Cornerstone Assisted Living

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a Case Management Incident and was greeted by Administrator (Admin) Shelley Reyes. On 5/22/2026 CCL received an incident report regarding a resident (R1) having a rash. Family came to Med Tech and let them know that resident had scabies. Resident was put to quarantine. As of today 5/29/2026, R1 had a doctor appointment whether R1 had a scabies diagnosis. It is currently undetermined until after doctor appointment. Admin to send IR with update once received. In addition, no other residents showed signs of scabies in the facility. No deficiencies cited during todays visit. Copy of report given and read with administrator.the state’s words, verbatim · CDSS document, May 29, 2026

Type of visit: Required - 1 Year

At approximately 10:00am Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection visit and was greeted by Program Administrator (admin) Shelley Reyes. Facility is a Residential Care Facility for the Elderly (RCFE) with currently one hundred and seven (107) residents in care. Facility has a hospice waiver for twelve (12), a bedridden waiver for thirty (30), and is approved for all non-ambulatory residents. LPA and admin toured the buildings and grounds. Facility found to be at a comfortable temperature. All passageways and emergency exits were free from obstruction. LPA observed evacuation chairs on both stairways. Admin opened chairs and were observed to be functional. Elevator was operational and functional. Alarm system in exit door heading toward courtyard had minimal low volume, not loud enough to summon staff. Batteries were replaced. In addition, signal system heading toward back parking lot exit next to restrooms was not turned on. (Deficiency cited, see LIC 809D). Facility's fire extinguishers were observed charged and were last serviced 12/2024. Facility's fire system is hardwired though fire department. Four (4) water heaters throughout facility. Ten (10) residents' apartments were inspected and water temperatures in Residents' bathrooms and communal bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. Residents' bedrooms were inspected and observed to be clean with all the appropriate furnishings. The call system was tested in four (4) resident's rooms. Caregiver response time was 6 minutes and 17 seconds, 1 minute and 33 seconds, 1 minute and 50 seconds and 3 minutes and 50 seconds. Storage rooms containing cleaning supplies and other items that could pose a risk were locked. Continued to 809C... continued from 809... Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Facility kitchen and walk-in refrigerator and freezer were inspected and all food is being properly labeled and stored. LPA observed activity rooms including theater room, puzzle room and library room to be accessible for residents to use. Seating areas were observed in multiple outdoor courtyard spaces throughout the facility for activities. Facility has two transportation vehicles including a bus and van for resident outings. LPA observed fire extinguishers up to date and last serviced 12/24. LPA observed first aid kit in both vans to have multiple expired items (Technical Violation given). Admin showed proof of order receipt for first aid kits to be replaced for both cars. LPA reviewed nine (9) staff files and ten (10) resident files. All staff files reviewed have all of the required paperwork, proof of current First Aid and CPR training, and proof of all required training hours. Training certificates not placed in employee files, admin to send certificates to LPA by 11/19/25. Ten (10) of ten (10) resident files reviewed have all the required paperwork. LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. Facility does not handle residents P&I monies. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC500 Personnel Report LIC308 Designation of Responsibility Liability Insurance 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, or repeat violations, may result in a civil penalty assessment. Appeal rights provided to Administrator.the state’s words, verbatim · CDSS document, Nov 17, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ethel Contreras arrived unannounced to conduct a case management visit and was greeted by Program Director, Shelley Reyes. The purpose of the visit was to follow up and gather additional information on an incident that was self reported to CCL on 7/10/2025. On 6/24/2025 admin was informed by anonymous resident that they witnessed staff (S1) kissed a resident (R1) on the lips 2 1/2 months prior. Admin sent incident report to CCL on 7/10/2025. Staff (S1) has been terminated as of 7/01/2025. During todays visit LPA conducted interviews and obtained documentation pertaining to incident. No deficiencies cited during today's visit. Copy of report given and read with administrator.the state’s words, verbatim · CDSS document, Oct 15, 2025

Type of visit: Case Management - Other

Licensing Program Analyst(LPA) Contreras arrived unannounced to conduct a case management visit. LPA was greeted by care coordinator Josephine Garcia. The purpose of the visit was to gather documents regarding an incident report submitted on 7/21/2025 and a death report submitted on 7/24/2025. On 7/21/2025 CCL received IR regarding resident (R1) having a fall in the shower and hit their head on shower floor. Med tech called 911 and EMT's evaluated resident, however resident refused to be taken to ER for further evaluation. LPA asked care coordinator for refusal letter and discussed reporting and documentation requirements regarding resident refusals. Care coordinator provided LPA with resident incident report done by EMT/Firefighters stating resident refusal. On 7/24/2025 CCL received death certificate regarding resident (R1) DOD on 7/22/2025. LPA requested death certificate as resident was not on hospice. Care coordinator provided LPA with death certificate. No deficiencies cited during today's inspection. Exit interview conducted with Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 9, 2025

Allegation investigated: Staff did not dispense medications as prescribed

On 07/15/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint 21-AS-20250425105956 investigation findings regarding the above allegation and met with Shelley Reyes, Administrator. Reporting Party (RP) alleges that the facility staff did not dispense medications as prescribed for Resident 1 (R1). LPA Florio conducted a 10-day complaint investigation visit on 04/28/2025 and obtained documents, made observations, and conducted interviews. During this visit it was revealed through R1’s Centrally Stored Medication Record and an interview with Staff 1 (S1) that the facility received R1’s medications on 04/20/2025. S1 stated that the prescription “said to hold the medication if the blood pressure was at a certain level, but we did not have an order to check a daily blood pressure.” S1 attempted to reach the physician to obtain a separate order for blood pressure monitoring and was unsuccessful. Continued on LIC9099C... Substantiated Continued from LIC9099... S1 then left a note for Staff 2 (S2) to follow up with R1’s physician. There are no records of S2 following up. S1 stated that medication was held until orders could be obtained. On 5/28/2025, an interview with R1’s treating physician revealed that R1 was in stage four terminal heart failure and had pneumonia. Additionally, the physician stated that they did not believe that the medications in question would have changed R1’s terminal prognosis. However, during today’s complaint investigation visit, an interview with Staff 3 (S3) revealed that no log was maintained showing staff observed R1 for swelling or other symptoms of fluid retention. Based on interviews and record review, the facility was unable to provide proof that staff followed through with obtaining blood pressure parameter orders or that staff dispensed medications as prescribed, (see LIC9099D). Based on interviews conducted and records obtained, the allegation that the facility staff did not dispense medications as prescribed is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Appeal rights provided.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 21-AS-20250425105956

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

Incidental Medical and Dental Care 87465(a)4 The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews and records review, facility did not dispense R1's medications as prescribed. This poses an immediate health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: Administrator to submit scheduled training date with a self-certification to CCLD by POC date 07/16/2025.

Allegation investigated: Facility is in disrepair.

Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to initiate complaint investigation and deliver findings regarding the allegation listed above and met with Shelley Reyes, Administrator. During visit LPA observed that facilities A/C unit that controls southern corridor, dining room, and activity room is not functional. Interviews with staff and Administrator indicate that A/C has been broken for a few months and had intermittent functionality summer of 2024. According to Administrator, licensee purchased a new unit a few weeks ago, however, it was the wrong unit. During visit, Administrator received email correspondence that the correct unit will be installed July 1st. Based upon the observations and interviews, there is preponderance of evidence to prove that the allegation(s) have/has been SUBSTANTIATED and are/is valid. Deficiency cited on LIC9099-D, per Title 22 Regulations, Division 6. Exit interview conducted. Appeal rights given. Copy of report discussed and provided to Administrator whose signature on form confirms receipt of document(s). Substantiatedthe state’s words, verbatim · CDSS document, Jun 25, 2025 · control 21-AS-20250623170032

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 3, 2025

87303(a). The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors This requirement has not been met as evidenced by A/C was observed non-functional resulting in increased temperatures within parts of facility. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 25, 2025

Plan of correction: Licensee to submit plan on how they will ensure resident safety from heat in areas affected by non-functional A/C by POC due date of 7/3/2025. Additionally, Licensee shall submit self-certification to CCL of functional A/C when new unit has been installed.

Allegation investigated: Facility staff not ensuring contaminated surfaces are disinfected Facility staff not addressing change in resident’s condition

On 04/28/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint 21-AS-20250127085410 investigation findings regarding the above allegations and met with Shelley Reyes, Administrator. Reporting Party (RP) alleges that the facility is not addressing changes in Resident 1 (R1’s) condition and that facility is not ensuring contaminated surfaces are disinfected which RP says have resulted in odors in the facility and visibly soiled furniture within the facility. LPAs Florio and Stevenson conducted 10-day complaint investigation visit on 01/28/2025 and obtained documents, made observations, and conducted interviews with Staff (S1) and Staff 2 (S2). Based on LPA’s interviews, observations made, and documents obtained, LPA received conflicting information regarding the above allegations. During 01/28/2025 facility visit, LPA toured the facility, and no odors were present nor where any surfaces observed soiled during the inspection. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... LPA was informed that the facility activities director wipes down all chairs and surfaces in the activities area regularly, the facility has the cleaning crew clean the carpets every Friday, and the facility has a carpet cleaner/extractor on site that they use to clean up any visibly soiled areas immediately. LPA received copies of R1’s pre-placement appraisal and care plan documentation from Licensee which confirm that R1 has a known, documented history of lymphedema and has been receiving home care to wrap their legs three times per week since being admitted to the facility 06/2024. Additionally, based on documentation and shower logs received, facility staff offer R1 bathing assistance two times per week, but R1 often refuses. Lastly, on 4/23/2025, LPA obtained a staff roster showing sufficient staffing, and LPA spoke with facility administrator who informed LPA that R1 relocated to a new facility that offers memory care. Based on record review, interviews conducted, and observations made, the allegations that the facility is not addressing changes in Resident 1 (R1’s) condition and that facility is not ensuring contaminated surfaces are disinfected are UNSUBSTANTIATED. A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. 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, Apr 28, 2025 · control 21-AS-20250127085410

Type of visit: Required - 1 Year

At approximately 11:20 AM, Licensing Program Analysts (LPAs) Julie Florio and Robert Frank arrived unannounced to conduct a required 1-year annual inspection. Administrator, Shelley Reyes was contacted via telephone and arrived at approximately 12:00pm. Facility is a Residential Care Facility for the Elderly (RCFE) with ninety-two (92) residents in care. Facility has a hospice waiver for twelve (12), a bedridden waiver for thirty (30), and is approved for all non-ambulatory residents. At approximately 12:45 PM, LPAs initiated a tour of the facility with Administrator and observed the following: Facility is two stories, was a comfortable temperature, and passageways were free from obstructions. LPAs observed evacuation chairs at each stairwell. Six (6) residents' apartments were inspected and water temperatures in Residents' bathrooms and communal bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed a supply of hygiene products, clean linens, paper products, and incontinent care briefs available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. The call system was tested in five (5) resident's rooms and Caregiver response time was between two (2) and four (4) minutes. Storage rooms containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Facility kitchen and walk-in refrigerator and freezer were inspected and all food is being properly labeled and stored. Additionally, LPAs observed a menu with a variety of options as well as a communication board for staff to communicate residents' dietary restrictions. Medications were centrally stored and locked. There are covered seating areas in the multiple outdoor courtyard spaces throughout the facility for activities. Facility has internet available to residents and has a library with two community desktop computers available to residents in care. Residents were observed engaged in Bingo and there was an activities calendar posted with a variety of engaging events and outings planned daily. There are activity/game rooms on both the first and second levels. Continued on LIC809C... Continued from LIC809... A small movie theater was observed on the 2nd level with a large selection of movies/DVDs for viewing. There is a salon available on site. Facility's fire extinguishers were observed charged and were last serviced 12/2024. Facility's fire system is hardwired and was serviced in 1/2025. Facility conducts quarterly disaster drills with the most recent drill conducted 11/2024. LPAs observed facility's infection control plan and emergency disaster plan which was last updated 8/2024. LPAs observed a supply of PPE, emergency supplies, a first aid kit, and flashlights for emergency preparedness. At approximately 2:00 PM, LPAs reviewed ten (10) staff files and ten (10) resident files. Ten (10) of ten (10) staff files reviewed have all of the required paperwork, proof of current First Aid and CPR training, and proof of all required training hours. Ten (10) of ten (10) resident files reviewed have all the required paperwork. Administrator and residents' families coordinates medical and dental visits for the residents and transportation to and from their appointments. Additionally, facility has a podiatrist who visits once per month. At approximately 3:30 PM, LPAs reviewed medications and medication records which are maintained and stored in compliance with regulation. However, LPAs observed centrally stored medication records which do not accurately reflect the prescription labels for each respective medication, (see LIC809D). Facility does not manage P&I for residents. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC500 Personnel Report (updated) 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, or repeat violations, may result in a civil penalty assessment. Appeal rights provided to Administrator. Exit interview conducted with Administrator whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 15, 2025

Allegation investigated: Staff did not provide adequate supervision resulting in a resident wandering away from the facility.

Licensing Program Analyst (LPA) Julie Florio arrived unannounced to initiate a 10-day complaint investigation, regarding the allegation listed above for complaint 21-AS-20241014153520 received by Community Care Licensing (CCL) on 10/14/2024, and met with Shelley Reyes, Administrator. During inspection LPA obtained documents, made observations, and conducted interviews (see LIC812s). The complaint alleges that on 10/13/2024, at approximately 4:30 PM, Resident 1 (R1) was found wandering in the nearby shopping center by a concerned bystander. Facility self reported R1's elopement from the community on an Unusual Incident/Injury Report (UIR) submitted to CCL on 10/16/2024. The UIR stated on 10/13/2024 R1 left the facility and was found by Kohl's security in the shopping center's parking lot. CCL's Officer of the Day requested the facility submit R1's LIC602 Physician's Reports and Appraisal Needs and Services Plan to CCL, which facility submitted on 10/17/2024. Per R1's LIC602 dated 01/03/2022, they have Mild Cognitive Impairment (MCI) and are unable to leave the facility unassisted. Continued on LIC9099C... Substantiated Continued from LIC9099... The allegation, staff did not provide adequate supervision resulting in a resident wandering away from the facility is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency was cited on LIC9099-D, per Title 22 Regulations, Division 6. Exit interview conducted. Appeal rights given. Copy of report discussed and provided to Administrator whose signature on form confirms receipt of document(s).the state’s words, verbatim · CDSS document, Oct 22, 2024 · control 21-AS-20241014153520

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 23, 2024

87468.2(a) … [R]esidents ... shall have […] the following personal rights: (4) To...supervision...that meet their individual needs.... This requirement was not met as evidenced by: Based on review of facility submitted UIR, resident record review, and interviews with facility staff, facility did not provide adequate supervision for R1, which resulted in R1's elopement from the facility. This poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 22, 2024

Plan of correction: Administrator to provide in-service training for all staff to be alert and aware of residents wandering and/or exiting the facility and review of the facility's protocols in these situations. Administrator to submit scheduled training date to CCLD by POC date 10/23/2024 and submit completed signed training log to CCLD by POC due date 11/8/2024 EOB.

Type of visit: Case Management - Incident

On 10/22/2024, at approximately 12:40 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Incident follow up visit regarding 5 Unusual Incident/Injury Reports (UIRs) and 1 Death Report received by Community Care Licensing (CCL) between 09/23/2024 and 10/22/2024. LPA met with Shelley Reyes, Administrator. Facility is an assisted living community Incident #1 Received by CCL on 09/23/2024: On 09/22/2024, Resident 1 (R1) was given 1/2 tab instead of the doctor ordered 1/4 tab of Metropalol succ ER 25mg due to a pharmacy error. The pharmacy filled the incorrect quantity and this was discovered by the Facility's med tech after the medication had been given to R1. The Pharmacy was contacted and R1 was placed on 72 hour monitoring for any change in condition. A corrected prescription was processed by the pharmacy and sent to the facility. R1 did not report any change in condition. Incident #2 Received by CCL on 10/7/2024: On 10/4/2024, Resident 2 (R2) was "accidentally given Protonix 40mg medication" (See LIC809D). R1's primary care physician (PCP) and family were notified and R1 was placed on 72 hour monitoring for any change in condition. R1 did not report experiencing any adverse affects. Incidents #3 & #4 Received by CCL on 10/7/2024 & Death Report Received by CCL on 10/08/2024: On 10/3/2024, Resident 3 (R3) "had an unwitnessed fall and was found on the floor in [their] apartment by staff when doing safety checks." Another UIR for the same incident stated R3 "had a fall and had leg pain." EMS was called, R3 was sent to the ER, and later R3's family called the facility to report that R3 passed away due to Heart Failure on 10/4/2024. R3 was not on Hospice. On 10/7/2024, the CCL Officer of the Day requested a death report be submitted. Death Report was received on 10/8/2024 and stated that a copy of the death certificate would be requested. Based on record review, R3 was found at 4:00 AM on 10/3/2024. Continued on LIC809C... Continued from LIC809... Facility Administrator provided LPA with a copy of R3's Death Certificate which states cause of death: Cardiogenic Shock, Acute Hypoxemic Respiratory Failure, and Acute On Chronic Congestive Heart Failure. Incident #5 Received by CCL on 10/21/2024: On 10/14/2024, Resident 4 (R4) "was found on the floor when call light was answered. 911 was called. Resident was taken to the ER for further evaluation." The report states that R4 was discharged to a skilled nursing facility (SNF) on 10/17/2024. Per record review, R4 had previous falls on 7/18/2024 and 9/20/2024 which were not reported to CCL (See LIC809D). 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, or repeat violations, may result in a civil penalty assessment. Appeal rights provided to Administrator. Exit interview conducted with Administrator, whose signature on document(s) confirms receipt.the state’s words, verbatim · CDSS document, Oct 22, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 23, 2024

87465 Incidental Medical and Dental Care (a) …. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on observation, interviews, and record review, the Licensee did not ensure R2 received the correct medication as prescribed which poses an immediate health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 22, 2024

Plan of correction: Licensee has already conducted medication training on ensuring the correct medication and dosages are given to residents in care per the physician's order. Additionally, Licensee counselled the staff member who made the medication error. LPA cleared POC during today's visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Nov 22, 2024

87211 (a)(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of…. (D) Any incident which threatens the welfare, safety or health of any resident….This requirement was not met as evidenced by: Based on observation, interviews, and record review, the Licensee did not ensure CCL received Unusual Incident/Injury reports for two falls R4 experienced which poses a potential health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 22, 2024

Plan of correction: Licensee will conduct in-service training with all care staff on the proper reporting requirements as outlined in CCR 87211. Licensee will submit a signed training log with names of attendees, date, time, location and subject of the training, and who conducted the training to CCL by POC due date 11/22/2024.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Nakagawa and Mutialu were at facility to conduct case management. LPAs met with Administrator Shelley Reyes. The purpose of this case management is to follow up on a self-reported incident report submitted to Community Care Licensing (CCL). CCL received a self reported incident report on 04/24/2024 reporting on 05/01/2024. At 4:30 AM care staff went to check on resident (R1) and R1 was not in their apartment. Care staff and Medication Technician reported they conducted a search of building and were unable to locate R1. At that time care staff called 911. Dispatch reported R1 had been located and taken to hospital for evaluation. LPA reviewed physician's report which states that R1 has memory loss and is at risk if allowed to leave the community unsupervised due to dementia or cognitive decline, as well as a high fall risk. Facility is being cited for Regulation 87705(b)(2)(see LIC809-D). The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, May 9, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: May 9, 2024

87705 Care of Persons with Dementia (b)In addition to the requirements as specified in Section 87208..., the plan of operation shall address the needs of residents with dementia, including:Safety measures to address behaviors and ingestion of toxic materials. This requirement is not met as evidenced by: Based on record review, self-incident report dated 05/01/2024, and interviews with Administrator, R1 eloped without staff knowledge on 4/24/2024. The facility did not comply with section above,when R1 eloped from facility, which poses an immediate Health, Safety risk to residents in care.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: Administrator to ensure all exits have working auditory alarms that staff can hear or receive a signal when doors are opened. In addition Administrator to provide proof of scheduling of elopement training for staff (by EOB 5/10/2024). Administrator to reassess R1 for change in condition.

Allegation investigated: Staff did not meet resident's needs Facility is unclean Facility has an infestation of insects Staff did not provide adequate food service Staff did not provide a safe and comfortable environment for resident

At approximately 9:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegations. LPA met with Administrator Shelley Reyes, toured the building, reviewed records and interviewed staff. Based on records reviewed and interviews conducted, LPA did not find evidence to support the allegation that staff did not meet residents needs. LPA reviewed medical assessment regarding R1 which shows they are able to communicate their needs to staff. Resident assessments are updated every six months or as needed. LPA observed residents care plan was updated after staff observed a change in residents condition. Based on interviews conducted, staff conduct 2 hour checks on residents throughout the day. If a staff were to observe an issue with a resident or their room, they address the problem or call the appropriate department. Continued on LIC9099-C... Unsubstantiated During the visual inspection of the facility, LPA observed clean hallways and exits that were free from obstructions. LPA reviewed pest prevention reports from Clark Pest Control, which show what work was done. Facility has a monthly visit from Clark's, to have preventative measures taken to control and prevent pests in the building. The reports did not comment on any abnormal pest infestation. LPA reviewed menus prepared by the facility. LPA observed the food prepared and served by the facility to meet regulation. Facility posts a weekly menu for residents review, in addition to placing a daily menu at each table for residents to order from. If a resident is not pleased with the daily meal, the facility has an alternate menu for them to choose from. LPA was not able to find evidence to support the allegation of staff did not provide adequate food service. LPA did not observe any areas of the building that were in disrepair or dangerous to residents. The temperature of the building was within regulation and each resident apartment has controls to regulation their own temperature. LPA observed a large activity room with scheduled activities for resident enjoyment. LPA was not able to find evidence to support the allegation that staff did not provide a safe and comfortable environment. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.the state’s words, verbatim · CDSS document, Jan 29, 2024 · control 21-AS-20231206093509

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 12/02/2023 at approximately 9:20 AM to conduct an annual inspection. LPA was allowed access to facility by receptionist. Administrator Shelley Reyes was contacted and arrived shortly. There were 89 residents. LPA inspected 5 personnel and 5 resident files and found them to be complete. LPA then toured the facility with Care Coordinator Irene Heryford. 10 out of 10 rooms were found to be clean and furnished appropriately, with water temperature measuring between 110 - 116 degrees F, which is within regulation. Rooms were found to be a comfortable temperature. The facility was a comfortable temperature and passageways were free from obstructions. Visitor bathrooms are equipped with paper towels and handsoap. The Great Room was adorned with a large Christmas Tree and other holiday decor. The dining room was clean, sanitary and equipped for table service for the residents, with regular and alternative meal choices. The kitchen was clean and sanitary, and equipment was stored appropriately. There was adequate perishable and nonperishable food as required per regulation. LPA noted an Activity Room with arts and crafts available, a Game Room, a Beauty Salon (open several hours each week), a Library and ample outside areas which provide cover from the elements. Fire extinguishers were last serviced December 14, 2022. The Fire Department conducted an inspection on 02/08/2023. Emergency drills are conducted quarterly. An emergency/fire/earthquake drill was done at the end of November. Continued on 809-C Continued from 809 LPA requested proof of Liability Insurance. There were no deficiencies found at the time of inspection. No citations issued. This report was reviewed with Administrator.the state’s words, verbatim · CDSS document, Dec 2, 2023