to the facility from the hospital on November 19, 2025. There were no injuries reported and R1 had a change in their medication. According to R2’s Behavioral Expression Monitoring Log, R2 had incidents of aggressive behaviors towards other residents on October 27, 2025, October 28, 2025, and October 31, 2025 without injuries. The facility responded to the incidents by conducting a care conference with R2’s responsible party and reassessing them with the update in behaviors, which was signed on October 30, 2025. Between October 30, 2025 and November 12, 2025, the facility was in communication with R2’s physician and their responsible party to ensure they address R2’s changes in behaviors. The facility provided documentation indicating that R2’s physician had made adjustments to medications for behaviors as well as included antibiotics for Urinary Tract Infection (UTI). One medication utilized to reduce behaviors was increased on November 12, 2025 as well as another Urinalysis ordered for monitoring of UTI. Due to the November 16, 2025 incident, the facility immediately implemented one on one care to provide additional care and supervision for R2. The facility provided invoices indicating the dates of service from November 17, 2025-November 23, 2025. Based on interviews conducted and documentation obtained, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 19, 2026 · control 59-AS-20251124123646

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Liz Cruz, to conduct a case management visit. The purpose of today's visit was to amend reports from a visit conducted on February 3, 2026. The department has determined that, due to the citation issued on February 3, 2026, an immediate civil penalty per Health and Safety Code § 1548 in the amount of $500 will be assessed for a violation that the department determines resulted in the injury or illness of a person in care. An additional civil penalty assessment is under review and a determination is pending. LPA will return on a future date to assess an additional civil penalty if warranted. No additional citations issued. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Feb 19, 2026

Allegation investigated: -Due to neglect and lack of care and supervision, a resident pushed another resident resulting in the resident sustaining fractures.

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Liz Cruz, to deliver complaint investigation findings regarding the above stated allegation. During the course of the investigation, the department conducted interviews and obtained documentation pertinent to the investigation. ********************************************Continued on LIC9099-C******************************************************* Substantiated According to hospital medical records, resident (R1) was admitted to the hospital on July 30, 2025, after reportedly being pushed by another resident (R2) and falling. R1 was diagnosed with right fourth (4th) through eighth (8th) rib fractures and right hemothorax. R1 was discharged from the hospital on August 1, 2025. Emergency Medical Services (EMS) records indicated that a staff (unknown) informed them that R1 went into R2’s room and R2 pushed R1 out of their room causing the fall. The Unusual Incident/Injury Report LIC624 indicated that the incident occurred at approximately 7:30am and R1 verbalized that they were pushed by R2. R2’s Behavioral Expressions Monitoring Log indicated that, on July 30, 2025, R2 was agitated, anxious, and frustrated by R1 going into their apartment. R1 was found on the floor and had an unwitnessed fall. R1 indicated that R2 pushed them. R1’s Daily Log, dated July 30, 2025, indicated that R2 pushed them down. According to staff schedules and timecards, there were three (3) care staff present at the care home, with no med tech on duty, at the time of the incident on July 30, 2025. Staff interviews indicated that, due to the facility not having a med tech on duty, staff (S2) was responsible for passing medications. Staff interviews indicated that S2 was pulling medications at the time of the incident between R1 and R2 leaving two (2) care staff available to assist residents. Interviews with staff (S3) and S2 indicated that, upon response to R1’s fall, R1 informed them that they were pushed by R2. Staff interviews indicated that the incident between R1 and R2 was unwitnessed. However, staff interviews also indicated that the facility was aware of R2’s aggressive behaviors and did not ensure there were enough staff scheduled based on the care needs of the residents. Based on interviews conducted and documentation obtained, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is being cited on the attached 9099-D page. As a result of the resident's serious bodily injury, an immediate civil penalty per Health and Safety Code § 1548 in the amount of $500 was assessed on an LIC809 provided on February 19, 2026 for a violation that the Department determines resulted in the injury or illness of a person in care. An additional civil penalty assessment is under review and a determination is pending. LPA will return on a future date to assess an additional civil penalty if warranted. Exit interview conducted. A copy of the report and appeal rights provided. and S5) indicated that the caregivers and med techs on duty will make sure all residents attend mealtimes. Interviews indicated that, if a resident is not present, staff will locate the resident to see if they want to join. If any refusals or a resident is out of the facility, the med tech will document in the resident’s progress notes. R1’s progress notes dated May 1, 2025-July 26, 2025 had no indication of mealtime refusals. Interview with S1 indicated that R1 always appeared clean and showered. Interviews with S1, S4, and S5 indicated that the facility has a shower log that the facility follows. S4 and S5 indicated that they have never witnessed a resident that appeared to need to be bathed. S4 and S5 indicated that, if a resident refuses showers, care staff will attempt several times or may try a change of face so a resident will take their scheduled shower. Staff indicated that they keep a shower log indicating when showers were given. LPA attempted to obtain the shower log for R1. However, according to the Regional Health and Wellness Director, Karen Silva, the facility does not keep shower logs passed 90 days. R1’s progress notes dated May 1, 2025-July 26, 2025 had no indication of shower refusals. LPA observed that the facility has a current shower schedule as well as a skin check shower sheet used when providing showers. On November 25, 2025, December 11, 2025, and December 23, 2025, LPA toured the facility, which included all common areas and five (5) resident rooms. LPA observed the facility to be free of odor, clean, and in good repair. On December 11, 2025, LPA observed housekeeping cleaning in one of the facility hallways. Interview with S1 indicated that they never observed R1’s room to be dirty. S1, S4, and S5 indicated that housekeeping is good at ensuring the facility, including residents’ rooms, are clean. S1, S4, and S5 indicated that, if a resident has an incontinence accident, staff will clean up the resident and housekeeping will clean the floors, if needed. Staff also indicated that any linens or clothing will be laundered. LPA visited the facility on multiple dates between November 25, 2025-January 14, 2026 and observed care staff providing care to residents, residents either waiting for mealtime or eating at mealtimes, and residents appeared clean wearing laundered clothing. The facility was also clean and in good repair. Based on observations made, interviews conducted, and documentation obtained, although the allegations 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 are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 3, 2026 · control 59-AS-20250801124816

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 4, 2026

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision... This requirement is not met as evidenced by: Based on documentation reviewed and interviews conducted, the facility did not ensure staff were sufficient in number to provide care and supervision to residents, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Facility will provide a statement of understanding and provide to LPA by POC due date of 2/4/26. ED, Liz Cruz, has provided LPA with 2 months of staff schedules indicating they ensure that AM and PM shifts have 3-4 caregivers and 1 med tech, and NOC shift has 2 caregivers and 1 med tech. ED informed LPA that the Health and Wellness Director will be taking over staff schedules in February 2026. Facility agrees to provide LPA with staff schedules for 2 months after Health and Wellness Director begins.

Allegation investigated: -Facility is malodorous

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director (ED), Liz Cruz, to deliver complaint investigation findings regarding the above stated allegation. On December 11, 2025, LPA toured the facility with the Regional Health and Wellness Director (RHWD) and the local Long-Term Care Ombudsman (LTCO). The tour included resident (R1's) room and surrounding rooms. The LPA, local LTCO, and RHWD did not observe any abnormal odors in the care home. On December 23, 2025, LPA toured the facility with the ED, which included R1's room and surrounding rooms. LPA and ED did not observe any abnormal odors in the care home. Based on observations made, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 23, 2025 · control 59-AS-20251205121209

Allegation investigated: Facility staff did not ensure that resident's showering needs are being met. Facility staff did not intervene in verbal altercation between residents. Facility staff spoke inappropriate to resident.

On October 14, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the findings of the allegations cited above. LPA met with interim Executive Director and explained the purpose of the visit. During the course of this investigation, LPA conducted extensive interviews. The result of the allegation is as follow on LIC9099-C(1). Unsubstantiated LIC 9099-C For the allegation of, Facility staff did not provide resident medications at prescribed, the Department conducted file reviews of R1’s medication list, narcotic count record, medication release record, and emergency paper medication administration record. Records revealed that on the medication list effective January 24, 2025, R1 was prescribed PRN Ativan 0.5mg one tablet by mouth twice a day as needed. Then effective February 3, 2025, PRN Ativan 0.5mg was changed to one tablet by mouth three times a day as needed. File review of narcotic count record revealed that after R1’s first dose given on February 1, 2025, there was a remaining of 87 tablets of Ativan 0.5mg and after the last dose given on February 10, 2025, there was a remaining of 68 tablets. From February 1, 2025 to February 2, 2025, R1 received maximum of one tablet per day as needed. From February 3, 2025 to February 10, 2025, R1 did not receive more than three tablets per day, compliance to R1’s physician order of the PRN Ativan. Medication release record revealed it was signed off by R1’s responsible party that Ativan 0.5mg was entrusted to R1’s responsible party with the total count of 68 tablets. Therefore, allegation is unfounded. Based on the information obtained, the Department concluded that the allegations are unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted, and a copy of the report was provided. LIC 9099-C(1) For the allegation, Facility staff did not ensure that resident's showering needs are being met, the Department conducted several interviews. Interview conducted with resident (R2) revealed that staff does assist R2 with showering. When asked if R2 is having any issues with staff not meeting R2's showering needs, R2 indicate R2 does not think there is any issues. R2 stated R2 cannot remember much but think they are getting all their showers. File review of R2's LIC 602 revealed that R2 has dementia. Interview conducted with resident (R3) revealed that R3 has recently moved in the facility but really likes the staff. R3 denied having any issues regarding showering needs, and expressed that R3 is satisfied at the facility. R3 receives showering twice a week. Interview conducted with resident (R4) revealed that R4 does not need much assistance from staff with showering but likes stand-by assist. R4 does not know if there are any concerns with showering needs. File review of R4'sLIC 602 revealed that R4 does have dementia. Interview conducted with R5 revealed that R5 receives assistance with showering. R5 does not believe there are any issues with staff not meeting resident's showering needs. Due to the lack of information the Department was able to obtain, the allegation is unsubstantiated. The allegation of, Facility staff did not intervene in verbal altercation between residents, the Department conducted extensive interviews. Interview conducted with Health and Wellness Director revealed that when residents are having a verbal altercation, staff are to assist with de-escalating the situation. Staff are to isolate the aggressor to see if they want to do any activities. Interview conducted with Executive Director revealed that the facility is a memory care facility where residents are often having behaviors. If residents are engaged in an altercation, staff should intervene to ensure the health and safety of residents in care. The facility has several corners where if guests or visitors are observing an altercation, they are to report the incident to staff for staff to redirect. Executive Director reported that this alleged incident was not brought to their attention and there was not enough information to investigate further. There were no known witnesses to such an incident. Interview conducted with R2, R3, R4 and R5 reported they feel safe at the facility. Therefore the allegation is unsubstantiated. Please continue on LIC9099-C (2). LIC 9099-C(2). For the allegation of, Facility staff spoke inappropriate to resident, the Department conducted interviews to investigate the following. Interview conducted with Health and Wellness Director revealed that R1 was new at the facility and was very dependent on R1's roommate for social interaction and activities but staff did not speak to R1 in any ill manner. Interview further revealed that staff are to assist and motivate R1 with integrating into the community and ensuring R1 feels comfortable with other residents in care. Interview conducted with R3 revealed that R3 has not witnessed staff speaking to residents inappropriately. Interview conducted with Executive Director revealed that the alleged incident was brought to her attention by a family member but there was no information on what day this occurred, no information on which staff member allegedly spoke inappropriately to R1 and/or other residents. Due to lack of information available for the Department to investigate, the allegation is unsubstantiated. As a result of this investigation, it was determined the allegations are to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Exit interview and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 14, 2025 · control 59-AS-20250305101720

Type of visit: Office

On September 16, 2025 at 3:30 PM, a virtual office meeting was held with Sacramento North Regional Office using Microsoft Teams. Present in the meeting was Community Care Licensing representatives: Regional Manager, Alycia Rayner; Licensing Program Manager (LPM), Maribeth Senty; and Licensing Program Analyst (LPA), Cassie Yang. Present in the meeting was Licensee representatives: Senior Vice President of Care and Compliance, Holly McMurray; Senior Vice President Operations Northern CA, Kristina Munoz; Assistant Chief Operating Officer, Justin Stein; National Director of Resident Care, Kimberly Eldridge; Regional of Health and Wellness, Karen Silva; and Legal representative, Joel Goldman. The purpose of today's meeting was to discuss the recent non-compliance at the facility. Topics discussed during this meeting were: Significant leadership changes Continuation of staff training Observation of residents behavior expressions Appropriate oversight at the facility Additionally, a follow-up office meeting will be scheduled in three months to discuss the progress of new facility implementation. A copy of this report was emailed to Senior Vice President of Care and Compliance Holly McMurray, following today's meeting. A signed copy will be returned to the LPA by close of business September 16, 2025. There are no deficiencies issued in this report.the state’s words, verbatim · CDSS document, Sep 16, 2025

Allegation investigated: Staff did not update resident's medical records.

On September 10, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to continue a complaint investigation and deliver the finding. LPA met with the Regional Executive Director and the Regional Director of Health and Wellness. During the course of this investigation, LPA conducted interviews and file reviews. The result of the investigation is as follows in LIC 9099-C. Substantiated LIC 9099-C Allegation: Staff did not update resident's medical records. The department conducted extensive interviews regarding the allegation cited above. An interview conducted with the reporting party revealed that R1 has been switched from Kaiser Permanente to Mercy Health effective January 1, 2025, which the facility was notified and provided with an updated medical card. An interview conducted with the Health and Wellness Director on March 7, 2025, revealed that the resident (R1) was sent out to Kaiser Permanente Roseville for evaluation due to leg pain. The Health and Wellness Director stated a new medical card was provided; however, it was not updated on the chart, therefore, R1 was sent to the wrong medical facility for evaluation. Based on R1’s identification and emergency information, it revealed that R1’s hospital to be taken in an emergency was previously written as “Kaiser Roseville” and then crossed out with new input of “Mercy Folsom”. File review of hospital discharge paperwork and progress notes revealed that R1 was sent out to Kaiser Roseville for evaluation. Based on the information obtained, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Please see LIC9099-D. Exit interview conducted, copy of report and appeal rights was provided. LIC9099-C Allegation: Staff did not provide adequate supervision resulting in resident falling. Based on file review of resident’s (R1) progress notes, it revealed that R1 was transported to the emergency room for evaluation due to leg pain. No further indication of a fall. An interview conducted with R1’s responsible party revealed that facility staff have alleged two separate statements that R1 had a fall while in the shower; however, also being informed that R1 did not have any fall in the shower. The interview conducted with Health and Wellness Director on March 7, 2025, revealed that R1 has showering assist getting in and out of the shower, but there is no reporting of R1 sustaining a fall in the shower. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with administrator. LIC 9099-C Allegation: Facility AC/Heater wall unit is in disrepair and accessible to residents. On February 25, 2025 the Department received the complaint with the allegation cited above. On March 7, 2025, the Department conducted an inspection of the facility's air conditioning unit located at the end of the common area. Based on observation, the air conditioning unit was operating and in good condition. There was no observation of the air conditioning unit being a danger to residents in care. Allegation: Staff did not seek medical attention to resident. Based on file review of the resident’s (R1) progress notes, it revealed that R1 was experiencing pain at approximately 4:30 AM and was given PRN medication. Approximately an hour later, R1 continued to express leg pain which facility then contacted emergency medical services. File review of R1’s hospital discharge paperwork revealed X-rays were taken and found to be normal and discharged at approximately 12:52 PM. Allegation: Staff did not notify resident's responsible party of incident. Based on file review of the resident’s (R1) progress notes documented by medication technical, it revealed that R1 was experiencing pain at approximately 4:30 AM and was given PRN medication was administered. Follow up notes revealed R1 continued to express pain which facility then contacted emergency medical services, and then notified Health and Wellness Director and R1’s responsible party. Based on the information above, the department concluded that the allegations are unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 10, 2025 · control 59-AS-20250225082520

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(9) · Plan of correction due date: Sep 30, 2025

87506 Resident Records (b) Each resident’s record shall contain at least the following information: (9) Name, address and telephone number of physician and dentist to be called in an emergency. This requirement is not met by: Based on file review and interview, Licensee did not comply as R1's resident record did not have R1's updated medical physician information which R1 was transported to wrong emergency medical facility which poses a potential risk for resident in care.the state’s words, verbatim · CDSS document, Sep 10, 2025

Plan of correction: Licensee is to submit a procedure of how facility will update residents medical information as needed to ensure resident records remain accurate. POC is due September 30, 2025. As a reminder, failure to correct by plan of correction due date may result to $100 per day until corrected.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced on to conduct case management visit regarding a SOC 341 received. LPA met with Regional Executive Director and explained the purpose of the visit. A SOC 341 was submitted by facility regarding a sexual incident between residents, R1 and R2. Additionally, Facility notified law enforcement, long term care ombudsman (LTCO) and residents' responsible parties regarding this incident. Facility has implemented 1 on 1 care and supervision for R1 to ensure the safety of residents in care as R1 is pending further medical evaluation. No deficiencies cited. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Sep 10, 2025

Allegation investigated: Staff did not ensure that resident was administered their medications as instructed by their physician.

On August 19, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to deliver the findings of the allegation cited above. LPA met with Interim Administrator and explained the purpose of the visit. For the allegation of staff did not ensure that resident was adminstered their medications as instructed by their physician. The Department conducted extensive file reviews and medication audit to investigate the allegation. Please continue on LIC 9099-C to see the result of the investigation. Substantiated LIC 9099-C Allegation: Staff did not ensure that resident was administered their medications as instructed by their physician. Based on file review of resident (R1) electronic medication administration records (e-MAR), it revealed that R1 was prescribed pentoxifylline 400MG tablets to take one tablet by mouth daily, effective February 11, 2025. File review of R1's July 2025 and August 2025 e-MAR revealed that on Sunday, August 3, 2025, medication technician failed to administered R1 a dose of pentoxifylline as there is no initials observed. Medication audit was conducted with medication technician of R1's pentoxifylline bubble pack and it revealed that the pack contains 30 tablets. Bubble pack was dated, opened on "7/23/25". From July 23, 2025 to date of visit, August 19, 2025, there should have been 28 tablets given if administered as prescribed but based on medication audit, there was only 27 tablets administered, which confirmed the missing initial on August 3, 2025. Based on the information obtained, the allegations are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegations cited above are substantiated, but no deficiency will be as LPA substantiated the similar allegation for Complaint #59-AS-20250623112243 on August 19, 2025. Exit interview conducted, copy of report and appeal rights was provided.the state’s words, verbatim · CDSS document, Aug 19, 2025 · control 59-AS-20250623112243

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

Allegation investigated: Licensee did not ensure staff qualified to assigned duties. Staff mismanaged residents’ medications.

On August 19, 2025, Licensing Program Anlayst (LPA) Cassie Yang arrived unannounced at the facility to deliver the findings of the allegations cited above. LPA met with Interim Administrator and explained the purpose of the visit. During the course of this investigation, LPA conducted extensive interviews, file review and medication audit related to: Licensee did not ensure staff qualified to assigned duties; and Staff mismanaged residents’ medications. Results are as follow in LIC 9099-C. Substantiated LIC 9099-C Allegation: Licensee did not ensure staff qualified to assigned duties. The Department conducted a file review which revealed that staff (S1) has been employed with the facility since September 2024 and recently was placed on leave in August 2025. File review of Guardian revealed that S1 required a criminal record exemption in order to work at the facility. A criminal record exemption request was sent to facility on September 21, 2024. Additionally, a letter of case closure was issued on November 18, 2024 due to no response. Live scan was then resubmitted on April 8, 2025 which facility was issued another criminal record exemption request on April 28, 2025 which then a letter for case closure was issued on June 29, 2025 due to no response. Interview revealed that Executive Director was made aware that S1 needed to get the exemption granted in order to work at the facility, but S1 continued to work at the facility until August 2025. The allegation is substantiated as prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall obtain a California clearance or a criminal record exemption. Allegation: Staff mismanaged residents’ medications. Based on file review of resident (R1) electronic medication administration records (e-MAR), it revealed that R1 was prescribed pentoxifylline 400MG tablets to take one tablet by mouth daily, effective February 11, 2025. File review of R1's July 2025 and August 2025 e-MAR revealed that on Sunday, August 3, 2025, medication technician failed to administered R1 a dose of pentoxifylline as there is no initials observed. Medication audit was conducted with medication technician of R1's pentoxifylline bubble pack and it revealed that the pack contains 30 tablets. Bubble pack was dated, opened on "7/23/25". From July 23, 2025 to date of visit, August 19, 2025, there should have been 28 tablets given if administered as prescribed but based on medication audit, there was only 27 tablets administered, which confirmed the missing initial on August 3, 2025. Based on the information obtained, the allegations are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D. Exit interview conducted and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Aug 19, 2025 · control 59-AS-20250728134556

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g)(1) · Plan of correction due date: Aug 20, 2025

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption... This requirement is not met as evidenced by: Based on file review and interview, Licensee did not comply as S1 has been working at the facility since September 2024 when an exemption request has not been completed, which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Aug 19, 2025

Plan of correction: -S1 was immediately removed from schedule. S1 may not return until exemption has been granted. -Licensee is to conduct an audit of staff roster and file to ensure all individuals working at the facility has a clearance and/or exemption. POC due August 20, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465() · Plan of correction due date: Aug 26, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on file review and medication audit, Licensee failed to comply as R1 was not administered one dose of pentoxifylline as prescribed, which poses a potential risk for resident in care.the state’s words, verbatim · CDSS document, Aug 19, 2025

Plan of correction: Licensee is to conduct an in-service for medication technicians to ensure all residents are administered medications as prescribed by physicians. Proof of in-service is due on August 26, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a case management visit regarding deficiencies that LPA observed. LPA met with Interim Administrator and explained the purpose of the visit. Today's visit, LPA continued a complaint investigation and discovered that staff (S1) has been working at the facility since September 2024 when S1 did not have a criminal record exemption. LPA was informed that this matter was brought to Executive Director's attention at the beginning of S1's employment and S1 did not know it was a concern as S1 continued to be scheduled for shifts. S1 has since been removed from schedule until exemption is granted. Additionally, based on the investigation regarding resident (R1)'s medication error which was previously cited on August 15, 2025, LPA was informed that staff (S2) had informed Executive Director and Health and Wellness Director that R1's medication is running out and did not have an active primary care physician on file to fill the medications. S2 was informed that Executive Director will resolve the issue; however, LPA was informed this matter was not resolved until August 7, 2025, after R1 had missed all routine medications for approximately 30 days. As a result of the information obtained, deficiencies cited. Please see LIC 809-D. Exit interview and a copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 19, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(2) · Plan of correction due date: Aug 26, 2025

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on interviews, Licensee did not comply to the section cited above as Executive Director knowingly failed to comply with criminal record regulations as well as failure to assist resident to ensure medications are given as prescribed, which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Aug 19, 2025

Plan of correction: Licensee is to submit a new LIC 200 to appoint a new Executive Director. POC due August 26, 2025. Additionally, an office meeting will be held to discuss this matter.

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

Licensing Program Analyst (LPA) Cassie Yang arrived on August 19, 2025, to follow up on substantiated allegations resulting from a complaint investigation. Licensing staff met with Facility Representative, Liz Cruz, to discuss the Department’s findings. On December 23, 2024, the Department concluded a complaint investigation substantiating the following allegations: Due to facility staff's lack of care and supervision, resident sustained serious bodily injury, and facility staff's lack of care and supervision resulted in resident's death. The Licensee was cited for California Code of Regulations (CCR) Title 22, § 87468.2(a)(4) Personal Rights of Residents in All Facilities. At the time of the complaint investigation on December 23, 2024, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis of the following incident and has determined that a civil penalty is warranted for a violation that the Department determines resulted in the death of a resident. This is evidenced by facility staff’s inadequate supervision of residents in care, resulting in a fatal altercation between residents. Please continue on LIC 809-C. LIC 809-C Today, August 19, 2025, the Department will be issuing a civil penalty in the amount of $15,000 per Health and Safety Code §1569.49(e), for a violation that the Department determines to have resulted in the death of a resident. However, since an immediate civil penalty of $500 was previously issued on December 23, 2024, the amount of the civil penalty issued today will be $14,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. A signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Aug 19, 2025

Allegation investigated: Staff's neglect resulted to resident dehydration.

On August 15, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to deliver the findings for the allegation cited above. LPA met with Regional Vice President of Operation and Interim Executive Director and explained the purpose of the visit. Throughout the course of the complaint investigation, the Department conducted interviews and reviewed documents relevant to the allegation: Staff's neglect resulted to resident hospitalization. Please continue on LIC 9099-C (1) for the results of the investigation. Substantiated LIC 9099 C On May 30, 2025, at approximately 5:53 PM, emergency medical services was contacted when staff (S1) found resident (R1) outside on the ground in the courtyard of the facility, R1 was then transported to Mercy Hospital of Folsom Emergency Room for evaluation. According to hospital paperwork, it revealed R1 was admitted with temperature of 39.1* C (converting to 102.4* F) and "hot to the touch". R1 was discharged at approximately 9:25 PM on May 30, 2025 with reasons for visit to be "heat exposure" due to "the patient had a heat exposure incident related to his care home losing track of him during a fire drill" and discharge diagnosis of heat exposure, dementia, dehydration, and acute kidney injury. Statements gathered on June 4, 2025, it revealed a fire drill was conducted at approximately 3:00 PM on May 30, 2025, where all emergency exits where released opened. It was revealed that part of the fire drill protocol is for caregivers to conduct a head count on their assigned residents to ensure all residents are accounted for at the end. Additionally, caregivers are to conduct hourly observations on the residents. Interview conducted with staff (S2) revealed that as a caregiver, S2 is responsible for conducting a head count of the residents, checking to see if the residents are wet and need to be changed, giving the residents showers, participating in activities, transporting the residents to their meals, and getting the residents up for the day or getting them ready to go to bed. Interview indicated a resident head count after the fire drill was not conducted. S2 admitted to losing track of R1 and did not realized R1 was missing until close to dinner time. Staff (S3) then located R1 outside after 5:00 PM. Based on information obtained, the Department finds the allegation to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty in the amount of $500.00 assessed for R1 sustaining injury and/or illness due to staff's neglect. As a result of the resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess an additional civil penalty if warranted. Deficiencies cited on the attached LIC 9099-D. An exit interview was conducted, a copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 59-AS-20250604120039

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.319(d) · Plan of correction due date: Aug 16, 2025

§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by: Based on interview conducted, Licensee did not comply as R1 managed to escape out of the facility to the locked courtyard, unnoticed for hours by staff, which resulted to an injury, which poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: In-service training was conducted on June 10, 2025. Licensee is to update fire drill procedure to ensure staff complete head counts after fire drill completion. POC is due August 16, 2025.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident report the Department received. LPA met with Regional Vice President of Operation and Interim Executive Director and explained the purpose of the visit. On August 7, 2025, the Department received an incident report regarding a medication error for R1. The incident report revealed that on August 7, 2025, it was discovered by Regional Director of Health and Wellness that R1 has missed all his medications for more than 30 days since R1 does not have an active primary care physician to prescribe refills. LPA and Regional Director of Health and Wellness discussed over the phone that the medication error was brought to the community's attention but it was not addressed until Regional Director of Health and Wellness was informed. Regional Director of Health and Wellness informed LPA that it has since been resolved, R1 now has a primary care physician who has since prescribed refills for medications. As a result of today's visit, deficiencies cited. Please see LIC 809-D. Exit interview conducted and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Aug 15, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 16, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on file review, Licensee did not comply as incident report revealed R1 did not receive medications for more than 30 days which poses an immediate health and safety in care.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: Licensee will conduct an in-service training for all medication technicians on properly notifying administrative team. Training is due by September 15, 2025. Licensee is to provide a training date to LPA by August 16, 2025.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a case management visit regarding multiple incident reports that was submitted to the Department earlier this month. LPA met with Regional Vice President of Operation and Interim Executive Director and explained the purpose of the visit. On the incident report submitted on August 1, 2025, it revealed the incident regarding R1 being aggressive towards other residents in care occurred on July 19, 2025. On the incident report submitted on August 1, 2025, it revealed the incident regarding R2 being transported for evaluation occurred on July 23, 2025. On the incident report submitted on August 7, 2025, it revealed the incident regarding R3 trying to get in R4's bed occurred on June 26, 2025. On the incident report submitted on August 10, 2025, it revealed the incident regarding R5 touching R6's food which R6 then hit R5 in the face, triggering R7 to push R6 down on the floor occurred on June 10, 2025. On the incident report submitted on August 11, 2025, it revealed the incident regarding R8 becoming weak and unable to respond occurred on June 30, 2025. LPA observed an additional 12 other reports submitted to the Department that was reported outside of reporting requirement. Deficiencies cited. Please see LIC 809-D. Exit interview conducted. A copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 15, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 22, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence ...(D) Any incident which threatens the welfare, safety or health of any resident... This requirmenet is not met as evidenced by: Based on file review, Licensee did not comply as LPA received approximately 17 incident reports that exceed the seven days timeframe, which poses a potential risk for residnets in care.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: Licensee is to submit a procedure to ensure how LIC624 incident reports will be submitted to Licensing in a timely manner. POC is due to LPA Yang by August 22, 2025.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a case management annual continuation visit, utilizing the inspection tool. LPA met with Executive Director (ED), Deborah Taylor and explained the purpose of the visit. During today's inspection, LPA and ED conducted a tour of the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: residents bedrooms, bathrooms, dining area, kitchen, activity rooms, medication room and the common areas. LPA observed residents bedrooms to have the required furnishing. LPA observed residents showers to have nonskid strips present. LPA observed facility temperature to be at a comfortable temperature of 74*F. LPA observed access to the kitchen to be locked with pin code entry. Kitchen was observed to be clean and free of pest. LPA observed ample supply of perishable and nonperishable foods available for residents in care. LPA observed exits to be free of obstructions. LPA observed activities available in the common areas for resident social interactions. LPA observed medication room to be occupied with medication technicians, assisting residents in care. In areas toured, LPA observed facility to be clean and in good repair. No immediate health, safety and/or personal rights violations was observed. File review was conducted for five resident records and five personnel records. LPA observed the required documents signed and completed on file. At this time, LPA is requesting a copy of facility liability insurance to be emailed to LPA by Friday, August 8, 2025. CARE tool was completed and no deficiencies was cited. Exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 30, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the care tool. LPA met with Executive Director and explained the purpose of the visit. Prior to entering facility, LPA wore a N-95 mask due to reports of COVID-19 outbreak. Today's inspection, LPA and Executive Director discussed the six active cases at the facility. LPA will return at a later day to complete walk-through inspection. Additionally, LPA and Executive Director discussed staffing and COVID-19 protocols. Exit interview and a copy was provided.the state’s words, verbatim · CDSS document, Jun 30, 2025

Type of visit: Office

On May 29, 2025, a Non-Compliance Conference was held at the Sacramento North Regional Office located at 9835 Goethe Road Suite 100, Sacramento CA 95827. Present were in the office meeting were: Licensing representatives - Regional Manager, Alycia Rayner, Licensing Program Manager, Maribeth Senty, and Licensing Program Analyst, Cassie Yang. Facility Representatives - Senior Vice President of Operations, Phil Altman, Regional Vice President of Operations, Lyndee Whaley, Executive Director, Deborah Taylor, Health and Wellness Director , Shayla Hill, and Legal Counsel, Payam Saljoughian. A non-compliance plan was developed with the licensee on today's date as it relates to previous compliance history. The licensee was in agreement with the drafted non-compliance plan. Due to the improvement of the compliance and new procedure implementation at the facility, no citations are issued as a result of today's meeting. Exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 29, 2025

Allegation investigated: Staff left resident unattended for an extended period of time resulting in hospitalization Staff are not meeting residents needs

On May 2, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the findings of the allegations cited above. LPA met with Executive Director and explained the purpose of the visit. During the course of this investigation, LPA conducted intensive file reviews and interviews regarding the allegations of the complaint. The result of the investigation is to follow on LIC 9099-C. Unfounded LIC 9099-C Allegation: Staff left resident unattended for an extended period of time resulting in hospitalization. File review of R1's medication order on March 13, 2024, it revealed R1 has a previous medical history of hypertension and CKD (chronic kidney disease) stage G3b/A1. Incident report submitted for R1 revealed R1 was sent to the hospital for evaluation due to discoloration around mouth and high temperature. File review of R1's hospital discharge document, it revealed R1 was treated fro acute kidney injury. Document stated the cause of injury may be due to "heart and blood vessel disease". Based on information gathered from R1's physician report it revealed R1 has a primary diagnosis of dementia and secondary diagnosis of atrial fibrillation. Interview conducted with Health and Wellness Director revealed residents in care are checked during rounds every two hours. Health and Wellness Director denied any observation of sunburns on R1. Therefore, allegation is unfounded. Allegation: Staff are not meeting residents needs The Department conducted extensive file reviews for the following allegation. File review of R2's care plan conducted on February 22, 2024 revealed R2 is a "one to two" person assist with transfer. File review of R2's care plan conducted on June 13, 2024 revealed R2's level of care has changed which R2 is now a two person assist with mechanical lift. Interview with Health and Wellness Director revealed hospice agency has trained fcaility staff how to use mechanical lift. For new staff, Health and Wellness Director then train staff through demonstration. File review of staff training revealed training was completed by Health and Wellness Director and Suncrest Hospice regarding Safe Transfer with Hoyer Lift, with approximately 17 staff present in attendance. Therefore, allegation is unfounded. Based on information obtained, the following allegations of: Staff left resident unattended for an extended period of time resulting in hospitalization, and Staff are not meeting residents needs, are UNFOUNDED. Unfounded meaning that the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 2, 2025 · control 59-AS-20240506103132

Allegation investigated: Staff do not respond to resident calls for assistance Staff do not meet resident toileting needs Staff did not seek medical attention for resident in a timely manner Staff are not properly training to meet resident needs

Licensing Program Analyst (LPA) Cassie Yang arrived to the facility to deliver the findings of the allegations cited above. LPA met with Executive Director and explained the purpose of the visit. During the course of this investigation, LPA has conducted extensive interviews and file review for the allegations Staff do not respond to resident calls for assistance, Staff do not meet resident toileting needs, Staff did not seek medical attention for resident in a timely manner, and Staff are not properly training to meet resident needs. Please continue on LIC 9099-C (1) for the result of the investigation. Unfounded LIC 9099-C (1) Allegation: Staff do not respond to resident calls for assistance. The Department conducted interviews and file review regarding the allegation. Based on interview conducted with R1 on March 22, 2024, it revealed R1 likes the staff at the facility. R1 stated staff are helpful and responds to calls as needed. R1 stated R1 has a slight cognitive impairment but is sharp for the most part. Interview conducted with Executive Director on April 3, 2024 revealed the call system is an alert at the front receptionist desk, which indicates which room is in need for assistance which receptionist then call caregivers to the room. Executive Director stated there is no systematic program that collects data of the alerts trigger by room cord plugs. Executive Director stated all rooms are installed with fall detection camera which will record videos of each fall, and alert the facility via telephone. File review of standard report of March 2024 call response data provided by room camera system revealed there was a total of 14 falls detected, the median time to respond was one minute and 14 seconds with the average time to respond to be one minute and 43 seconds. File review further revealed time to respond less than five minutes was the total of 92.31%. Interview conducted with Executive Director on February 5, 2025 revealed when a call for assistance is activated from a room, it will create a ring which cannot be deactivated until staff go to the resident room to turn it off when they respond. The allegation above is unfounded. Allegation: Staff do not meet resident toileting needs. Based on LPA's observation to seven bedrooms on April 3, 2024 and five bedrooms on June 21, 2024, there was no indication of incontinence mal odor. Interview conducted with R1 on March 22, 2024 revealed R1 does not have any issues with staff not fulfilling resident toileting needs. Interview conducted with R2 revealed R2 is happy and does not have any current issue regarding incontinence care. Interview conducted with Health and Wellcare Director revealed that she does not have any issues with staff not assisting residents with toileting and/or incontinence care. Health and Wellcare Director stated residents in care are changed and/or assisted with toileting needs before bed. Night (NOC) shift are not to disturb residents while they are sleeping to check their depends unless residents wake up in the middle of the night, and notify staff for a change. Health and Wellcare Director stated when morning shift starts it is usually when residents are waking up for the day which will require toileting/incontinence assistance. Residents may have had a bowel movement in their sleep at night but it does not mean residents were neglected. The allegation is unfounded. Please continue on LIC 9099-C (2) LIC 9099-C (2) Allegation: Staff did not seek medical attention for resident in a timely manner. Incident in question indicated that on February 26, 2024 during night shift, staff failed to seek medical attention for R1. Based on file review, it revealed on February 17, 2024 at approximately 9:10 p.m, R1 was vomiting after given PRN medication. Hospital documents revealed R1 was admitted to Mercy Hospital of Folsom for vomiting on February 17, 2024. File review of incident report submitted on February 28, 2024 revealed on February 25, 2024 at approximately 11 a.m, R1 informed staff R1 had an episode of emesis, and was transported to Mercy Hospital of Folsom for evaluation. During time of the faxed incident report, R1 has not been discharged from the hospital to the community. File review of R1's hospital documents confirmed R1 was admitted to the hospital on February 25, 2024. File review of submitted incident report revealed on March 11, 2024, R1 had an episode of emesis and was transported to Mercy Hospital of Folsom for evaluation. Hospital documents confirmed R1 was admitted to the emergency room on March 11, 2024. Therefore, the allegation is unfounded. Allegation: Staff are not properly training to meet resident needs. The Department conducted file review of medication training. File review revealed S1 was hired as an employee in August 2022, then scheduled for training to be a medication technician starting February 21, 2024. S1 completed the mandated training of 8 hours of instruction on February 23, 2024 and completed 16 hours of hands-on shadowing training on February 27, 2024. S2 was hired as an employee in December 2023, and completed the mandated medication administration training of 8 hours of instruction on January 1, 2024 and completed 16 hours of hands-on shadowing training on February 27, 2024. S3 was hired as an employee in December 2023, and completed the mandated medication administration training of 8 hours of instruction in February 2024 and completed 16 hours of hands-on shadowing training on December 31, 2024. Therefore, the allegation is unfounded. Based on information obtained through file review and interviews, the allegations listed above are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 59-AS-20240314145724

Allegation investigated: Staff did not provide showers to residents in care Staff did not ensure residents were kept clean Staff did not provide transportation services to residents in care

On February 5, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to deliver the findings of the allegations cited above. LPA met with Executive Director and explained the purpose of the visit. During the course of the investigation, the Department conducted interviews and file reviews. The result of the allegations are to follow on LIC 9099-C(1). Unfounded LIC 9099-C(1) Allegation: Staff did not provide showers to residents in care Based on file review conducted for the facility shower sign off sheet for March 2024, it revealed residents in care was provided showers. Shower sign off sheet revealed R1 was showered total of nine (9) times on the following days in the month of March 2024: 2nd, 9th, 12th, 16th, 21st, twice on 22nd, 24th, and 27th. Shower sign off sheet revealed R2 was showered eight (8) times on the following days in the month of March 2024: 3rd, 4th, 6th, 10th, 13th, 17th, 21st, and 27th. Interview conducted with Executive Director on February 5, 2025 revealed since change of Executive Director, documentation has changed where facility will document on shower logs if there was any refusal and/or exceptions. Residents in care organized in scheduled showering schedules twice a week. The following allegation is unfounded. Allegation: Staff did not ensure residents were kept clean Based on interview conducted with Co-Reporting Party, it revealed Co-Reporting Party has observed residents in care having a dirty shirt on while eating or food on their faces. Co-Party Reporting stated that staff should utilize a bib for residents who are messy eaters. Interview conducted with Executive Director on April 3, 2024 revealed that there are a few residents in care who has mobility limitations with self-feeding. Executive Director stated facility cannot enforce residents in care to wear bibs. Executive Director stated after meals, staff assist with wiping food off resident’s clothing and may ask the residents if they want to change, but residents still have the rights to decline. Based on LPA's observation on April 3, 2024, facility staff were observed to be assisting residents in care with cleaning after meal. Interview conducted with Executive Director on February 5, 2025 revealed that facility are providing independent eaters with garment covers during meal times. The following allegation is unfounded. Please continue on LIC 9099-C(2). LIC 9099-C (2) Allegation: Staff did not provide transportation services to residents in care. Based on interview conducted with Executive Director on April 3, 2024, it revealed that the facility bus is utilizing for extracurricular activities such as city tours. Executive Director explained that the registration tag on the bus has expired therefore the bus cannot be utilized at this time. Executive Director stated that if residents in care needs transportation to medical and/or dental appointments family members are to pick up the resident from the facility to the appointment. If family members are unable to, facility staff can assist residents to an appointment when notified in advance and at an additional charge. Interview conducted with Executive Director and Health and Wellness Director on February 5, 2024 revealed that the facility bus is currently in the shop, but if residents in care are in need for transportation services, facility will provide third party transportation such as Heart of Gold. If family is unable to escort the residents then facility will schedule additional staff for escorting when notified in advance and with additional charge for the staffing. The allegation is unfounded. Based on information obtained through interviews, file review and observation, the allegations listed above are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Feb 5, 2025 · control 59-AS-20240325153758

Allegation investigated: Staff are mismanaging resident medication.

On February 5, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to deliver the finding of the allegation cited above. LPA met with Executive Director and explained the purpose of the visit. The Department conducted extensive file review. Result of the allegation cited above is listed in LIC 9099-C. Substantiated Allegation: Staff are mismanaging resident medication. Based on file review, it revealed R1 was prescribed Levetiracetam 500 mg tablet to be given one tablet by mouth, twice a day, effective date April 3, 2024. File review of R1's e-MAR, it revealed on April 25, 2024, one Levetiracetam tablet was administered at 9 a.m but not at 5 p.m as facility was "waiting refills". On April 26, 2024 at 9 a.m, it was recorded one Levetiracetam was administered, but then at 5 p.m Levetiracetam was not administered due to "waiting for delivery". Interview conducted with Health and Wellness Director revealed she was not working at the facility during this time in question and cannot explained why one dose was recorded as administered at 9 a.m on April 26, 2024 when it was pending on delivery as stated at 5 p.m. The Department finds the allegations to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Although the allegation was found to be substantiated, deficiency is not cited as LPA has cited facility for similar allegation in complaint control # 59-AS-20240610163326. An exit interview was conducted, a copy of the report and appeal rights provided to Executive Director.the state’s words, verbatim · CDSS document, Feb 5, 2025 · control 59-AS-20240314145724

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

Allegation investigated: Resident not receiving medication.

On February 5, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to deliver the finding of the allegation cited above. LPA met with Executive Director and explained the purpose of the visit. The Department conducted extensive file review. Result of the allegation cited above is listed in LIC 9099-C. Substantiated LIC 9099-C Allegation: Resident not receiving medication. The Department conducted extensive file reviews. Based on R1's e-MAR Order Administration Tracking report type of "Recorded As Given", it revealed that Levetiracetam 500 mg was prescribed to be taken one tablet by mouth, twice daily for seizure management. File review revealed on the date of 2nd, 5th, 6th, 14th, 17th, and 22nd of January 2024, only one Levetiracetam tablet was administered for the day. File review of Order Administration Tracking report type of "Recorded As Drug Not Available" "Recorded As Drug Not Given" and "Recorded As OTHER", LPA did not observe any reasoning documented as to why resident did not receive medication. File review revealed on the date of 9th, 20th, and 29th of February 2024, only one Levetiracetam tablet was administered for the day. File review of Order Administration Tracking report type of "Recorded As Drug Not Available" "Recorded As Drug Not Given" and "Recorded As OTHER", LPA observed only February 9th, 2024 to have a reasoning of " GIVE ON TIME" but no reasoning documented for February 20th and 29th, 2024. File review revealed on the date of 2nd of March 2024, no Levetiracetam tablet was administered for the day. File review of Order Administration Tracking report type of "Recorded As Drug Not Available" "Recorded As Drug Not Given" and "Recorded As OTHER", LPA did not observe any reasoning documented as to why resident did not receive medication. File review revealed on the date of 21st, 25th, and 26th of April 2024, one Levetiracetam tablet was administered for the day. File review of Order Administration Tracking report type of "Recorded As Drug Not Available" "Recorded As Drug Not Given" and "Recorded As OTHER", LPA observed "AWAITING REFILLS" and "waiting delivery" to be documented for April 25th and April 26th but no reasoning documented for April 21st. Due to this information obtained, the Department finds the allegations to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on the attached LIC 9099-D. An exit interview was conducted, a copy of the report and appeal rights provided to Executive Director. LIC 9099-C Allegation: Staff dropped resident during transfer. Based on interview conducted with R1 revealed R1 needed transferring assistance from the commode to a chair when R1 felt weak. R1 stated R1 was then dropped onto the floor. R1 stated it was a male staff assisting R1 with transfer. File review of R1's LIC 602 Physician Report revealed R1 has dementia. Interview conducted with S1 revealed that S1 was working on call in the night shift and assisted R1 with S2. R1 reported R1 felt weak so S1 and S2 provided R1 with a "guided fall" onto the floor to rest until R1 had the strength to stand. File review of the guided fall internal report revealed that R1 sustained a minor skin tear which first aid was administered. The following allegation is unsubstantiated as R1 is unable to recall the story in multiple settings. Allegation: Staff falsified resident records. File review of the guided fall internal report revealed S1 and S2 assisted in R1's transfer. Interview conducted with S1 revealed R1 is a two person assist with transfer. The night of the incident S1 was assisting R1 with S2. Interview conducted with R1 revealed R1 does not recall who assisted R1 but does recalled S1 to be in the room. Interview conducted with S2 revealed that S2 does not recalled being in the room with S1 to transfer R1. File review revealed no unusual incident report was submitted to Licensing as the incident was a "guided fall" and R1 did not need medical services. The following allegation is unsubstantiated. Based on information obtained, the following allegations are unsubstantiated meaning that although the allegations 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 are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was provided to Executive Director..the state’s words, verbatim · CDSS document, Feb 5, 2025 · control 59-AS-20240610163326

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 28, 2025

87465 Incidental Medical and Dental Care (a) ... The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on file review, Licensee did not comply to the section cited above as R1 was not administered medications as prescribed, which posed a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Feb 5, 2025

Plan of correction: Licensee is to submit a plan on how facility will ensure residentsin care are receiving their medications as prescribed. This plan is to be submitted to LPA Yang by February 28, 2025..

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management visit. LPA met with Executive Director and explained the purpose of the visit. Today's visit, LPA is requesting a copy of S1 and S2's 2023 and 2024 Training documents. Please provide to LPA the following documents by end of day via email. No deficiencies cited. Exit interview.the state’s words, verbatim · CDSS document, Jan 13, 2025

Allegation investigated: Due to facility staff's lack of care and supervision, resident sustained serious bodily injury Facility staff's lack of care and supervision resulted in resident's death

**This report has been amended** On January 13, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the findings of the allegations cited above. LPA met with Executive Director and explained the purpose of the visit. Throughout the course of the complaint investigation, the Department conducted interviews and reviewed documents relevant to the allegations: due to facility staff's lack of supervision, resident sustained serious bodily injury and facility staff's lack of care and supervision resulted in resident's death. Please continue on LIC 9099-C (1) for the results of the investigation. Substantiated LIC 9099-C (1) Note: There has been a change of Executive Director and Health and Wellness Director since the incident. On January 12, 2024, at approximately 5:35 PM resident (R1) was sent to the emergency room and was discharged back to the community the following day on January 13, 2024, at approximately 5:30 AM. On January 13, 2024, at approximately 12:55 PM, staff observed R1 vomiting and complaint of neck and shoulder pain. Staff sent R1 back to the hospital. Documents indicated that R1 died at the hospital three days later on January 16, 2024. Corners report documented R1’s cause of death to be “probable sepsis” and “acute spinal fracture of T3 and T4 with epidural hemorrhage and acute osteomyelitis with spinal epidural abscess”. According to statements and interviews conducted, On January 12, 2024, R2 had walked up to the nurse's station and became combative with staff. Staff observed R2 grabbing R1 by the wheelchair and pushing R1 towards the nurse’s station. Staff observed R2 slammed R1 into the nurse’s station door. R2 then pushed R1 down the hallway in their wheelchair. R2 went around the corner with R1 at which time staff heard R1 screaming. Staff came around the corner and observed R1 on the floor. Interviews with staff provided multiple accounts of the incident however, staff present did not attempt to redirect R2 from R1. The Department conducted interviews with staff which regarding the protocol to take when two residents are having an altercation. Staff indicated they are to redirect and distract residents with something they like. Staff stated when two residents are having an altercation, staff are to intervene and separate the two residents as the safety of residents is a priority. Based on the information staff provided regarding the altercation between R2 and R1, staff did not follow facility protocols and failed to ensure R1’s wellbeing and safety. Staff indicated R2 had a history of being aggressive physically and verbally. Documents reviewed revealed on October 23, 2023, at approximately 3:30 PM, R2 told another resident in care (R3) to get out of R2's room and pushed R3 down onto the hallway floor. Please continue LIC 9099-C (2) LIC 9099-C (2) Staff indicated they had expressed concerns to Health and Wellness Director that R2’s medication may need to be adjusted to help with agitation. File review of R2's physician report revealed R2 has dementia, primary diagnosis of Alzheimer's disease, and with no secondary diagnosis listed. In section Mental Condition, the physician’s report was marked yes for confused/disoriented, inappropriate behavior, and aggressive behavior. Review of R2's Care Plan Detail signed on January 3, 2024, revealed R2's psychosocial needs stated occasional behavior issues, can become aggressive when R2 wants to leave. Staff are to redirect or let the director know they need assistance. Interview conducted with Health and Wellness Director revealed when two residents are having an altercation, staff are to intervene and redirect. Staff are to try to get the agitated resident to go on a walk by verbal redirecting cues. Interview revealed that an internal investigation was conducted on January 15, 2024, which revealed staff did not follow facility protocols and did not intervene as trained to do so. Based on interviews conducted and records reviewed, staff failed to follow facility protocols when there is an altercation between residents. Staff’s failure to ensure R1’s safe and wellbeing resulted in R1 sustaining severe injuries from R2’s actions resulting in R1’s death. Due to this information obtained, the Department finds the allegations to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty in the amount of $500.00 assessed for R1 sustaining a serious bodily injury while in care at this facility. As a result of the resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess an additional civil penalty if warranted. Deficiencies cited on the attached LIC 9099-D. An exit interview was conducted, a copy of the report and appeal rights provided to Executive Director.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 59-AS-20240116142714

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

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on file review and interviews, Licensee did not comply with the section cited above as staff failed to follow protocol during the incident with R2, which poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: -Licensee is to conduct an audit to identitfy residents with combative behaviors and agitation. POC due within 24 hours on December 24, 2024. - Licensee is provide implementation in care plans for resident’s with aggressive behaviors and state how to ensure staff are aware of the care plans. -Licensee is to provide a training on intervention methods/skills for all staff (regardless of job duty and title) . Licensee is to provide LPA a copy of the training plan. Following information above due January 23, 2025.

Allegation investigated: Facility staff served expired food to residents

On 9/26/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to open and deliver the finding of the allegation cited above. LPA met with Executive Director and explained the purpose of the visit. During the course of today's investigation, LPA conducted an inspection of the facility walk-in refrigerator and the facility dry pantry storage. Additionally LPA conducted an interview with Executive Director. The result of the investigation for the allegation is as follow on LIC 9099-C. Substantiated LIC 9099-C Allegation: Facility staff served expired food to residents The Department conducted a kitchen inspection, file review and interviews regarding the following allegation. Interview conducted with Executive Director revealed that a photo was circulating around the facility of an expired salad dressing. Executive Director stated the bottle itself did not have an expiration date, only a manufactured date but there may have been some discoloration on the dressing container. File review of the incident report received by the Department on 9/20/2024 revealed "upon inspection of the kitchen we did find the expired salad dressing and properly disposed". Kitchen inspection conducted on 9/26/2024 revealed that in the facility dry pantry storage, Hollandaise Sauce Mix was observed on the shelf with best by date of "JAN2724" indicating January 27, 2024. Inspection further revealed a jar of peanut butter to be on the shelf with best if used by date of "SEP0424" indicating September 4, 2024. Based on observing the following food items, the allegation is substaniated. Based on the information obtained for the allegation, facility staff served expired food to residents, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D. Exit interview conducted and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 59-AS-20240917095150

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Oct 4, 2024

87555 General Food Service Requirements (a) The total daily diet shall be of the quality...necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Based on kitchen inspection, Licensee did not comply with the section cited above as LPA observed two items in the pantry that was expired, which poses a potential health, safety, and personal rights violation to the residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Licensee is to submit a plan how to ensure residents in care are not given expired food. POC due to LPA Yang by due date of 10/04/2024.

Type of visit: Office

On 8/13/2024 at 8:30AM, an informal conference was conducted virtual via Microsoft Teams Meeting. The purpose of this informal conference meeting is to discuss the pending open investigations. Present in the meeting is, Licensing Program Manager (LPM) Anthony Perez, Licensing Program Analyst (LPA) Cassie Yang, and Licensee representatives: - Deborah Taylor, Executive Director for Cogir of Folsom - Lyndee Whaley, Regional VP of Operations for Cogir Senior Living - Phil Altman, Senior VP of Operations for Cogir Senior Living - Kim Eldridge, Regional Director of Health & Wellness for Cogir Senior Living - Holly McMurray, Senior VP of Care & Compliance for Cogir Senior Living The informal conference process was explained during this meeting. Topic discussed: - Staffing concerns At this time, the Department agreed to monitor facility. Additionally, Facility will provide the Department proof of staff training on personal rights of residents. No deficiencies cited. Exit interview conducted. Informal meeting concluded and a copy of report will be emailed. Facility Representative Signature is expected to be signed and returned to LPA by close of business, 8/13/2024.the state’s words, verbatim · CDSS document, Aug 13, 2024

Allegation investigated: Licensee denied resident's hospice worker entry to the facility

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the finding of the allegtaion cited above. LPA met with Executive Director, Deborah Taylor, and explained the purpose of the visit. During the course of the investigation, LPA conducted extensive interviews. Please continue LIC9099-C for the result of the investigation. Unfounded Allegation: Licensee denied resident's hospice worker entry to the facility The Department conducted extensive interviews. Based on the interview conducted with hospice agency supervisor, it revealed that facility had informed supervisor of potential conflict of interest and asked if hospice nurse will no longer provide services at the facility. Interview revealed that hospice nurse was not denied at the facility to enter. Based on interview conducted with hospice nurse revealed hospice nurse was informed by their supervisor that facility had requested hospice nurse to not return to the facility and hospice agency agreed to comply. Hospice nurse stated they were not denied at the door, the request was asked after a visit. Interview conducted with Executive Director and Health and Wellness Director revealed that the request was made after observations during a visitation and no denial of entry was made. Based on information above, the department concluded that the allegation is unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies cited. Exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 8, 2024 · control 59-AS-20240513150556

Type of visit: Case Management - Incident

On 7/25/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding the LIC 624 Unusual Incident/Injury Report the Department received. LPA met with new Executive Director, Deborah Taylor, and explained the purpose of the visit. The incident occurred on 7/17/2024 when R1 reported to staff that S1 had threatened R1 to stop utilizing the call light or else S1 will rip the call lights out of the wall. R1 disclosed R1 is afraid to utilize call light after this incident. Facility conducted an investigation and S2 confirmed the incident had taken place as S2 was a witness of the encounter when S1 stated that if R1 does not stop pulling the call lights, S1 will move R1's bed. Facility has since placed S1 on suspension, and S1 is no longer working at the facility. Facility notified Community Care Licensing, Long Term Care Ombudsman and responsible party of this incident. LPA and Regional Director discussed that S1's last shift was the date of the incident. As a result of the incident of S1 violating CCR Title 22, Section 87468.1 Personal Rights of Residents in All Facilities, please see LIC 809-D. Exit interview conducted an a copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jul 26, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse... This requirement is not met as evidenced by: Based on interview, Licensee did not comply with the section cited above as S2 confirmed that S1 had informed R1 to stop pulling the call light, resulting to R1 being afraid to use call light, which poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: -S1 had been removed from scheduling/ termination. -Licensee will submit a compliance statement of the cited section by Friday July 26, 2024.

Type of visit: Case Management - Incident

On 7/25/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding the LIC 624 Unusual Incident/Injury Report the Department received. LPA met with new Executive Director, Deborah Taylor, and Regional Director, Davina Barker, and explained the purpose of the visit. The incident occurred when R1 was eating lunch in the common dining room when S1 observed R1 to be choking. S2 then helped dislodged meat out of R1's throat. R1 was sent out for evaluation. Incident report stated primary care physician was notified. R1 returned to the facility with no changes. LPA and Regional Director discussed and confirmed that R1's responsible party was notified via "voice to voice". It was further discussed that R1 was not on special diet but after the incident, R1 is now on a new order of mechanical soft diet. Facility reported no staffing issues and/or additional concerns. As a result of today's visit, no deficiencies cited. Exit interview conducted an a copy of the report provided.the state’s words, verbatim · CDSS document, Jul 25, 2024

Allegation investigated: Facility did not notify responsible person of an increase in monthly rent rates.

On 06/21/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the findings for the allegation cited above. LPA met with Executive Director, Davina Barker, and explained the purpose of the visit. Duirng the course of the investigtaion, LPA conducted file review and interviews. Result is as follow, please see LIC 9099-C. Unfounded Allegation: Facility did not notify responsible person of an increase in monthly rent rates. The Department conducted an extensive file review regarding the allegation above. Based on file review conducted, a letter of Annual Care Level Rate Adjustment Notice was provided to responsible party on October 31, 2023 with effective date of January 1, 2024. File review revealed that care service for Level 1 is $2550, with additional care level at $600. File review additionally revealed a reassessment service plan was conducted on 01/03/2024 by Health and Wellcare Director Nurse where R1's level of care changed from Memory Care 02 to Memory Care 06. Document revealed that responsible party signed the updated service plan on 01/18/2024. File review revealed on 03/08/2024, a letter was addressed to responsible party to inform of annual base rent increase from $4875 to $5216, effective date of 06/01/2024. File review further revealed in Levels of Care Price list, Memory Care Level 2 ranged from 426 to 525. Memory Care Level 6 ranged from 826 to 925. File reviewed revealed in the initial assessment conducted on 06/23/2023, grand total of R1's care was 590. In most updated assessment conducted 01/03/2024, grand total of R1's care was 940. Based on information above, the department concluded that the allegation is unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies cited. Exit interview was conducted.the state’s words, verbatim · CDSS document, Jun 21, 2024 · control 59-AS-20240402165409

Type of visit: Required - 1 Year

On 6/21/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the full care tool. LPA met with Executive Director, Davina Barker, and explained the purpose of the visit. Today's census is 22 residents with eight (8) residents on hospice services. Facility is licensed for 66 residents, hospice waiver of 16. Executive Director reported no staffing concerns. LPA was informed there are three care staff and one med tech for AM and PM shift and with two care staff for NOC shift. LPA and Executive Director conducted a tour the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: five residents bedroom, Tahoe Room, main dining, kitchen, laundry room, activity room and the common areas. LPA observed facility to have 2+ days of perishable and 7+ days of non-perishable foods. LPA observed the facility to be at a comfortable 72* degree. LPA observed facility to have ample supply of linens. LPA observed residents in care to be in the activity room, listening to music with care staff. During today's visit, LPA observed facility to be clean, sanitary and in good repair. File review was conducted for 5 residents and 5 personnel files. LPA observed files to be completed. Inspection tool completed and found facility to be in substantial compliance. No deficiencies cited. LPA observed facility liability insurance to be current and active. Exit interview conducted and a copy of report was provided.the state’s words, verbatim · CDSS document, Jun 21, 2024

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Post Licensing

On 6/21/2024, Licensing Program Analyst (LPA) Cassie Yang arrived to the facility unannounced to conduct a required annual inspection. LPA met with Executive Director and explained the purpose of the visit. Today's visit, LPA is conducting an annual inspection today but this report is being generated to clear the Post-Licensing inspection in the system. There are no citations issued on this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 21, 2024

Type of visit: Case Management - Incident

On 06/12/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident report the Department received on 6/11/2024. LPA met with Interim Executive Director and Health Wellcare Director Nurse and explained the purpose of the visit. According to the incident report received, it stated local law enforcement arrived to the facility on 6/10/2024 to conduct a welfare check on R1 due to a recent fall R1 sustained. LPA, Executive Director and Health Wellcare Director Nurse discussed the following incident. LPA was informed by Health Wellcare Director Nurse that on 6/3/2024 R1 had a "guided fall" at approximately 2:40 AM. Health Wellcare Director Nurse informed LPA that in the middle of a transfer between Health Wellcare Director Nurse, S1 and R1, R1's legs became weak and needed to be placed on the floor temporarily to rest before Health Wellcare Director Nurse and S1 assisted R1 back to the commode. After R1 was placed back on the recliner, Health Wellcare Director Nurse provided first aid to R1 as R1's elbow was observed to have a skin tear. When asked for the incident report of the incident, Health Wellcare Director Nurse informed LPA LIC624 was not created and submitted as R1 did not have a fall, it was a guided fall, and no injury was sustained, R1 was not sent to the hospital. LPA was provided a copy of internal incident report. This incident is currently under review, No deficiencies cited today. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 12, 2024