Cogir of San Rafael

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

At approximately 12:45PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Legal/Non-Compliance visit and met with Executive Director, Kimberly Humphrey. The purpose of today's visit was to conduct the facility's quarterly Non-Compliance inspection. LPA reviewed files for staff members hired from May 2026 - July 2026 related to the below concerns: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives LPA observed that identified staff members hired within this time frame had appropriate training documented or their training was scheduled to be completed. LPA requested for copies of scheduled training to be submitted to the Department once complete. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 27, 2026

Type of visit: Case Management - Other

At approximately 8:55AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other visit and met with Executive Director, Kimberly Humphrey. The purpose of today's visit was to conduct the facility's quarterly Non-Compliance inspection and to follow up on self reported incident reports that were submitted to the Santa Rosa Regional Office (SRRO). LPA reviewed files for staff members hired from February 2026 to April 2026 related to the below concerns: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives LPA observed that identified staff members hired within this time frame had appropriate training documented or their training was scheduled to be completed. LPA requested for copies of scheduled training to be submitted to the Department once complete. Community Care Licensing (CCL) received the following incident reports: Incident Report 1 was submitted to CCL on 02/04/2026. Report states that on 01/31/2026, Resident 1 (R1) was observed sitting in a car in the facility's parking lot. The car belonged to another resident's family member. R1 was redirected back to the facility. Facility made all appropriate notifications per regulation. Review of R1's care plan dated 12/31/2025 stated that R1 did not have a history of elopement. Per Executive Director, this Continued on LIC809C Continued from LIC809 incident prompted facility to have R1 reassessed for this change of behavior. Review of R1's updated Physician Report dated 02/16/2026 and updated Care Plan dated 02/12/2026 showed they are unable to leave unassisted. Incident Report 2 was submitted to CCL on 03/26/2026. Report states that on 03/25/2026, R1 was observed pulling the hair of Resident 2 (R2). Facility staff intervened, separated the residents, and assessed for injury. Facility made all appropriate notifications per regulation. Incident Report 3 was submitted to CCL on 03/26/2026. Report states that on 03/25/2026, R1 was observed to hit Resident 3 (R3) twice on the cheek with a closed hand. Facility staff intervened, separated the residents and assessed for injury. Facility staff provided first aid. Facility made all appropriate notifications per regulation. Incident Report 4 was submitted to CCL on 04/02/2026. Report states that on 04/02/2026, R4 fell and hit their head on the floor in their room. Per report, the incident occurred due to Staff Member 1 (S1) not ensuring that R4 was sitting properly in their wheelchair before being transferred, causing R4 to fall forward onto the floor. Paramedics were contacted to further evaluate R4 and responsible party refused transport to the Emergency Room. R4 was placed on 72 hour observation. Facility made all appropriate notifications per regulation. Incident Report 5 was submitted to CCL on 04/20/2026. Report states that on 04/15/2026, Resident 5 (R5) was observed to grab Resident 6 (R6) by the back of their head and hit the top of their head with an open palm. Facility staff intervened, separated the residents, and assessed for injury. Facility made all appropriate notifications per regulation. LPA obtained copies of documents related to the incidents. Elopement training was conducted on 02/04/2026 and 02/18/2026. Deficiency cited under Regulation 87705(e)(7) is being cleared today during visit. Plan of Corrections Letter provided. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, Plan of Corrections, Appeal Rights, Plan of Corrections Letter, and LIC811 (Confidential Names) discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 23, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(e)(7) · Plan of correction due date: May 4, 2026

87705 Care of Persons with Dementia (e) Licensees that use delayed egress devices...shall meet...requirements: (7) Delayed egress devices shall not substitute for trained staff...including staff needed to escort residents who need supervision to leave the facility. Requirement was not met as evidenced by: based on record review, Licensee did not comply with the section cited above. Resident 1 (R1) eloped from facility and was found in a car in the parking lot. R1's assessment stated they can't leave unassisted. This poses an potential health/safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Licensee provided proof of elopement training dated 02/04/2026 and 02/18/2026. Deficiency cleared during visit.

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

At approximately 1:10PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Legal/Non-compliance visit and met with Business Office Manager, Ditter Vazquez, Health and Wellness Director, Ashley Perrone, and Regional Director of Operations, Caiya Peevy. The purpose of today's visit was to conduct the facility's quarterly Non-Compliance inspection. LPA reviewed files for staff members hired from November 2025 and January 2026 related to the below concerns: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives LPA observed that identified staff members hired within this time frame had appropriate training documented or their training was scheduled to be completed. LPA requested for copies of scheduled training to be submitted to the Department once completed. Exit interview conducted. Copy of report discussed and provided to Business Office Director and Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 30, 2026

Allegation investigated: Staff do not respond to resident's call for assistance

At approximately 8:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a complaint investigation regarding the above allegation and met with Maintenance Director, Guy Webber. Business Office Director, Ditter Vazquez, arrived during visit at approximately 9:40AM and Executive Director, Kimberly Humphrey, arrived during visit at approximately 11:20AM. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The Department investigated the following allegation, “Staff do not respond to resident's call for assistance.” Complaint alleged that that on 08/24/2025, Resident 1's (R1) emergency cord was pulled but was not responded to. Complaint alleged that facility staff didn’t respond to R1's emergency cord because they weren't wearing their pagers to receive notifications. Additional information provided also alleged that R1's emergency pull cord was pulled and not responded to on 09/24/2025. Continued on LIC9099C Substantiated Continued from LIC9099A Review of facility schedule for 08/23/2025 showed that there were 8 direct care staff on-site during the evening shift. Review of staff records indicated that 8 of 8 facility staff members had first aid training certificates on file. This allegation is Unsubstantiated. The Department investigated the following allegation, “staff do not ensure that facility is in good repair.” Complaint alleged that facility’s camera system was not working. Complaint alleged that facility staff were aware that the system was down on the morning of 08/23/2025 but did not communicate it to residents or their responsible parties. Facility partners with a third-party vendor, Safely You, that has cameras throughout the building to notify the facility staff of a potential fall. Interview conducted with Executive Director stated that Safely You Technicians were on-site for 3 to 4 days to resolve the camera issue. Facility documents also indicated that on 08/29/2025, the Safely You cameras were online and active. The camera system is maintained and managed by Safely You. Therefore, it is the third-party vendor’s responsibility to ensure that their system is functioning appropriately and not the facility’s. This allegation is Unsubstantiated. A finding that a complaint allegation is Unsubstantiated means 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. Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents. Continued from LIC9099 Review of R1’s call pendant records for August 2025 indicated that on 08/24/2025, R1’s pendant was pulled at 8:11AM and was not received or responded to as of 8:56AM. Review of R1’s call pendant records for September 2025 indicated that on 09/24/2025, R1’s pendant was pulled at 9:45AM and was not received or responded to as of 10:30AM. Additional review of R1's pendant call records also showed that on 09/25/2025, R1’s pendant was pulled at 6:06PM and was not received or responded to as of 6:51PM. Per interview with Health and Wellness Director, it was identified that some facility staff were not wearing or using their pagers as required. Health and Wellness Director also stated that they identified that the facility also had a low supply of employee pagers. Review of facility documents showed that an Standard Operating Procedure (SOP) document titled, "Use of Pagers for Responding to Pull Cord Alerts," was signed by facility staff on 08/30/2025. Based on record review, interviews, and observations made, this allegation is Substantiated. A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 21-AS-20250825160019

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 29, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities:(a) In addition to...Section 87468.1... residents...shall have...following personal rights: (4) To care, supervision, and services that meet their...needs and are delivered by staff that are sufficient in numbers, qualifications & competency...Requirement was not met as evidenced by: based on record review & interviews, Licensee did not comply with section cited above & did not ensure that R1's pendant call was responded to timely. This poses a potential health/safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Licensee to submit self-certification that training will be conducted for all care staff reviewing equipment expectations by POC due date of 12/29/2025. In-service training to include: Trainer, Date of Training, Topic, Job Title, Staff Names and Signatures. In-service training to be submitted to CCL by POC due date of 01/09/2025.

Type of visit: Required - 1 Year

At approximately 8:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year Visit and met with Business Office Director, Ditter Vazquez and Resident Care Coordinator, Mariana Ramirez. Executive Director, Kimberly Humphrey, arrived during visit at approximately 9:50AM. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 70 non-ambulatory residents, of which 20 residents can be bedridden. Facility has an approved hospice waiver for 16 individuals. Facility is currently on a Non-Compliance Plan. Upon arrival, LPA was informed that there were 55 residents in care and 20 staff members on-site. At approximately 9:25AM, LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Executive Director and observed the following: Facility is a 2 story building. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Facility fire extinguishers were last inspected March 2025. During walk-through, LPA observed the following deficiencies: 4 of 8 resident sinks were found to be out of compliance with Title 22 regulations of 105 to 120 degrees Fahrenheit, measuring at 120.7F, 120.2F, 121.4F, and 122.1F (deficiency cited, regulation 87303(e)(2)), 5 instances of unlabelled and undated foods were observed (deficiency cited, regulation 87555(a)), and facility did not have adequate emergency water supply in the event facility had to shelter in place for at least 72 hours (deficiency cited, Health and Safety Code, 1569.695(a)(2)). Continued on LIC809C Continued from LIC809 LPA reviewed a sample size of 4 staff files. Files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and/or CPR certification and required annual training. Administrator Certificate for Kimberly Humphrey (7009689740) was current with an expiration date of 09/01/2026. LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Dec 4, 2025

Type of visit: Case Management - Other

At approximately 11:55AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other visit and met with Executive Director, Kimberly Humphrey. The purpose of today's visit was to conduct the facility's quarterly Non-Compliance inspection and to follow up on an incident report that was self submitted to Community Care Licensing (CCL). LPA reviewed files for staff members hired between July 2025-October 2025 related to the below concerns: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives LPA observed that identified staff members hired within this time frame had appropriate training documented. LPA followed up on an incident report that was submitted to CCL on 10/01/2025. Report states that on 09/25/2025, Resident 1's (R1's) medication was administered to Resident 2 (R2). Per report, both residents have the same medication with the same dosage. Residents were placed on 72 hour monitoring to observe for any adverse effects (deficiency cited, LIC809D, regulation 87465(a)(4)). Facility provided proof of training conducted on 09/25/2025 on "The Six Rights" related to the incident report. Deficiency cleared during visit and Corrections Letter provided. Continued on LIC809C Continued from LIC809 **An immediate civil penalty assessment in the total amount of $250.00 has been issued for a repeat violation of Regulation 87465(a)(4) more than once in a 12 month period. Regulation last cited on 01/23/2025.** (See LIC421FC) Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, LIC421FC, Plan of Corrections, Appeal Rights, and Corrections Letter discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 29, 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 was not met as evidenced by: Based on record review, Licensee did not comply with the section cited above and did not ensure that medication was administered to the correct resident as required. Incident Report stated that R1's medication was given to R2. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Licensee provided proof of training that was conducted on 09/25/2025 on "The Six Rights" for staff that administer medications. Deficiency cleared during visit.

Type of visit: Case Management - Incident

At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director, Kimberly Humphrey, and Health and Wellness Director, Florence Van Heusden. The purpose of the visit was to follow up on incident reports that were submitted to Community Care Licensing (CCL). Incident Report 1: CCL received an incident report on 07/23/2025. Report stated that on 07/18/2025, facility staff witnessed Resident 1 (R1) exit the facility through the main door. Facility staff immediately followed R1 to redirect back to the facility but R1 refused. Facility staff followed R1 on foot and by car to the freeway. Facility contacted San Rafael Police Department and R1 was taken to the hospital for further evaluation. Facility made all notifications per regulation. Incident Report 2: CCL received an incident report 07/30/2025. Report stated that on 07/26/2025, Resident 2 (R2) exited the facility through the main door and crossed the street. Staff Member 1 (S1) was outside with another resident's dog and observed R1 outside. S1 notified additional staff members for assistance and R1 was redirected back to the facility. Facility made all notifications per regulation. LPA obtained additional documentation related to the incidents and copies of elopement training conducted on 07/31/2025 and 08/04/2025. *Deficiency issued today under Regulation 87705(d) has been cleared with Plan of Corrections letter provided during visit. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, Plan of Corrections, Appeal Rights, and Plan of Corrections Letter discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Sep 4, 2025

87705 Care of Persons with Dementia: (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement...This requirement was not met as evidenced by: based on record review, Licensee did not ensure that staff were aware that R2 left the facility without assistance. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Facility conducted elopement training on 07/31/2025 and 08/04/2025. Deficiency cleared during visit and Plan of Corrections Letter provided.

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

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Legal/Non-Compliance visit and met with Executive Director, Kimberly Humphrey and Health and Wellness Director, Florence Van Heusden. LPA obtained copies of in-service training related to the below concerns: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 31, 2025

Type of visit: Office

An Office meeting was conducted today, 06/20/2025, in the Santa Rosa Regional Office. The following individuals were present in the meeting: Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Victoria Bertozzi, Licensing Program Analyst, Caitlynn Felias, Regional Vice President of Operations, Kristina Munoz, Executive Director, Kimberly Humphrey, Senior Vice President of Operations, Phil Altman, and Partner with HansonBridgett, Payam Saljoughian. The purpose of the office meeting was to discuss recent substantiated allegations and extend the Non-Compliance Plan for the facility. On 07/17/2023, the facility was placed on a Non-Compliance plan related to the following areas of concern: · Reporting Requirements related to: · Personal Rights · Incidental, Medical, and Dental Care · Welfare and Institutions Code · Administrator and Designated Representative Facility’s Non-Compliance plan will be extended for an additional two years with an end date of 06/20/2027. Department will review facility's compliance plan after 1 year to review progress. The Department discussed the Technical Support Program (TSP) should Facility be open to having TSP work with them on concerns listed. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 20, 2025

Allegation investigated: Staff handled resident roughly causing resident to fall Facility did not seek timely medical Facility did not report abuse to responsible party

At approximately 11:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Business Office Director, Ditter Vasquez. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There are allegations that "Staff handled resident roughly causing resident to fall, Facility did not seek timely medical, and Facility did not report abuse to responsible party." Complainant alleged the following: Staff Member 1 (S1) roughly handled Resident 1 (R1) while providing care causing R1 to fall and hit their head, facility did not seek timely medical for R1 after the fall, and facility did not report abuse to R1's responsible party. Continued on LIC9099C Substantiated Continued from LIC9099 "Staff handled resident roughly causing resident to fall" - Community Care Licensing received an Incident Report and SOC341 Report on 02/25/2025. Reports stated that 02/21/2025, facility received a notice from their fall-detection camera system. Reports stated that in the video footage, Staff Member 1 (S1) was seen grabbing R1, was trying to clean them after they used the bathroom, and that R1 was resistant to receiving the care. Reports further stated that R1 was seen falling backward hitting their head against their bedroom furniture, that S1 did not report the fall to Facility Medication Technicians or the Health and Wellness Director (HWD) on duty, and that Staff Member 2 and Staff Member 3 (S2 and S3) conducted a visual assessment of R1. LPA reviewed the facility video footage from 02/21/2025. LPA observed that R1 was shown to fall backward with force and significantly hit their head on their nightstand while S1 was providing care. "Facility did not seek timely medical" - Review of R1’s physician orders indicated that R1 was on a blood thinner medication/anticoagulant. Interviews conducted with S2 and S3 confirmed that they reviewed the video footage on 02/21/2025 and conducted a visual assessment of R1. Interviews revealed that S2 and S3 did not send R1 to the hospital for evaluation per facility protocol because they were instructed by the HWD to not send R1 to the hospital unless they exhibited a change in condition. Per interview with Executive Director, facility protocol is to call emergency services when a resident hits their head. Review of facility’s fall policy stated the following: “…Associates will call Emergency Medical Services (911) when: (a) the resident has…received obvious head or significant trauma, (b) if the resident is on anticoagulants and there is a question of head trauma.” "Facility did not report abuse to responsible party" - Review of SOC-341 report showed that R1's incident occurred on 02/21/2025 and that the report was received by Community Care Licensing (CCL) on 02/25/2025. Welfare and Institutions Code section 15630(b)(1) states the following: "Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse...shall report the known or suspected instance of abuse...within two working days." Interviews conducted with S2 and S3 confirmed that they viewed the video of R1 and S1 on 02/21/2025 and did not report the suspected abuse incident timely per mandated reporting requirements. Continued on LIC9099C Continued from LIC9099C Based on record review, interviews conducted, and observations made, these allegations are Substantiated. A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Business Office Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 21-AS-20250401143349

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jun 6, 2025

87468.1 Personal Rights of Residents in All Facilities:(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: based on observations made, Licensee did not comply with the section cited above. Licensee did not ensure R1's personal rights. R1 was shown to be handled roughly by S1 while being provided incontinence care. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: Licensee to submit self-certification that all care staff will receive training on the personal rights of residents by POC due date of 06/06/2025. Licensee to submit training by POC due date of 06/16/2025. Training to include: Topic, Trainer, Date, Name/Job Role, and Staff Signatures.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87208(a) · Plan of correction due date: Jun 6, 2025

87208 Plan of Operation:(a)The licensee shall have and maintain a current, written definitive plan of operation...The licensee shall operate the facility in accordance with the terms specified... pursuant to Health and Safety Code…This requirement was not met as evidenced by: Based on record review, interviews conducted, and observations made, Licensee did not comply with section cited above. Licensee did not ensure that facility staff followed protocol and ensure that R1 was evaluated timely after hitting their head from a fall. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: Licensee to submit self-certification that all care staff will receive training on facility fall protocol by POC due date of 06/06/2025. Licensee to submit training by POC due date of 06/16/2025. Training to include: Topic, Trainer, Date, Name/Job Role, and Staff Signatures.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 15630(b)(1)(A)(i) · Plan of correction due date: Jun 6, 2025

Welfare and Institutions Code: 15630(b)(1)(A)(i): "Any mandated reporter who...has knowledge of an incident...shall report...within two working days (A)If the suspected... abuse occurred in a long-term care facility...(i)...report shall be made within two hours of the mandated reporter...obtaining knowledge of...physical abuse." Requirement not met as evidenced by: based on interviews, record review, and observations, Licensee did not comply with section cited above and did not ensure that R1's suspected abuse was reported timely. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: Licensee to submit self-certification that all care staff will receive training on Reporting Requirements by POC due date of 06/06/2025. Licensee to submit training by POC due date of 06/16/2025. Training to include: Topic, Trainer, Date, Name/Job Role, and Staff Signatures.

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

At approximately 12:35PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Legal/Non-Compliance visit and met Executive Director, Kimberly Humphrey. LPA requested and reviewed documents for all employees hired from January 2025 to April 2025. Per Executive Director, facility conducted in-service training for current staff and newly hired staff. Facility is scheduled to have another in-service training at the end of the month to review the following: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives LPA obtained copies of in-service training. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 9, 2025

Allegation investigated: Staff did not assist resident with self-administration of medication Personal Rights

At approximately 1:50PM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for this Complaint Investigation regarding the above allegations and met with Executive Director, Kimberly Humphrey and Business Office Manager, Ditter Vazquez. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Staff did not assist in self-administration of medication, and Personal Rights.” “Staff did not assist in self-administration of medication” – Complainant alleged that facility staff refused to administer Resident 1 (R1’s) morphine medication when they were in extreme pain on 11/03/2025 and 11/04/2025. Complainant also alleged that facility staff forced R1 to take their morphine when they were dying even though R1’s family asked facility staff to not administer it. Continued on LIC9099 Unsubstantiated Continued from LIC9099 Review of R1’s medication records and narcotic log indicated that facility staff were administering R1’s morphine per physician and hospice orders. Review of R1’s routine medications showed that R1 had a prescription for a morphine oral tablet. The morphine oral tablet instructions stated: “Morphine Sulfate Oral Tablet 15MG – Take ½ tablet (7.5MG) by mouth every 4 hours as needed for pain/shortness of breath.” Record Review for 11/03/2025 showed the following: · Review of R1’s Narcotic Log shows that R1 was administered morphine at the following times: 5AM, 9:43AM, 11:48AM, 12:10PM, 1:10PM, 4:22PM, 5:43PM,7PM, 9:18PM and 11:25PM. · R1’s Progress Notes for 11/03/2024 showed that facility staff were communicating with R1’s hospice agency about R1’s increase in pain and were following their instructions. Notes also indicated that Hospice visited R1 on 11/03/2024 to assess them and administer PRN (as needed) morphine. · At 6:47PM, facility received physician order for “Morphine 15MG oral tablet – Take 1 tablet(s) oral every hour as needed for severe pain; OK to dissolve in water then administer.” Facility documentation showed that the Facility received this verbal order in the evening after the facility had been giving morphine per hospice instructions. Hospice Record Review for 11/03/2025 showed that the Hospice Agency conducted visits with R1 at the following times: · 12PM-2PM; Hospice Notes indicated that R1 was transitioning and that R1 was administered medication · 5:22PM-8:39PM; Hospice Notes indicated that R1 was administered medication around 3-4PM. Hospice observed R1 to be visibly calm. Record Review for 11/04/2025 showed the following: · Review of R1’s Narcotic Log shows that resident was administered morphine at the following times: 9:18AM, 1:57PM, 3:54PM, 5:30PM, 7PM, 8PM, and 9PM · R1’s Progress Notes showed that R1 was observed to be calm and comfortable at 12:34PM, 2:44PM, 6:55PM, and 6:57PM by facility staff · At 11:42AM, the facility received verbal orders for the following morphine prescription: 11/4/24; oral concentrate morphine (20MG/ML) administer 0.75ML oral every hour. Facility documentation indicated that after facility received the new morphine order, they began to administer the new medication order at 3:54PM. Continued on LIC9099C Continued from LIC9099C Hospice Record Review for 11/04/2025 showed that the Hospice Agency conducted visits with R1 at the following times: · 11:45AM – 12:30PM; Hospice Notes indicated that R1 was observed to be safe and comfortable · 5:30PM to 6:03PM; Hospice Notes indicated that facility staff administered morphine 15 minutes prior to Hospice’s arrival · 9:45PM-10:45PM; Hospice Notes indicated that R1 passed and a narcotic medication count was conducted. “Personal Rights” – Complainant alleged that facility staff argued and verbally harassed R1’s family while R1 was dying. Report received stated that Staff Member 1 (S1) accused R1’s family of physically grabbing and shaking them. Report received stated that Facility’s Executive Director confronted R1’s family about the alleged altercation in front of R1 and did not provide R1 dignity. Interviews conducted with involved parties revealed conflicting statements. Interview conducted with S1 stated that R1’s family grabbed them to make them administer more morphine to R1 even though R1 didn’t look like they were in pain. Interview conducted with Executive Director stated that they were unable to determine if the altercation happened as S1 and the family were the only ones involved. Interview conducted with Witness 1 (W1) denied that the physical altercation occurred, and that the accusation was false. W1 stated that there was a verbal conversation that occurred between themselves, the Facility Executive Director, and S1, but asserted that there had been no physical contact between them and S1 prior to the verbal exchange. Interview conducted with Witness 2 and Witness 3 (W2 and W3), corroborated W1’s statements that there was no physical altercation between W1 and S1 and that there was no yelling or raised voices during the conversation between the family, the Facility’s Executive Director, and facility staff in front of R1. Based on interviews conducted, document review, and observations made, these allegations are Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means 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. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 28, 2025 · control 21-AS-20241108085658

Allegation investigated: Staff do not provide residents with adequate food service Staff do not prepare meals in a sanitary manner Staff do not use soap to wash facility dishes Staff do not seek medical attention for residents in a timely manner

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. Through interviews, document reviews and unannounced site visits, the following determinations are made: LPA Leibert made unannounced inspections of the kitchen and food service on 2/4/25, 2/27/25, and 3/13/25; Inspections found the dishwasher to be operative with adequate detergent on site; Interviewed staff deny using vinegar to clean dishes; Staff were observed following appropriate sanitation protocols; Facility menus comply with Title Twenty-Two regulations and inspections found food on hand to fulfill the menu requirements; Adequate beverages, snacks, and deserts were observed to be stocked; 2 out of 10 family members asked to comment on food service report satisfaction with the food served; Facility Care Notes for Resident (R1) indicate R1 was sent out on 11/30/24 when observed to be pale with breathing problems; R1 was noted to be at Baseline prior on 11/29; R1 remained out of facility until returning on 1/7/25 and was noted to be at Baseline on 1/9/2025; Care Notes through the rest of January, 2025, indicate some issues addressed by Hospice but no send out for pneumonia and UTI as alleged by Complainant; Continued on next page..... Unsubstantiated Staff Nurse denies hearing complaints of pain from R1 prior to the day R1 was sent out for medical care. Although the allegations may be true, or valid, based upon records reviewed, statements taken, and observations made, there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore the complaint is UNSUBSTANTIATED. No citations issued today. Report left.the state’s words, verbatim · CDSS document, Mar 25, 2025 · control 21-AS-20250127130724

Allegation investigated: Facility's emergency call system was in disrepair

At approximately 9:05AM, Licensing Program Analyst (LPA) Felias arrived unannounced to initiate a Complaint Investigation regarding the above allegations and met with met with Executive Director/Administrator, Kimberly Humphrey. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation of "Facility's emergency call system was in disrepair.” Complainant alleged that there were many occasions that the facility's pull cords were not functional and that facility staff were not receiving the calls on their pagers. Interview conducted with Executive Director stated that the facility's call system was not working approximately four weeks ago and was fully repaired this past Monday, 03/10/2025. Per Executive Director, Continued on LIC9099C Substantiated Continued from LIC9099 residents' calls were still showing up on the facility's monitors if a resident's pull cord or resident pendant was used. Executive Director stated that issue was that the system was not allowing new pendants to be programmed and therefore current residents that required a replacement pendant were unable to receive one. Facility contacted their Call System company, Lifeline Senior Living, to have a systems technician conduct a repair. Per Executive Director, as of Monday, 03/10/2025, the facility's call system has been updated, all pull cords and resident pendants have been checked to ensure they are fully functioning/operable. Executive Director stated that when the system was malfunctioning, care staff were doing increased checks on residents. LPA conducted staff interviews. 4 of 5 interviews conducted stated that resident pull cords have not been working as expected and that sometimes they do not receive the calls on their pagers. Interviews conducted revealed that they have been told it's a problem with the system and that management has been working on getting it resolved. Review of facility documents showed that Lifeline Senior Living provided a quote of repairs to the facility on 03/04/2025. Based on interviews conducted and document review, this allegation is Substantiated. A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 14, 2025 · control 21-AS-20250306172541

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(A) · Plan of correction due date: Mar 24, 2025

87303 Maintenance and Operation: (i) Facilities shall have signal systems which shall meet the following criteria:(1) All facilities licensed for 16 or more and...separate floors or buildings shall have a signal system...(A) Operate from each resident's living unit. This requirement was not met as evidenced by: based on interviews and document review, Licensee did not comply with the section cited above and did not ensure that facility's pull cord system was operating as required. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 14, 2025

Plan of correction: Facility to submit the following documents: Lifeline Senior Living Receipt of Repairs and Audit of Resident Pull Cords to be done by Maintenance Director to ensure that they are operable. Documents to be submitted by POC due date of 03/24/2025.

Allegation investigated: Reporting Requirements

At approximately 10:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with met with Business Office Director, Ditter Vasquez. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation of "Reporting Requirements.” Complainant alleged that facility did not submit a report to the Department regarding potential abuse. Further information provided to LPA indicated that the incident involved a medication error. Review of documents showed that the Department received a report involving the identified incident. Continued on LIC9099C Unfounded Continued from LIC9099 This report and incident were addressed during the facility's Annual visit. Based on interviews conducted, documents reviewed, and observations made, this allegation is Unfounded. A finding of unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No Deficiencies Cited during Visit. Exit interview conducted. Copy of report discussed and provided to Business Office Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 26, 2025 · control 21-AS-20250113133346

Type of visit: Case Management - Incident

At approximately 10:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Business Office Director (BOM), Ditter Vasquez. The purpose of the visit was to follow up on an incident report that was self-submitted to Community Care Licensing (CCL). Incident Report 1/SOC341: CCL received an incident report and SOC341 on 02/25/2025. Reports stated that on 02/21/2025, the facility received a notice from their fall-detection camera system. Facility reviewed camera system which showed Staff Member 1 (S1) grabbing Resident 1 (R1). Reports stated that S1 was shown to be trying to clean R1 after using the bathroom and that R1 was resistant to receiving care. R1 was seen falling backward hitting their head against their bedroom furniture. Reports stated that S1 did not report the fall. On 02/25/2025, Staff Member 2 and Staff Member 3 (S2 and S3) conducted an assessment of R1. Facility made all notifications per Title 22 Regulations. Reports stated that S1 was currently suspended pending internal investigation. LPA discussed with BOM and facility nurse the importance of having a resident evaluated by medical personnel when a fall occurs and results in a head injury. LPA obtained additional documentation related to the incident. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Business Office Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 26, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst Ali Deniz and Licensing Program Manager Victoria Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Kimberley Humphrey. CCL staff followed up regarding a recent self-reported incident where staff was observed throwing water on a resident. Facility is in the process of conducting an internal investigation. CCL obtained documents and spoke with a witness. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Feb 7, 2025

Type of visit: Case Management - Annual Continuation

At approximately 9:00AM, Licensing Program Analysts (LPAs) Felias and Magdaleno arrived unannounced to continue a Required 1 Year Visit and met with Business Office Director, Ditter Vasquez, and Wellness Nurse, Remy Fairbairn. Executive Director, Kimberly Humphrey, arrived during visit at approximately 12:30PM. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 70 non-ambulatory and bedridden residents. Of the 70 residents, 20 residents can be bedridden. Facility has an approved hospice waiver for 16 individuals. Facility is currently on a Non-Compliance Plan. Upon arrival, LPAs were informed that there were 47 residents in care and 19 staff members on-site. LPAs reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPAs reviewed staff and resident files and resident medication. During staff file review, LPAs observed that 5 of 6 staff members did not have current First Aid certification, and 3 of 6 staff members did not have CPR certification (deficiency cited, LIC809D, Health and Safety Code 11569.618(c)(3)). During resident file review, LPAs observed that 1 of 5 residents did not have an updated Physician's Report as required (technical violation issued, LIC9102, regulation 87463(h)). Medication was found to be centrally stored and secure. As part of their Non-Compliance Plan, LPAs also requested and reviewed documents for all employees hired from November 2024 to January 2025. Review of documents showed that facility hired 5 individuals during this time frame. Document review showed that facility has conducted training or have scheduled training for them in the following areas: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives LPAs followed up on incident reports that were submitted to Community Care Licensing (CCL): Continued on LIC809C Continued from LIC809 Incident Report 1/SOC341: CCL received an incident report and SOC341 on 12/02/2024. Reports state that on 11/25/2024, Staff Member 1 (S1) observed Staff Member 2 (S2) taking Resident 1's (R1) medication card from the facility medication cart. Per reports, S2 also took two Tylenol tablets from R1's medication bottle. Facility conducted an internal investigation and medication audit and found that 42 tablets were missing from R1's medication. Reports stated that facility conducted an in-service training. Facility made all appropriate notifications per regulation. Executive Director informed LPAs that S2 has since been terminated and is no longer working at facility. LPAs obtained copy of in-service training. Incident Report 2: CCL received an incident report on 01/23/2025. Report states that on 01/15/2025, Staff Member 3 (S3) observed that Staff Member 4 (S4) did not give Resident 2 (R2) their medication as prescribed on 01/14/2025. Additional documentation showed that R2's medication was documented as given. S2 notified management and a medication audit was conducted (deficiency cited, LIC809D, regulation 87465(a)(4)). Report stated that S4 was suspended pending internal investigation and that facility would receive in-service training. Facility made all appropriate notifications per regulation. Executive Director informed LPAs that S4 has seen been terminated and is no longer working at facility. LPAs reviewed Facility's Guardian Roster and confirmed that S2 and S4 have been removed from the facility and are no longer working on-site. LPAs requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Updated Liability Insurance Active and Current Administrator Certificate Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 23, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At approximately 2:30PM, Licensing Program Analysts (LPAs) Felias and Stevenson arrived unannounced to conduct a Required 1 Year Visit and met with Executive Director, Kimberly Humphrey, and Health and Wellness Nurse, Angela Ramos. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 70 non-ambulatory and bedridden residents. Of the 70 residents, 20 residents can be bedridden. Facility has an approved hospice waiver for 16 individuals. Facility is currently on a Non-Compliance Plan. Upon arrival, LPA's were informed that there were 43 residents in care and 22 staff members on-site. At approximately 2:50PM, LPAs reviewed Facility Staff Roster with Executive Director and found that all staff members on site were background cleared and associated to the facility per regulation. LPAs conducted a walk-though of the facility with Executive Director and observed the following: Facility is a 2 story building. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 6 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. LPAs unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. No Deficiencies cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 9, 2025

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

At approximately 11:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Legal/Non-Compliance visit and met Executive Director, Kimberly Humphrey. LPA requested and reviewed documents for all employees hired from July 2024 to October 2024. Review of documents showed that facility hired 2 individuals during this time frame and has either conducted training or have scheduled training for them in the following areas: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives LPA received Administrator paperwork to update Administrator to Kimberly Humphrey. Administrator paperwork to be processed. LPA and Executive Director did a walkthrough of the facility. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 29, 2024

Allegation investigated: Staff is not following doctor's orders for resident's wound care Staff is overcharging resident in care

At approximately 11:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for this Complaint Investigation regarding the above allegations and met with Regional Executive Director, Davina Barker. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation that “Staff is overcharging resident in care.” Complainant stated that Facility billed Resident 1 (R1) for a compression sleeve that R1 does not use or need. Complainant also alleged that the facility refused entry to the home health agency that was ordered to provide wound care and instead provided the wound care in the facility costing more money and more levels of care for the resident. Review of facility documents show that R1’s Physician ordered for them to have a compression leg machine and compression stockings dated 06/03/2021 and 05/17/2023. Continued on LIC9099C Unsubstantiated Continued from LIC9099 Facility received discontinue orders for R1’s compression devices on 05/06/2024 and 05/08/2024. Per document review, Facility stopped providing service for the compression socks once the doctor discontinued their use. During the investigation, Complainant also stated that R1 received orders for wound care to be done by Home Health and that R1 and their Responsible Party were being charged for the service. This concern was substantiated on 08/08/2024 in Complaint Investigation: 21-AS-20240424094747. Per discussion with Regional Executive Director, these charges since have been removed from R1’s bill. This allegation is Unsubstantiated. There is an allegation that “Staff is not following doctor’s orders for resident’s wound care.” Complainant stated that wound care was ordered for the resident for wound care to be provided at Cogir by a home health agency. Complaint alleged that facility was not allowing home health in the building and instead provided the wound care themselves. Again, this concern was substantiated on 08/08/2024 in Complaint Investigation: 21-AS-20240424094747. Per discussion with Regional Executive Director, these charges since have been removed from R1’s bill. Per investigation, facility did not deny entry to the home health agency. This allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means 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. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and Confidential Names (LIC811) discussed and provided to Regional Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 21, 2024 · control 21-AS-20240514163205

Allegation investigated: Facility did not provide representative with an updated care plan with explanation of care charges Facility does not respond to representative timely

At approximately 12:50PM, Licensing Program Analysts (LPAs) Felias and Loera arrived unannounced to deliver findings for this Complaint Investigation regarding the above allegations and met with Regional Executive Director, Davina Barker, and Health and Wellness Director, Victoria Mozaffari. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation that “Facility did not provide representative with an updated care plan with explanation of care charges.” Complainant stated that R1’s Responsible Party was being charged $100 per day for R1 to receive wound care treatment and that R1’s care increased from a Level 5 to a Level 9 with no explanation. Interview conducted with Facility’s Health and Wellness Director (HWD) stated that R1 was put on a Temporary Service Plan (TSP) in February 2024 due to increased care needs. Continued on LIC9099C Substantiated Continued from LIC9099 Per HWD, TSPs are temporary services provided by the facility that goes on a resident’s care plan. A resident’s level of care is determined by a point system which is generated into an invoice. Review of facility documents showed that R1 received wound care orders on 02/06/2024 which were not discontinued until 02/27/2024. Facility documents indicated that R1’s Responsible Party received verbal notification on 02/06/2024 that R1’s care level would be affected due to requiring wound care services. On 02/21/2024, R1’s Responsible Party was verbally notified that the wound care services would stay in place since the orders were not discontinued by the Physician. Facility was unable to provide documentation showing that R1’s Responsible Party had received a written notice of R1’s updated service plan with the additional charges included. Therefore, this allegation is Substantiated. There is an allegation that “Facility did not respond to Representative timely.” Complainant stated that R1’s Responsible Party contacted the facility multiple times to address charges related to R1’s care. Email correspondence provided to LPA indicated that R1’s Responsible Party contacted the facility on 04/04/2024. Responsible party was told that they would have an answer to their inquiry by 04/08/2024. Further correspondence indicated that R1’s Responsible Party followed up on 04/17/2024 and still did not receive a response. Therefore, this allegation is Substantiated. A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC811 (Confidential Names), LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Regional Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 8, 2024 · control 21-AS-20240424094747

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Aug 19, 2024

HSC 1569.657(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative...written notice of the rate increase within two business days... This requirement was not met as evidenced by: Based on document review and interviews, Licensee did not comply with the section cited above and did not ensure proper notice was provided within two days to resident and/or their responsible party as required. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2024

Plan of correction: Licensee to conduct training reviewing the requirements of HSC 1569.657(a) with Managerial Team. Training to include the following: Date of Training, Training Topics, Job Role, Staff Names, and Signatures. Training to be submitted to CCL for review and approval by POC due date of 08/19/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: Aug 19, 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: (9)To have communications to the licensee from their representatives answered promptly and appropriately. This requirment is not met as evidenced by: Based on document review and interviews conducted, facility did not ensure communication with R1’s representative was answered promptly and appropriately as required by regulation. This poses a potential health and saftey risk to residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2024

Plan of correction: Licensee to submit self-certification stating that they have reviewed the regulation. Certification to be submitted to CCL by POC due date of 08/19/2024.

Type of visit: Case Management - Other

At approximately 1:25PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other visit and met with Administrator, Kaitlyn Clarey, Regional VP of Operations, Kristina Munoz, and Regional Executive Director, Davina Barker. The purpose of today's visit is to conduct a Non-Compliance (NCC) inspection. LPA requested and reviewed documents for all employees hired from April 2024 to July 2024. Review of documents showed that facility hired 2 individuals during this time frame and has either conducted training or have scheduled training for them in the following areas: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives. During visit, LPA was informed that Regional Executive Director, Davina Barker, will be overseeing the community as the new Administrator. LPA requested Administrator documents to be submitted to Community Care Licensing (CCL) by 08/10/2024. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 31, 2024

Allegation investigated: Staff did not provide responsible party with 30 day eviction notice.

At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Executive Director/Administrator, Susan Edwards. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation that “Staff did not provide responsible party with 30 day eviction notice.” Complainant alleged that Resident 1 (R1) and their designated representatives conducted a meeting with the facility where it was discussed that R1 be relocated or discharged from the facility. Complainant stated that the facility did not provide R1 and their designated representatives with any documentation and did not use the word “eviction” and only used terms like “decision to relocate” or “discharge.” Complainant stated that facility did not provide R1 and their designated representatives with a written eviction notice. Continued on LIC9099C Unsubstantiated Continued from LIC9099 LPA conducted staff interviews and found that R1 is still a resident at the facility and has not been evicted. Review of R1’s file showed a document that addressed R1’s behaviors and interventions and stated that failure to uphold the commitments agreed upon may result in alternative placement being needed. Per Administrator, R1's Responsible Party received and acknowledged the document but refused to sign. A formal letter of this document was also received by the Department on 03/20/2024. Based on review of documents, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means 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. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents. Continued from LIC9099A Based on documents reviewed and observations made, this Agency has investigated the above allegation. We have found that the allegation is Unfounded. A finding that the complaint is Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 2, 2024 · control 21-AS-20240308152416

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

At approximately 9:10AM, Licensing Program Analysts (LPAs) Florio and Felias arrived unannounced to conduct a Case Management - Legal/Non-compliance visit and met with Administrator/Executive Director, Susan Edwards. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 70 non-ambulatory and bedridden residents. Of the 70 residents, 20 residents can be bedridden. Facility has an approved hospice waiver for 16 individuals. LPAs requested and reviewed documents for all employees hired from January 2024 to April 2024. Review of documents showed that facility hired 2 individuals during this time frame and has either conducted training or have scheduled training for them in the following areas: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives. LPAs conducted a walkthrough with Executive Director. During walkthrough, LPAs observed that a medication cart was unattended and unlocked. LPAs observed that routine and narcotic medications were on top of the unlocked cart. LPAs notified the medication technician on duty who immediately put the medications away and locked the cart (this deficiency has been cited, see LIC809-D, Regulation 87705(f)(2)). Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An Immediate Civil Penalty in the total amount of $1,000 is being assessed for a repeat violation of Regulation 87705(f)(2) for a third or subsequent cited violation within 12 months of the last violation. (See LIC421IM)** Exit interview conducted. Copy of report, LIC809D, LIC421IM, Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 22, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Apr 23, 2024

87705 Care of Persons with Dementia:(f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication... alcohol... and toxic substances... This requirement is not met as evidenced by: Licensee did not comply with the section cited above. LPAs observed medication cart was unattended and unlocked. LPAs observed routine and narcotic medications were on top of the unlocked cart. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 22, 2024

Plan of correction: LPAs notified the medication technician on duty who immediately put the medications away and locked the cart. Licensee to submit self certification that training for Regulation 87705(f)(2) will be conducted for all Medication Technicians by POC due date of 04/24/2024. Training to review items that are inaccessible to residents in care and to review proper storage of medications. Licensee to conduct Inservice Training and submit a sign in sheet to CCL that includes the following: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 05/2/2024.

Allegation investigated: Resident has been issued an unlawful eviction

At approximately 1:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to initiate a Complaint Investigation regarding the above allegation and met with Executive Director/Administrator, Susan Edwards. During the course of the Investigation, LPA requested and reviewed documents, conducted interviews, and made observations. There is an allegation of an Unlawful Eviction. Reporting Party stated that R1 and their Responsible Party had a verbal agreement with the former company of the facility, Sunrise Senior Living, where they were allowed to pay their rent one month late. This verbal agreement was continued when the facility was taken over by Cogir Senior Living in July 2021. Record Review showed that there is no written agreement between Cogir Senior Living Management and R1 and their Responsible Party agreeing to continuing this verbal agreement. Continued on LIC9099C Unfounded Continued from LIC9099 R1 and their Responsible Party were issued a total of four Eviction Notices on the following dates: 09/08/2023, 09/26/2023, 09/28/2023, and 11/20/2023. R1 and their Responsible Party were also provided with letters from Cogir Senior Living Management on 08/2023, 10/27/2023, and 01/15/2024. Review of the Eviction Notices showed that the reason for eviction was due to nonpayment of fees. Further review also showed that the notices included the following information required by Title 22 Regulations: the full name of the resident, the address of the facility resident was being evicted from, the licensee’s signature and date, the reasons for the eviction, the effective date of the eviction, resources available to assist the resident in finding alternative housing, information about the resident’s right to file a complaint with Community Care Licensing (CCL), contact information for CCL and the State Ombudsman, and appropriate wording regarding “an unlawful detainer” if R1 were to stay beyond the identified eviction date. R1 and their Responsible Party were also provided with a billing ledger identifying fees and amounts due. Per Title 22 Regulations, Eviction Procedures 877224(a)(1), it states: "(a) The licensee may evict a resident for one or more reasons listed in section 87224(a)(1) through (5). (1) Nonpayment of the rate for basic services within ten days of the due date." Based on documents reviewed, interviews conducted, and observations made, this Agency has investigated the above allegation. We have found that the complaint of Unlawful Eviction is Unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 14, 2024 · control 21-AS-20240205134542

Type of visit: Case Management - Annual Continuation

At approximately 9:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Annual Continuation visit and met with Executive Director/Administrator, Susan Edwards. Upon arrival, LPA was informed that there were 49 Residents in care and 26 staff members on-site. At approximately 10:00AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA reviewed 6 resident files and 4 resident medication records. Resident files were all found to be well organized, thorough and contained the required documentation. Medication was found to be centrally stored and secure. LPA also followed up on an incident report that was submitted to Community Care Licensing (CCL). Incident Report 1: CCL received a incident report on 02/12/2024. Report stated that on 02/09/2024, Resident 1 (R1) was found by facility staff at the end of the facility's driveway. Report stated that the facility's front door has delay egress and was alarmed. Facility made all appropriate notifications per regulation. (This deficiency has been cited, see LIC809D, Regulation 87705(b)(2). LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Active and Current Administrator Certificate Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 03/14/2024. Continued on LIC809C Continued from LIC809 Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 14, 2024

Type of visit: Required - 1 Year

At approximately 11:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year Visit and met with Administrator/Executive Director, Susan Edwards. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 70 non-ambulatory and bedridden residents. Of the 70 residents, 20 residents can be bedridden. Facility has an approved hospice waiver for 16 individuals. Facility is currently on a Non-Compliance Plan. Upon arrival, LPA was informed that there were 49 residents in care and 9 direct care staff on-site. At approximately 11:30AM, LPA reviewed Facility Staff Roster with Executive Director and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 12:00PM, LPA conducted a walk-though of the facility with Executive Director and observed the following: Facility is a 2 story building. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 10 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected April 2023. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected December 2023. Facility's last fire/disaster drill was conducted January 2024. LPA reviewed staff files. Files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Continued on LIC809C **Report has been Amended** Continued from LIC809 As part of their Non-Compliance Plan, LPA also requested and reviewed documents for all employees hired from November 2023 to January 2024. Review of documents showed that facility hired one individual during this time frame. Document review showed that facility has conducted training or have scheduled training for them in the following areas: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives LPA also followed up on an incident report/SOC-341 that was submitted to Community Care Licensing (CCL). Incident Report 1/SOC341: CCL received an incident report/SOC-341 report on 01/08/2024 and 01/10/2024. Reports stated that on 01/07/2024, during a routine check, facility staff found Resident 1 (R1) and Resident 2 (R2) in bed together in R1's room. Facility self-reported incident, facility contacted responsible parties for both residents. Facility has implemented the following; · 1:1 supervision for R2, · 30 minute checks after 8PM · Continuous alert charting for R1 and R2 · Service care plans have been updated for both residents Facility understands that residents are able and allowed to have a relationship with each other. Facility understands that if residents were prevented having a relationship or are prohibited from seeing each other, it may be a personal rights violation. Based on review of incident report and SOC-341, Facility has been compliant with Title 22 Regulations regarding Personal Rights. Incident Report 2: Executive Director also informed LPA that yesterday evening, 01/28/2024, facility staff found a box of wine in Resident 3's (R3) room. The wine was immediately removed from R3's room. LPA informed that R3 has a Physician's Order to have alcohol, and an LIC624/Unusual Incident Report submitted to the Regional Office. Continued on LIC809C **Report has been Amended** Continued from LIC809C Facility sent out a notice to all Responsible Parties outlining items that are not allowed to be in the building and plans on conducting an in-service training for staff reviewing prohibited items such as alcohol. (This regulation has been cited, see LIC809D, Regulation 87705(f)(2)).” Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An Immediate Civil Penalty in the total amount of $250 is being assessed for a repeat violation of Regulation 87705(f)(2) more than once in a 12 month period. (See LIC421IM)** Exit interview conducted. Copy of report, LIC811 (Confidential Names), LIC809D, LIC421IM, Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents. Physical Copy of signatures on file.the state’s words, verbatim · CDSS document, Jan 29, 2024

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

At approximately 9:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other Visit and met with Administrator/Executive Director, Susan Edwards. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 70 non-ambulatory and bedridden residents. Of the 70 residents, 20 residents can be bedridden. Facility has an approved hospice waiver for 16 individuals. Facility is currently on a Non-Compliance Plan. The purpose of today's visit is to conduct a Non-Compliance (NCC) inspection and to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). LPA requested and reviewed documents for all employees hired from July 2023 to October 2023. Review of documents showed that facility hired 5 individuals during this time frame and has either conducted training or have scheduled training for them in the following areas: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives. LPA was informed that an all staff in-service training is scheduled on 10/31/2023 to review the following topics: Elder Abuse and Mandated Reporting. LPA obtained copies of training documents. LPA was informed that facility has scheduled two renovations to be done. The facility's bathroom located in their smaller neighborhood will be turned into a laundry room, and their roof tiles will be replaced. Facility has ensured that all construction tools required for renovations will be inaccessible to residents. Executive Director stated that there is a locked room available for contractors to leave their equipment in during renovations. LPA was informed that only the Executive Director, Maintenance Director, and Contractor will have keys to access the room. Continued on LIC809C Continued from LIC809 LPA followed up on the following self-reported incidents: Incident Report/SOC341 #1: CCL received an incident report/SOC-341 report on 06/30/2023. Reports state that on 06/29/2023, Resident 1 (R1) was visiting the facility's smaller neighborhood with their robotic therapy cat. Facility staff observed Resident 2 (R2) approach R1 to pet the cat. R1 became upset and hit R2 across the face. R2 then hit R1 back and they started pulling each other's hair. Facility staff immediately separated the two residents. Facility made all appropriate notifications per regulation. Incident Report/SOC341 #2: CCL received an incident report/SOC-341 report on 07/03/2023. Reports state that on 07/02/2023, R1 and Resident 3 (R3) had a physical altercation that was stopped by Resident 4 (R4). Facility does not know how altercation started but were able to separate R1 and R3 to be evaluated. Facility observed R1 to have an injury and contacted Emergency Personnel. Personnel determined that R1 did not need medical attention. Facility made all appropriate notifications per regulation. SOC341 #3: CCL received an SOC-341 report on 07/20/2023. Report states that on 07/19/2023, Resident 5's (R5's) Hospice Team reported to the facility the following information: the Chaplain observed R5's Responsible Party slap their arm during lunchtime. R5 was seen to have placed feces on the dining table. Executive Director spoke with Responsible Party and was told that they were trying to prevent more feces from being placed on the table during the meal. Facility made all appropriate notifications per regulation. Incident Report/SOC341 #4: CCL received an incident report/SOC-341 report on 09/06/2023. Reports state that on 09/04/2023, Staff Member 1 (S1) reported a concern to the Executive Director regarding an incident they observed with Staff Member 2 (S2) and R4. S1 reported feeling uncomfortable with the way S2 addressed R4 when helping with their care needs. Executive Director conducted an internal investigation and concluded that S2 needed more training on how to appropriately communicate with residents while providing care. Facility conducted supplemental training with S2. Facility made all appropriate notifications per regulation. LPA conducted interviews during visit and was informed that S2's communication with residents has improved. LPA obtained copies of training documents. Continued on LIC809C Continued from LIC809C Incident Report/SOC341 #5: CCL received an SOC-341 report on 09/20/2023. Report states that on 09/19/2023, Resident 6 (R6) approached facility staff in the medication room for assistance with dental hygiene. Resident 7 (R7) was observed telling R6 not to go into the medication room and tightly grabbed R6 by the arm. Staff intervened and attempted to place themselves between R6 and R7. R7 was observed to escalate and increase their aggressive behaviors towards staff by yelling and not letting go of R6. Once staff were able to separate R6 and R7, staff observed R7 repeatedly knock on the medication room's door in an aggressive manner while they assisted R6. Facility made all appropriate notifications per regulation. Per conversation with Executive Director, LPA was informed of the following: R1 has been continuously monitored by staff for increased behavior. R1 was re-evaluated by their Physician and had a medication change. R1 has been observed to have less aggression. R7 has been evaluated by their Physician and had a medication change. Aggression towards staff has continued to occur when they assist R6. Facility has communicated with R7's Responsible Party regarding these incidents. Due to their care needs, R7's Responsbile Party has decided to relocate them to another facility. Facility to submit in-service training scheduled for 10/31/2023 to CCL once completed. Documents to be submitted by Monday, 11/06/2023. No Deficiencies Cited during visit. Exit interview conducted. Copy of report, and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 27, 2023