Cogir of Turlock

Allegation investigated: Facility did not provide appropriate care and supervision resulting in a harm/injury

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived to the facility unannounced to investigate a complaint investigation with the above allegation, LPA met with Executive Director Jackie Hernandez to discuss the findings. Specificly a large but first degree burn via some heated juice. In interview, the staff S1 reported that they had heated a prune juice and left it with the client. Record review of 602 for R1 indicates he has dementia and assistance with feeding. Administrator provided that the staff had recived a generalized training as a result of the incident about providing the clients with heated fluids. LPA asked for a log of the training. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D. A citation was issued, a copy of the report was read and given to the administrator, appeal rights were provided. exit interview was conducted. Substantiatedthe state’s words, verbatim · CDSS document, Jul 14, 2026 · control 27-AS-20260615110219

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80078(a) · Plan of correction due date: Jul 15, 2026

80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidinced by: In interview with S1, the staff is reporting that they heated and left a heated juice with the resident r1, record review of 602 for r1 indicates assistance with feeding/drinking. This requirement not being followed risks the clients health, safety, or personal rights.the state’s words, verbatim · CDSS document, Jul 14, 2026

Plan of correction: No immediate poc, the corrective action taken by the facility to do a staff training about the care for residents as related to heated fluids is what the department would have recommended, training was completed on June 16th 2026 for all staff.

Allegation investigated: facility had mismanaged a residents medication

Licensing Program Analyst, LPA Noel Wolf Petersen arrived to the facility unannounced to investigate a complaint investigation with the above allegations, LPA met with Executive Director Jackie Hernandez to discuss the findings. The record review of the perscriptive orders of the R1's medications do not reveal a measuring scale for determining how much or how little medication to distribute. The order as written is "apply to affected areas, 2x daily as needed for pain" without indication to a specific amount that would exceed "as needed." Clarification from a doctor was sought, the advisory was returned "do not apply to more than one affected area at time". LPA was informed of a bottle of nasal suspension for r1 had a suspicsious origin. LPA interviewed the facility Health and Wellness Director S3, who made the statement that over the counter medications, if they are out of the facility when the client needs them as part of a regular perscription, the facility policy is to go supply the medication from the pharmacy to meet the needs of the clients. record review of the MAR for R1, does not provide any indication that a dose for a medication was missed in the past two weeks. Two medtechs were interviewed, both indicated no order perscribed a specific amount of topical medcation and orders wer followed as perscribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. a copy of the report was read and left with the administrator. exit interview. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 14, 2026 · control 27-AS-20260706094019

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to continue an annual inspection. LPA Met with Executive Director Jackie hernandez to explain the purpose of the visit. On the previous visit, LPM reviewed 11 resident files of which 4/11 were hospice residents and 4/11 resided in the MC section of the community. During the file review the LPM reviewed associated incident reports ensuring the RP and MD were notified, medication orders were addressed and if a change of condition occurred an updated care plan was developed. 2 residents had a change of condition which would have triggered an updated reappraisal. tDuring the inspection, the weight logs, service notes and ADL charting were not reviewed. LPA has returned today to address any concerns related to these. Pullcord log from the last three weeks were reviwed, common reason is toilet/bathing, common response time is 20 seconds to 4 minutes, a few outlier times are 9-13 minutes. Weight logs are completed for residents with relevant issues to sudden changes in weight. no concerns. Service notes/ADL charting describes in detail the Bowel Movement, bathing, incontinence care, grooming, and shower habits appropriately to the concern of the residents. Logs have created by dates and authors consistant with daily use of the log. no concerns excepting R4 med error morphine double dose 02162026. Citations were issued. a copy of the report was read and given to the executive director. appeal rights were provided, exit interview was conducted.the state’s words, verbatim · CDSS document, Jul 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jul 3, 2026

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 in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs... This requirement was not followed as evidnced by: Record review of log notes(2/16/2026) for a resident(r4) where medication(morphine) should have been given as a half dose and was instead given as a full dose. Not following this requirement poses a risk to the health and safety and personal rights of a resident in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: No POC, the employee was given the rights of medication training again, and the incident was self reported by the next shit medtech when count was discovered to be off the following day. resident/hospice were informed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(b) · Plan of correction due date: Jul 30, 2026

87463 Reappraisals (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement was not followed as evidenced by: Of the 11 files reviewed, R5(fall 0512026), and R12 ( 02032026 addtion of home healthwoundcare) did not have an updated CP when there was a change in condition. Not following this requirement posed a risk to the health, saftey, or personal rights of clients in carethe state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: LPA suggested an signed understanding of the administrator of 87463 and 87466, and then updated these two residents needs and services plans

Type of visit: Required - 1 Year

Licensing Program Analyst, LPA, Noel Wolf Petersen and Licensing Program Manager, LPM Liza King arrived unannounced to conduct a annual inspection of the facility. The LPA and LPM met with the Executive Director Jackie Hernandez to explain the purpose of the visit. A physical inspection was completed, including but not limited to the bedrooms/bathrooms, the kitchen, the exterior and emergency route gate, the memory care unit, the common areas, and storage areas. Traffic areas are unobstructed and well lit. The fire extinguishers are dated may 6 2026, and the first aid kit has all necessary components. there are some ongoing repairs of the air conditioning, (a condenser tray leaking), the Maintenance director provided that the facility was probably going to replace the unit. at the time of the annual inspection, the air temperature within the facility is in range 68-85, and the LPA gave guidance that temperature should be maintained for the residents through the repair/replacement of the unit. Bedrooms * bathrooms: One of 6 observed bedrooms was malodorus for R1. LPA gave guidance that increased housekeeping checks should be included with the care plans for those residents with with inconteince issues. 5 of 5 resident rooms checked have functional bathroom hardware(sink facuets, showers, toilets). Water delivered at the sink measured between 110 and 115. 6 of 6 Bedrooms are furnished with required furniture, bathrooms have secure grab bars. Kitchen: Perishable/nonperishable food storage is at a capacity for 2/7 days for 65 residents plus 3 snacks per day, the sharps and toxics are stored seperately from each other and secure from the residents. Food for the residents is able to be held within the walk in, and a snack bar is maintained for resident access between meals. 4 residents have a concern about increasing menu options, specifically the availability of vegetables. The facility had a recent resident council and a meal suggestion survey where the issue was raised, and the LPA gave guidance that grievance procedure process should play out from here. Continued on c page 1 meal service was observed, turkey, mashed potatoes, gravy, cranberries, a jello/icecream. Senior Kitchen staff in interview outlined a desire to be more responsive to resident menu requests by adding additional vendors, adding a deep fryer, and adding a salad bar. There was a recent issue, a lack of spoons which was impacting service to the residents. New spoons have been ordered. 1 med pass was observed. Medtechs were observed to be handing out medications to the approprite parties in a timely fashion. No concerns with the medpass as observed. Recent medication MARs were checked for 11 residents, 1 had a discrepancy resolved as part of a complaint earlier in the month, and the other 10 were error free. There is a outstanding discrepancy on a the controlled substances log, which the facility resolved internally to the satisfaction of the department at this time. Exterior is clean, there is a water feature back by memory care the LPA gave guidance should have rocks added to make the basins shallow enough as to mitgate any risk of drowning. Evacuation routes all exit out the front of the facility which is ungated. Memory care doors unlock in the event of a fire. LPM reviewed 10 client files. Resident files were reviewed for the health training, admission agreements, recent medical assessments, and recent significant events. One resident deteriorated rapidly after a fall, internal investigation? LPM reviewed 10 staff files. 2/10 staff did not have current first aide training. A discussion occurred with the Administrator who verified that training is scheduled to be completed by 06/26/2026. 3/10 staff files reviewed showed there were past due annual trainings to be completed. According to the Administrator these staff have been counseled and will have the trainings completed by 06/26/2026. It appears that the facility needs to put systems in place to better hold staff accountable for upcoming and past due trainings. The facility currently uses relias which runs reports to show trainings that are coming/due and past due. Guidance was provided as well that although some trainings are only required upon initial hire, there are subjects which would be a best practice to revisit on occassion. Additionally, the facilities current practice is to use resumes in place of an application which provides a work history and is an acceptable alternative. Continued on c page Common areas: Common areas were observed to have adequate space for activites. in interview with the activities director and assistant activities director, they make observations about the accesibility and preferance of the clients for the scheduled activities. todays activities are morning walk, carnival, yoga, bingo, and card game(corner kings). the memory care has mostly the same activites minus the carnival. Memory care: is clean, traffic areas are well lit, 4 of 4 bedrooms have required furnishing and furniture, 4 of 4 bathrooms have functional hardware. water temperature delivered at the sink are measured between 108 and 112. Administrator files were reviewed including the administrators certificate, facility license, required postings (ombudaman poster, client rights poster, federal workers rights poster, activity calenders, menu calender), Liability insurance, workers comp insurance. No citations issued as part of this visit, a copy of the report was read and given to the administrator. Exit interview conducted. The Annual needs futher investigation to review service notes, emergency plan, fire drill log, pull cord log, resident council meeting notes, and infection control plan.the state’s words, verbatim · CDSS document, Jun 24, 2026

Allegation investigated: Facility is mismanaging medications.

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived to the facility to conduct a investigation into the above allegations. The LPA met with Executive Director Jackie Hernandez, and explained the purpose of the visit. In interview with the administrator and staff it was learned, a staff had mistakenly distributed a medication to a resident, the staff has since reviewed the rights of medication dispersal and recieved a written warning regarding the incident and recived sadow training which is ongoing. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.) 1 resident interviewed. Citation issued as part of this visit, A copy of the report was read and given to the administrator, appeal rights were provided, an exit interview was conducted. Substantiated As to the allegation that a resident was given another residents medication, the LPA reviewed the Log of the mar and interviewed two med techs, who were in agreement that the residents received corrected medications and dosages, excepting an incident for which medication mismanagment was cited as part of this complaint, where Eyedrops not perscribed to another resident were left on the cart of the same brand and given to a resident by mistake. Other medications on the log are described as being given appropriately. 2 medtech Staff are confirming in interview that other medications prescribed to the client were given appropriately to the orders as prescribed. 1 resident was interviewed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. A copy of the report was read and given to the administrator, appeal rights were provided, exit interview conducted.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 27-AS-20260602090314

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jun 18, 2026

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 in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs... This requirement was not met as evidenced by: In interview with administrators and staff it was learned that at least one resident was given medication that was not thiers. this poses a risk to the health and safety and personal rights of the residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: No POC, the staff have developed and implemented a plan to correct the medtech who had distributed the medication, which involved a review training, a shadowing period, and a write up.

Type of visit: Case Management - Other

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct a case management and deliver an amended report for a recent complaint. LPA met with the executive director Jackie Hernandez by phone and explained the purpose of the visit. LPA was informed Buisness Office Director Yaritza Alvarez would be the designated signatory for this report. LPA arrived, read the amended report, provided explanation for its amendments and responded to immediate questions, encouraged any follow up questions by the facility to reach out by phone(619-323-4509) or email(noel.wolfpetersen@dss.ca.gov). No citations issued as part of this visit, a copy of this report was read and emailed to the to the Business Office Director and the email address on file for the facility.the state’s words, verbatim · CDSS document, May 8, 2026

Allegation investigated: Staff are not showering residents Staff are not ensuring that residents are adequately fed

**This is an amended report, the report was ammened because the strength of the evidence collected supports a finding of unsubstantiated for the allegations rather than unfounded, meaning unlikely to have occured rather than proven definitively false. unsubstantiated lanugage was added and unfounded language was removed.** Licensing Program Analyst Noel Wolf Petersen arrived to the facility to deliver findings of a complaint concerning the above allegations, Met with administrator/executive Director Jackie Hernandez to exlain the purpose of the visit.LPA's review of client records shower schedule revealed cleints are on schedule to recive a shower roughly 1 day every 3 days(or 2x per week). 3 Staff and 3 client interviews provided a consensus that shower schedule was roughly accurate and there is sufficent staffing to flex emergency showers, refused/delayed showers, and incontinence care showers on a shift as necessisary to the clients needs. Showers can be accomodated with floor staff if home health aides are not availible. Continued on c page Unsubstantiated **This is an amended report, the report was amended because the strength of the evidence collected supports a finding of unsubstantiated for the allegations rather than unfounded, meaning unlikely to have occurred rather than proven definitively false. unsubstantiated language was added and unfounded language was removed.** LPA's review of client records regarding meal refusals revealed clients are given multiple opporutnities to refuse the same meal. 3 staff and 3 client interviews provided a consensus that meals are generally satisfactory. The LPA Witnessed a Meal service(noonish), where the clients were given serving sizes appearing proportionate to 1/3 of the daily serving values from the nutritional guide. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No citations issued. A copy of the report was read and given to the Administrator. exit interview conducted. appeal rights provided.the state’s words, verbatim · CDSS document, Apr 14, 2026 · control 27-AS-20260209084335

Type of visit: Case Management - Infectious Disease Outbreak

Licensing Program Analyst, LPA Noel Wolf Petersen arrived unannounced to the facility to follow up with two significant spikes in significant incidents (Some 16+ incident reports were submitted on 3/23-3/24, variations on confusion, unresponsive, unwitnessed fall, requiring send out) that occurred in proximity to infectious control events. LPA met with administrator/executive director jackie hernandez to explain the purpose of the visit LPA reviewed the infection control plan, with the administrator, Licensing was alerted to the outbreaks on 2/9 and 3/24 within three days to the facility noticing the coocuring symptoms. A licensed healthcare professional was consulted regarding the similar symptoms and the facility was logging the increased infection control measures(masks for staff/clients, sanitizing surfaces, letting guests know and sanitize prior to entry to the unit) to the current date. The facility reports 4 deaths during march. the facility stopped increased infection control measures after two weeks. Per 3 facility staff on shift (3) that were available for an interview, they are generally knowledgeable about the extra infection control measures. On a potentially related matter, LPA was informed of a clients infection that was septic during the past month, the facility provided the information that the client was out of the facility(Dec 30th(complaint of stroke) and at some point transfered to a SNF, and after coming to the facility after this period was immedately sent out to the hospital, staying at the facility for roughly the span of a day. Discharge paperwork related to the SNF visit and the Er visit after have already been submitted to the department for review. No citations were given as part of this visit, the LPA had no further questions about the spikes in incident reporting at this time. A copy of the report was read and given to the Administrator, exit interview was conducted.the state’s words, verbatim · CDSS document, Apr 14, 2026

Allegation investigated: Staff did not provide assistance in meeting residents necessary medical needs. Staff did not provide personal care and and assistance as needed by the resident which resulted in multiple falls and the care plan not being followed. Staff did not ensure reporting requirements were being followed Staff did not provide services necessary to meet resident needs such as cleaning and maintenance of buildings Staff did not provide care as needed for activities of daily living. Staff did not ensure residents bathing care needs were being met

On 03/27/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to deliver complaint findings. LPA Pascua met with Facility Designated Administrator (FDA), Jackie Hernandez and explained the purpose of the visit. Current census was 75. A brief interview with FDA Hernandez was conducted. Allegation: Staff did not provide assistance in meeting residents necessary medical needs. It was alleged that staff did not provide assistance in meeting residents necessary medical needs. During the course of this investigation, the department conducted interviews and reviewed facility records. Based on interviews conducted with 5 staff members, it was denied that staff did not provide assistance in meeting residents necessary medical needs. An interview with the residents responsible party was also conducted in which it was reported that there has not been any issues with the facility providing assistance. Based on the information gathered, there is not sufficient evidence to prove that the facility is not providing assistance with the residents necessary medical needs. Unsubstantiated As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff did not provide personal care and assistance as needed by the resident which resulted in multiple falls and the care plan not being followed. It was alleged that the staff did not provide personal care and assistance as needed by the resident which resulted in multiple falls and the care plan not being following. During the course of this investigation, the department conducted interviews and reviewed facility records. Based on interviews conducted with 5 facility staff members, it was denied that they did not provide personal care and assistance as needed. It was denied that due to the facility staff not providing personal care the resident falling. A review of the resident’s pre appraisal and care plan was conducted. It was learned that this resident was identified to have a walker to assist in mobility however was not dependent on this. In addition, a review of any incident reports and daily notes were conducted and did not indicate that the facility did not assist the resident resulting in multiple falls. In addition, there was no significant change in the resident resulting for an new care plan. Based on the information gathered, there is not sufficient evidence to show that this facility did not provide personal and assistance. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff did not ensure reporting requirements were being followed It was alleged that staff did not ensure reporting requirements were being following. During the course of this investigation, the department conducted interviews and reviewed facility records. Based on interviews conducted, it was denied by 5 staff members that they do ensure that reporting requirements were followed. It was stated that training is conducted to ensure that reporting requirements are always followed. In addition, it was learned through an interview with the responsible party that the facility notifies them of any changes regarding the resident in care and reports no issues. Based on the information gathered, there is not sufficient evidence to prove that the staff did not ensure reporting requirements were being followed. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff did not provide services necessary to meet resident needs such as cleaning and maintenance of buildings It was alleged that staff did not provide services necessary to meet resident needs such as cleaning and maintenance of buildings. During the course of this investigation, the department conducted interviews and reviewed facility records. Based on interviews conducted, it was denied by 5 facility staff that they do not meet the residents needs such as cleaning and maintaining the buildings. 5 out 5 residents state that the facility staff clean daily and report no issues. In addition, a facility visit was conducted on 09/17/2025, 10/15/2025, and 01/29/2026 were conducted and the department did observe any odors, items in disarray or items that needed maintenance. Based on the information gathered, there is not sufficient evidence to prove that the staff did not provide services necessary to meet residents needs such as cleaning and maintenance of buildings. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff did not provide care as needed for activities of daily living. It was alleged that staff did not provide care as needed for activities of daily living. During the course of this investigation, the department conducted interviews and reviewed facility records. Based on interviews conducted, it was denied by 5 out 5 staff members that the staff did not provide care as needed for activities of daily living. It was stated that each resident has a special care plan to ensure that their needs are being met. In addition, an interview with 5 residents were conducted. 5 out 5 residents denied that staff did not provide care with activities of daily living. Based on the information there is not sufficient evidence to prove that staff did not provide care as needed for activities of daily living. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff did not ensure residents bathing care needs were being met It was alleged that facility staff did not ensure that the resident’s bathing care needs were properly met. During the course of this investigation, the department conducted interviews and reviewed facility records. Based on interviews conducted, it was denied by facility staff the they did not ensure that the resident’s bathing needs were not met. Facility staff report there have been no issues with ensuring that the resident’s needs are met. In addition, an interview with the resident’s family report that they have no issues with the care needs of the resident. Based on the information gathered, there is not sufficient evidence to prove that the staff did not ensure that the resident’s bathing care needs were properly met. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Mar 27, 2026 · control 27-AS-20250911091201

Allegation investigated: Staff did not inform resident's responsible party of incidents.

On 02/27/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to deliver complaint findings. LPA Pascua met with Facility Designated Administrator (FDA), Jackie Hernandez and explained the purpose of the visit. Current census was 77. A brief interview with FDA Hernandez was conducted. Staff did not inform resident's responsible party of incidents. It was alleged that the staff did not inform resident’s responsible party of incidents. During the course of this investigation, the department conducted interviews and reviewed facility records. Based on conducted interviews, it was determined that on 05/26/2026 the facility reported an unwitnessed fall to the hospice agency. When asked whether the facility notified the resident’s responsible party of the fall, facility management stated that the hospice agency was informed and that it was the hospice agency’s responsibility to notify the responsible party. Substantiated However, 5 out 5 staff members report that the residents may have unwitnessed falls as they cannot prohibit the resident from falling but can assist to mitigate the falls. In addition, a review of the resident’s care plan dated on 05/26/2025, states that the resident may be a fall potential however the fall risk was scored as 0. This was acknowledged and signed by the resident responsible party on 05/26/2025. Based on the information gathered, there is not sufficient evidence to prove that staff did not provide adequate supervision to resident resulting in resident falling. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff did not assist with resident’s bathroom needs. It was alleged that staff did not assist with resident’s bathroom needs. During the course of this investigation, the department conducted interviews and reviewed facility records. Based on interviews conducted with 5 staff members. 5 out 5 staff members deny that they did not assist with the resident’s bathroom needs. 5 out 5 staff members state that they assist residents as needed. 5 out 5 staff members state that residents may have to wait for a couple minutes to get assistance however will always assist the residents. An interview with 5 residents were conducted. 5 out 5 residents denied not being assisted with their bathroom needs. Based on the information gathered, there is not sufficient evidence to prove that staff did not assist the residents with their bathroom needs. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. However, a review of the facility’s Plan of Operation, page 54, Reporting Requirements (6)(d), states: “any incident which threatens the welfare, safety or health of any residents, such as the following: falls…” must be reported. Additionally, page 55, Medical Emergencies, states: “In an event of a non-serious emergency…the physician will be contacted immediately for advice regarding treatment, the physician’s recommendations will be followed and documented, and the family contacted to report the incident.” Based on the information obtained, facility staff did not notify the resident’s responsible party of the incident. As a result of this investigation, the department found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. An exit interview was conducted and a copy of this report and appeals rights was provided to the facility at the end of this visit. Allegation: Staff did not properly discharge resident It was alleged that the staff did not properly discharge resident. During the course of this investigation, LPA Pascua conducted interviews and reviewed facility records. Based on interviews conducted, it was learned that this resident was at the facility for 1 week for respite care with assistance from Hospice. It was stated by facility management that due to the resident being on respite, the facility would be notified by the responsible party or hospice when the resident would leave. It was stated that the family would pick the resident up. A review of the facilities records show that the facility discharged the resident’s medication and belongings with the responsible parties signature acknowledging that they had obtained everything for the resident. Based on the information gathered, there is not sufficient evidence to show that the staff did not properly discharge the resident. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of the report was given to Jackie Hernandez.the state’s words, verbatim · CDSS document, Feb 27, 2026 · control 27-AS-20250818101558

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Mar 6, 2026

(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 This is not met as evidenced by: Based on interviews and record review, the licensee did not ensure that a resident’s responsible party was notified after a fall incident. This poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Feb 27, 2026

Plan of correction: Facility administrator states that a statement correction will be provided stating that the facilities new implementation and reporting requirement procedures.

Allegation investigated: Staff provided a meal to resident that contained a known food allergen

On 1/29/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to deliver complaint findings. LPA was met by Facility Designated Administrator (FDA), Jackie Hernandez and explained the purpose of the visit. The purpose of this visit was deliver complaint findings for the allegations above. Current census was 77. It was alleged that facility staff served a resident a meal containing a known food allergen. During the investigation, the department conducted interviews and reviewed facility records. Based on interviews with facility staff, it was confirmed that on 11/26/2025, during lunch, a staff member observed S1 consuming clam chowder. Facility staff reported that they were notified by a family member that the resident had a shellfish allergy. Kitchen staff subsequently confirmed that the soup contained shellfish.A review of facility records revealed that on 07/30/2024, the resident’s dietary needs were updated. A communication notice reflecting this change was completed and signed on that date to notify facility staff. Substantiated Based on the information gathered, the facility staff did serve a meal to the resident with a known food allergen. As a result of this investigation, the department found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. An exit interview was conducted and a copy of this report and appeals rights was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 27-AS-20251202092711

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jan 30, 2026

(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This was not met was evidenced by: Based on interview and record review, the licensee did not follow the assistance and care needs of the residents as indicated in their pre-admission appraisal for assistance in meals, food allergies, and eating. It was learned that facility staff provided the resident with a known allergen during meal time. This presented an immediate threat to the Health, Safety, and Personal Rights of the residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2026

Plan of correction: The facility designated Administrator stated that facility staff shall be sufficient and able to meet the needs of the residents at all times. Training, for no less than (1) hour in duration, will be conducted and completed for all facility staff providing care and supervision to the residents at this time. The topic shall cover the policies and procedures for this facility's meal service, food allergies, and ADLs delivered to the residents in care. A statement of correction, along with proof of training topic, trainer information, and list of attendees will be completed and submitted into CCL by the due date.

Type of visit: Case Management - Deficiencies

On 10/21/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the community to conduct a case management. LPA Campbell met with Andrea Eldridge, Memory Care Director, and explained the purpose of the visit. During the course of the visit, LPA Campbell spoke with S1 regarding the call button system and procedure, reviewed the PalCare alert system, and spoke with the S2 about prior and ongoing issues with the pendant system. Per S1, under 15 minutes is an acceptable response time for pendant calls though there there may be longer response times during med pass or meal times. S1 reported that when residents use their pendants, notifications are sent both to a department computer screen and the phone. If there is no response, the notification is sent to the front desk where the front desk staff can radio for assistance until the alert is cleared. The front desk is available from 8 am to 8 pm. LPA Campbell then worked with staff to produce a report that showed all alerts for R1 for the past month. Upon review of the Detailed Alert Report for R1 from 09/20/25 to 10/20/25, 20% of the pendant calls received had a response time longer than 15 minutes and 6% of the pendant calls had a response time longer than 30 minutes. Per S2, there are ongoing issues with clearing alerts and/or staff receiving alerts. S2 reports that pendant alerts either cannot be cleared or are not being received by staff. LPA Campbell and S1 discussed alternatives for the pendant that are more consistent. S1 was urged to ensure staff document all bed checks and to increase checks for R1 when they are on the way, or returning from other residents checks. LPA Campbell also discussed staff using active listening skills and showing empathy to residents and families to de-escalate emotional conversations. Due to documented alert response times that cannot be verified as technical issues and reported lack of response to pendant calls, the facility staff are unable to be reliably summoned to meet residents needs. Because the community pendant system is not working dependably for residents, the community is in violation of regulation 87303(i)(1) Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit. An exit interview was conducted, and copies of the report and appeal rights left.the state’s words, verbatim · CDSS document, Oct 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i)(1) · Plan of correction due date: Nov 4, 2025

87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1)All facilities licensed for 16 or more... shall have a signal system The licensee did not meet the above requirement when: Based on record review and interview, the pendant /call alert system has not been functioning properly since at least 09/01/2025. This posed/poses an immediate risk to the health safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: The licensee will identify the cause of the alert system problem and the steps needed to resolve it or decide to replace the system with a method that will document pendant calls to staff by the POC due date. The findings will then be emailed to LPA Campbell at renee.campbell@dss.ca.gov

Allegation investigated: Licensee did not ensure facility was maintained in good repair.

On 10/15/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the community to close a complaint. LPA Campbell met with Pa Vang, Health and Welness Director and explained the pupose of the visit. Regarding the allegation that the licensee did not ensure the facility was maintained in good repair, LPA Campbell interviewed staff and observed the areas of concern mentioned in the complaint. During visits on 07/13/2025 and 10/15/2025, LPA Campbell observed that the freezer was working and the temperature was at -1 degrees Fahrenheit. The ice machine chest was full and staff were seen providing ice water to residents during lunch. When LPA Campbell went into the kitchen on 10/15/2025, the temperature was comfortable and S1 reported that everything (AC, freezer and ice machine) was working. S2 described the repairs and work arounds that were made for the AC, freezer and ice machine so that staff and residents were not unduly impacted. Unsubstantiated Per 87303(a), the community did "include provision of maintenance services ... for the safety and well-being of residents, employees and visitors" by providing repairs and temporary options where necessary. Therefore, based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Oct 15, 2025 · control 27-AS-20250717103628

Allegation investigated: Staff handled resident in a rough manner causing bruising.

Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to open a complaint. LPA Campbell met with Jackie Hernandez, Administrator and explained the purpose of the visit. Regarding the allegation that staff handled resident in a rough manner, causing bruising, LPA Campbell interviewed staff, reviewed incident reports and images of the injury. Of the staff interviewed, (Staff 1, S2, S3 and S4) none reported that they had observed any staff treat Resident 1 roughly. However, S4 stated that R1 has a history of falls because "they are very indepenedent". When LPA Campbell reviewed In house Incident Reports,it was found that there had been several minor falls without injury since 11/2024. S5 also reported that R1 has a tendency to hit his arms on the bedrails. When asked, R1 stated the bruises happened when someone may have bumped into him but they could provide no further details. Due to the above noted information, 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, and therefore this allegation is UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, nothe state’s words, verbatim · CDSS document, Sep 3, 2025 · control 27-AS-20250829082834

Allegation investigated: Staff are misusing the facility's keys Staff mishandled the residents medications Staff is verbally abusing the residents while in care Staff have inadequate records keeping for the residents

On 07/15/2025, LPA Campbell arrived to the facility unannounced to present findings for a complaint for the above allegations. LPA Campbell met with Jackie Hernandez and explained the purpose of the visit. Regarding the allegation that Staff are misusing the facility's keys, when interviewed, S1 and S3 recounted that keys are kept with the caregiver during their shift. Since they keep the keys with them, they both would have no issues entering a residents room to check on them. Neither caregiver reported problems having the keys in the past or currently. Regarding the allegation that staff mishandled the residents medications, when interviewed, Med Techs (S3 and S4) and Caregivers (S1 and S2) reported no issues. MAR for documents reviewed were found to be complete. When family members were contacted, (F1, F2 and F3) all reported no problems with medication being successfully given to family members. Unsubstantiated Regarding the allegation that staff is verbally abusing the residents while in care. Of the four staff interviewed (S1 to S4), none reported observing staff verbally abusing residents. S4 stated that she always urges patience when speaking with residents. Family members contacted (F1 to F3) communicated no concerns regarding staff not being respectful towards their parents and/or family members Regarding the allegation that staff have inadequate record keeping for the residents, the complainant claimed that staff falsified documents. Documents (MAR) reviewed were complete and accurate and staff (S1, S2, S3 and S4) reported they were able to successfully complete documentation daily for crossover. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore this allegation is UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of the report was given to Jackie Hernandez.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 27-AS-20250225091641

Allegation investigated: Staff did not ensure resident’s signaling equipment was maintained in operable condition.

Licensing Program Analyst Renee Campbell arrived to the facility unannounced to open a complaint. LPA Campbell met with Jackie Hernandez, Administrator and explained the purpose of the visit. Regarding the allegation that staff did not ensure resident’s signaling equipment was maintained in operable condition, LPA Campbell observed that notifications were not heard or responded to by staff. LPA Campbell observed that when R9 pulled their cord, the call was received by the Memory Care phone but could not be heard. When asked, S4 stated that they had been experiencing problems with the Memory Care phone receiving notifications from residents. Based on LPA’s observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit. An exit interview was conducted, and copies of the report and appeal rights left. Substantiatedthe state’s words, verbatim · CDSS document, Jul 15, 2025 · control 27-AS-20250709140117

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i)(1)(B) · Plan of correction due date: Jul 25, 2025

Maintenance and Operation (i) Facilities shall have signal systems which shall ... (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement is not met as evidenced by: Based on observation and interviews, the licensee did not ensure the facility had a signal system that was able to summon staff based on statements by S4 and observations of LPA Campbell which poses an Immediate Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: The licensee will conduct an in-service regarding the Call System phone and relay consequences such as written warnings and possible termination for reducing the volume needed for notifcation & safety. The licensee will email the in-service sign in sheet to LPA Campbell by POC due date

Allegation investigated: Staff inappropriately solicited money from residents

On 06/26/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to present findings for a complaint. LPA Campbell met with Executive Director Jackie Hernandez and explained the purpose of the visit. Regarding the allegation that staff inappropriately solicited money from residents, when interviewed, the Executive Director stated solicitation is not allowed in the facility as stated in the Admission Agreement. LPA Campbell reviewed the newsletter provided by the community to residents and families requesting donations. According to the most recent admission agreement and/or handbook, staff are not allowed to request donations and this includes the Executive Director. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit. An exit interview was conducted, and copies of the report and appeal rights left. Substantiated Regarding the allegation that staff did not ensure they have enough supplies for residents, R2 stated that “I don’t need help with toileting but I use wipes sometime. I haven’t noticed them being slow to get.” and R3 said, “I haven’t noticed them running out of wipes or other supplies. I didn’t notice them using paper towels to clean me.” Staff 1 (S1) also stated, “I always make sure I have enough for my shift.” However, she informed LPA Campbell that “staff don’t does not supply wipes, the family must supply that.” As shown in the Admission Agreement under I. Basic Services. (D. Personal Supplies) residents may either provide hygiene supplies themselves or obtain them from Cogir Turlock for an additional charge. Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jun 26, 2025 · control 27-AS-20250123084448

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Jul 3, 2025

87208(a) The licensee shall have and maintain a current... definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation. This requirement is not met as evidenced by: Based on interviews and record reviews, the community solicits donations for staff which conflicts with the facility No Tipping policy as found in the community handbook that applies to tips and gifts for services rendered which poses a potential health, safety and personal rights risk.the state’s words, verbatim · CDSS document, Jun 26, 2025

Plan of correction: The community will update the handbook addressing the conflict between requesting holiday donations for staff and the No Tipping policy by the POC due date and provide the updated handbook via email to renee.campbell@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct an annual inspection. LPA Campbell met with Tony Montellano, Executive Director and explained the purpose of the visit. This facility is a single story building licensed to serve one-hundred (100) non-ambulatory residents, of which eight (8) may be bedridden and ten (10) may have a hospice waiver. LPA Campbell observed the facility to be free of odor, clean and in good repair. LPA Campbell observed bedrooms to be properly furnished with appropriate bedding and lighting. A fountain was observed in use outside but it was locked behind a gate. There are no other bodies of water present. LPA Campbell toured the facility and inspected common areas, the kitchen, bedrooms, bathrooms to ensure there are no safety hazards for residents. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature was tested in rooms 201 and 206. In room 201, the hot water temperature was measured at 115 degrees Fahrenheit. In room 206, the hot water temperature was measured at 116 degrees Fahrenheit . Both measurements are within the required range of 105 and 120 degrees. LPA Campbell observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Campbell observed locked storage areas for the storage of cleaning solutions . LPA Campbell reviewed 7 residents files. Of the files reviewed, 4 of them were missing TB tests or chest X-rays. Resident files will therefore require an audit and additional TB testing for residents where needed.. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit. An exit interview was conducted, and copies of the report and appeal rights left.the state’s words, verbatim · CDSS document, May 7, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a-c)(1)(A) · Plan of correction due date: May 23, 2025

87458 Medical Assessment. (a) Prior to a person's acceptance as a resident, . licensee shall obtain ... a ..., (1) A physical examination of the resident indicating the ... results for ... (A) Communicable tuberculosis. This requirement was not met based on: Based on record reviews, four of seven resident files reviewed did not have record of Tuberculosis tests or chest x-rays with their results. This poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: The facility will conduct a full audit of all resident files to ensure there is record of TB tests or Chest X-rays with results and arrange TB tests where needed. Once the audit is complete, the facility will use the resident roster to indicate the residents who are missing TB tests or chest x-rays and how new assessments for TB will be conducted.The resident admission dates will also be added to the roster to indicate the date is present on the ID page. Results are to be sent to LPA Campbell to renee.campbell@dss.ca.gov by the POC due date.

Allegation investigated: Staff are inappropriately charging residents for food delivery

On 02/12/25, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to present findings for a complaint. LPA Campbell met with Executive Director Anthony Montellano and explained the purpose of the visit. Regarding the allegation that staff are inappropriately charging residents for food delivery, per the admission agreement, clients are not charged for tray service if they are ill. In the admission agreement Under the section titled, Residential Services in Subheading MEALS, Tray Service is offered as an optional service if a client is not ill for an additional fee. Resident #1(R1), R2 and R3 stated they had not been charged when receiving tray service when they were ill and had not ordered Tray Service otherwise. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore this allegation is UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter nothe state’s words, verbatim · CDSS document, Mar 12, 2025 · control 27-AS-20250123084448

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Renee Campbell and arrived at the facility to conduct an unannounced annual inspection on 04/04/24. LPA Campbell met with,Tony Montellano, Executive Director and explained the purpose of the visit. LPA Renee Campbell toured the facility with the Executive Director Tony Montellano and inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve one-hundred (100) non-ambulatory residents, of which eight (8) may be bedridden and ten (10) may have a hospice waiver. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. A fountain was observed in use outside but it was locked behind a gate. There are no other bodies of water present. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies. The hot water temperature was measured in two bedrooms. One resident's bathroom water temperature measured at 110.7 degrees Fahrenheit.. LPA then measured another residents bathroom on the other side of the facility at 114.4 degree Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in good repair. Facility thermostat observed at 75 degrees Fahrenheit. LPA requested staff files for review. LPA reviewed 6 resident files. Toxins were made inaccessible to clients in care. Toxins are stored in the laundry room and staff maintenance closets. Current census was 74. LPA reviewed 6 staff files. Due to insufficient time, LPA will come at a later date to conduct a continued annual. No deficiencies or citations provided during the course of this visit. An exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 4, 2024

Allegation investigated: Staff are mismanaging resident's medication

On 03/14/24, Licensing Program Analyst Renee Campbell arrived unannounced to present findings for a complaint. LPA Campbell met with Tony Montellano, Executive Director and stated the purpose of the visit. Regarding the allegation that staff are mismanaging residents medication, F1 reported that R1 had observed several instances of missing or incorrect medication. However no missing medication was found on the eMAR. S2 admitted that no errors were found on the eMAR because when R1 would identify a med error, the Med Tech corrected the error immediately. Based on LPAs observation and interviews which were conducted and records reviewed, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D during this visit. Exit interview held, Appeal Rights discussed, Copy of report given. Substantiated In regards to the allegation that staff do not keep residents personal information confidential, the reporting party alleged that R2 had her blood pressure taken and was given her medication in the dining room in front of other residents. During two interviews, R2 stated that they took their own blood pressure and recorded the results for themselves and took her medicine with meals. Because R2 did not report a violation of their right to privacy, this allegation is UNSUBSTANTIATED. Due to the above noted information, 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, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 27-AS-20231109083759

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Apr 3, 2024

87464 : Basic services shall at a minimum include:Personal assistance and care as needed by the resident and ... assistance with taking prescribed medications... This requirement is not met as evidenced by Based on interviews and documentation; the licensee did not ensure the resident received assistance and care with taking prescribed medications which poses a potential Health, Safety and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: All med techs will repeat their inservice training with an 8 hr training module and med techs will be required to pass a proficiency exam. The exams with their names and scores will be sent to the department as proof of completion as of the POC date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Renee Cambell conducted an unannounced Case Management visit on this date and met with Administrator Tony Montellano and Health and Wellness Director Anneka Ogundipe. Upon entry, LPA Campbell was greeted by the facility receptionist and observed staff cleaning the entry and dining room. Over the course of the visit, LPA Campbell observed residents eating meals, socializing with other residents, and receiving staff assistance entering or exiting the dining room. Residents were observed eating peas and carrots, Sheppards Pie, Broccoli soup and rolls with iced tea or water. Staff were later seen clearing tables or passing out dessert at resident’s request. The Department received an incident report (IR) on 02/21/24 regarding a 02/06/24 med error. During the visit, the LPA met with Health and Wellness Director Anneka Ogundipe to conduct a short interview and collect any associated documents. LPA Campbell observed an eMAR with the doctors orders to change the frequency of a prescription as well as the IR for the event dated 02/06/24. According to the orders, the start date for the medication (02/07/24) occurred after the date of the incident report on 02/06/24 as shown on the IR. The Wellness Director, confirmed that the date entered on the IR was in error. The incident instead occurred on 02/07/24 . Also, the incident report was received on 02/20/24 and was therefore received 6 days past the reporting requirement of 7 days. The MedTech (S2) who had dispensed the medication incorrectly, reported that they were at fault because they had not read the med orders or followed the dispensing procedures to avoid med errors. Per California Code of Regulations (CCR) – a deficiency is being cited on the attached LIC 809-D. Appeal Rights provided. Failure to correct deficiencies may result in civil penalties. Exit interview held and copy of report given to Health and Wellness Director Anneka Ogundipe .the state’s words, verbatim · CDSS document, Feb 22, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Mar 19, 2024

87465 Incidental Medical and Dental Care. (a)A routine plan ... (5) may assist persons with self-administration as needed. Assistance shall be limited to medications... authorized by the person's physician. This requirement is not met based on: Based on interviews and record reviews, 1 of 2 staff reported that they did not assist persons with self-administration as authorized by a person's physician. This poses an immediate Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: The Health & Wellness Director will conduct an audit of client MARS bi-weekly to be charted on the eMAR & will conduct Medication Pass Training for Med Techs by 03/15/24. A sign in sheet with all participants will be faxed with LPA Campbell's name as the recipient.

Allegation investigated: Staff did not provide resident's authorized representative with resident's records

The allegation that staff did not provide residents authorized representatives with the resident’s records, has been found to be substantiated. During the initial complaint intake, it was stated that R1's MAR records were requested by resident representative after October of 2022. A document request via email on 10/18/23 and 10/25/23 came from a resident representative. In reply, Cogir stated in their October 25, 2023 email that they could not provide requested documents because they were archived with the prior owners of Cogir. All requested unredacted records were not received until 01/15/24 per a 01/15/24 email from the resident's representative. The request for records in October of 2023 was not completed in full until February of 2024 instead of the 2 days as required. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit. An exit interview was conducted, and copies of the report and appeal rights left. Substantiatedthe state’s words, verbatim · CDSS document, Feb 16, 2024 · control 27-AS-20231109083759

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Mar 25, 2024

87468.2(a)(19) (19) To have prompt access to review all of their records and to purchase photocopies of their records. .. within two (2) business days and at a cost that does not exceed the community standard for photocopies. This standard has not been met as evidenced by: -Based on observation, interviews and record review, it took the resident’s representative several months versus the two days required, to receive requested unredacted documents from the licensee which poses a potential Health, Safety or Personal Rights Risk.the state’s words, verbatim · CDSS document, Feb 16, 2024

Plan of correction: The administrator will work with the licensee to establish a procedure to obtain documents for legacy residents currently residing in the facily by the POC date.