Coronado Retirement Village

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA met with Executive Director, Rajni Kharbanda and Administrator, Meera Kharbanda. LPA verified staff had criminal record clearances on file. Administrator certificate is current. Review of the license, the facility is licensed to serve 120 non-ambulatory residents, ages 60 and above. Seven (7) residents my be bedridden. Facility has delayed egress for dementia residents. Hospice waiver is approved for to twenty (20) residents. During today's visit, there were a total of 98 residents in care. LPA, accompanied by Administrator, Kharbanda, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. (continue at LIC809C) Continue from LIC809) The facility features a delay egress device in the memory care unit. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The reviewed files contained required documents. Confidential records were stored in locked areas. First aid certificates and required training for direct staff were reviewed and confirmed they were current. Facility maintains detailed training records for staff. In service training sessions are conducted monthly inhouse by the Executive Director, Rajni Kharbanda. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Administrator, Kharbanda to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 20, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Case Management visit regarding an AWOL incident reported to the San Diego Regional Office on March 16, 2026. LPA met with Executive Director Rajni Kharbanda, identified herself, and explained the purpose of the visit. LPA reviewed the report with Wellness Director, Camille Nero. The incident report indicated that Resident #1 (R1; see Confidential Names List) left the facility unsupervised on Sunday, March 15, 2026, at approximately 12:36 p.m. At the time of the report, R1 had not returned to the facility. Documentation reflects that staff immediately contacted responsible parties, local hospitals, and law enforcement, and filed a missing person report. During today’s visit, LPA conducted record reviews, including facility and resident files and the facility’s AWOL policy, interviewed staff, and obtained pertinent documentation. Based on interviews conducted on March 18, 2026, R1’s family notified the facility that R1 is currently with a family member. Facility staff reported they are awaiting confirmation regarding whether R1 will return to the facility or be placed in another setting better suited to meet care needs. Staff also reported that R1 had previously expressed a desire to return to a prior living arrangement. Review of the Admission Agreement indicates R1 was admitted to the facility on January 7, 2026. (continue at LIC809C) (continue from LIC809) Review of medical records indicates R1 has a diagnosis of mild cognitive impairment and is not permitted to leave the facility unassisted. Additionally, the service care plan reflects that R1 requires assistance with certain activities of daily living and uses a wheelchair for mobility. Based on these findings, the facility failed to meet R1’s supervision needs. A deficiency is being cited in accordance with California Code of Regulations, Title 22, and is documented on the LIC 809D. A Plan of Correction was developed with Executive Director Rajni Kharbanda. An exit interview was conducted, with Wellness Director, Camille Nero. Copies of this report, LIC 809D, Confidential Names List, and Licensee/Appeal Rights were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 18, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 18, 2026

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c)..."Care and supervision" means the facility assumes responsibility for,... ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement was not met as evidenced by: Based on interviews and a review of records, the licensee failed to provide supervision to R1, which resulted in R1 going AWOL and not returning to the facility as of the date of this report. This poses a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: Licensee agreed to provide training to all care staff on all shifts regarding providing the necessary supervision to residents in care. Licensee agreed to submit a staff training roster confirming attendance of training, and a description of the training material to CCL by 4/18/2026. Licensee also agreed to obtain an updated medical assessment, or physician's report, for R1 by POC date 4/18/2026.

Allegation investigated: Unlawful Eviction.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced subsequent visit to deliver findings regarding the above mentioned allegation. LPA identified themselves and met with Wellness Director Camille Nero to discuss the purpose of the visit and elements of the complaint. On 01/30/2025, it was alleged that Resident 1(R1) was unlawfully evicted from the facility. The department's investigation consisted of interviews and records review. Interviews and records review revealed that on December 31st, 2024, R1 was sent out to the hospital and admitted for treatment of an illness. R1 was transferred to a different hospital on January 17th, 2025. Interviews revealed that R1 was medically cleared for discharge on January 21st, 2025. Interviews and records review revealed that on January 27th, 2025, Outside Source 1 (OS1) conducted a reassessment for R1 and concluded that based upon reassessment, R1 needed a higher level of care than what the facility could provide. Licensee did not allow R1 to return to the facility or provide R1 with a 30 day written eviction. R1 was unlawfully evicted. (Cont. on LIC 9099-C) Substantiated Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, is being cited on the attached LIC 9099D. An exit interview was conducted with Wellness Director Camille Nero and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, Jan 23, 2026 · control 08-AS-20250130095927

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(4) · Plan of correction due date: Feb 23, 2026

87224(a)(4) "The licensee may evict a resident for one or more of the reasons listed in…Thirty (30) days written notice to the resident is required…the reappraisal believe that the facility is not appropriate for the resident." This requirement was not met, as evidenced by: Based on records and interviews: Licensee evicted 1 out of 1 residents based on inability to meet their needs, without issuing them 30 days written notice. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 23, 2026

Plan of correction: Licensee will conduct eviction procedure training for all administrative staff, including licensee. Documentation of the training will include a sign-in sheet with participant names and the training topic clearly noted. Proof of completion due by 02/23/2026.

Allegation investigated: Facility in disrepair. Facility does not provide nutritiuous meals. Staff did not respond to resident's call button timely.

Licensing Program Analyst(LPA) Janet Ngallo conducted an unannounced subsequent visit to deliver findings regarding the above mentioned complaint allegations. LPA introduced themselves to and disclosed the purpose of the visit to Wellness Director Camille Nero. On 08/19/2024, it was alleged that the facility was in disrepair, does not provide nutritious meals, and that staff did not respond to resident's call button timely. The Department’s investigation consisted of unannounced facility visits, LPA observations, interviews with residents and facility staff, and records review. (Cont. on LIC9099-C) Unsubstantiated (Cont. from LIC 9099) Regarding the allegation that the facility is in disrepair, staff members and residents were interviewed. All interviews did not corroborate the allegations. Staff consistently stated that maintenance issues were documented in a designated binder, which maintenance staff reviewed each morning. They consistently reported that any issues are addressed promptly, including a common area bathroom door that was fixed shortly after it was reported that it was difficult to open. Residents consistently confirmed that they had no current maintenance concerns and that any past issues were resolved quickly. LPA reviewed the facility’s maintenance log and room inspection list dated June 2025. The checklist included room temperature, plumbing, wall heaters, call lights, grab bars, paint, lighting, and windows. Monthly inspections were conducted, though the time period for 2024 logs were unavailable. LPA observed clean, hazard-free hallways with fresh paint and intact walls. The reported common bathroom door opened freely, with no signs of disrepair. Resident rooms had accessible, functioning call lights. The Wellness Director demonstrated the call light system, which was verified by a staff member who correctly identified the room number. Regarding the allegation that the facility does not provide nutritious meals, staff interviews did not corroborate the allegation. Staff reported that resident complaints were primarily about the taste or flavor of the food, not its nutritional value. They consistently stated that alternative meals were available if residents did not want the main menu item(s). Staff also noted that the kitchen accommodated resident preferences and honored requests for different or additional food items. Resident interviews consistently reported satisfaction with the meals, stating that they liked the food, and received good portions of all food groups. One resident stated that while the food was generally acceptable, it was not always to their preference. They noted limited fruit options and occasional lack of protein, but also acknowledged dietary limitations due to dentures and stated that the food was “good enough.” (Cont. on LIC 9099-C pg. 2) (Cont. from LIC 9099-C) LPA reviewed the facility’s food menus from the first and fourth weeks of August 2024, which included a variety of fruits, vegetables, and proteins such as green beans, seasonal fruit, sausage, turkey, and beef stroganoff. The menu for the second week of November 2025 was similar. An alternative menu offering items like burgers, sandwiches, vegetarian, and vegan options was also available. Meal times were scheduled for approximately an hour and a half. A review of the facility’s Sysco food purchase history from March 2025 showed consistent orders across all food groups. LPA observed tray service being delivered to resident rooms by the head cook and kitchen staff. LPA observed facility dining area with residents being served pizza, salads, soups, sides of yogurt, seasonal fruit, and beverages. LPA observed the facility menu of the day with numerous alternative foods which consisted of all food groups. Regarding the allegation that staff did not respond to resident's call button timely, staff consistently reported that a designated personal care assistant handled call buttons, and that additionally, staff supported one another to ensure timely responses. They stated they aimed to respond within 7–10 minutes, often responding sooner. Residents confirmed their call lights were functional and that staff responded promptly. LPA reviewed the call button log for the week of 11/10/2025, which showed an average response time of 3 minutes and 33 seconds. The facility stated logs could only be retrieved for the past three months. LPA also reviewed the facility’s call light policy, which required responses within 3–7 minutes. Calls exceeding 7 minutes triggered a self-check by the receptionist, and unresolved calls over 10 minutes prompted investigation and possible disciplinary action. (Cont. on LIC 9099-C pg.3) (Cont. from LIC 9099-C pg. 2) LPA observed call lights in resident rooms and bathrooms, all hanging and accessible. The Wellness Director demonstrated the system, and a staff member correctly identified the room number in use, confirming functionality. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Wellness Director Camille Nero, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Nov 24, 2025 · control 08-AS-20240819155540

Allegation investigated: Licensee attempted unlawful eviction/discharge of resident

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit regarding the above-mentioned allegation(s). LPA met with Wellness Director, Camille Nero. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged that the licensee attempted unlawful eviction/discharge of resident. It was reported Resident #1 (R1) was not allowed to return to the facility once discharged from the hospital. On 10/03/25, R1 was trasported to the hospital due to an order written by R1's physician requiring a psyche evaluation. However, R1 was taken to the incorrect hospital for the evaluation and was discharged and returned the same day to the facility. The Wellness Director explained there was a miscommunication with the hospital but R1 was allowed to return. R1 returned to the facility and went to their room. The Executive Director documented a letter dated 09/09/25 to R1 indicating R1's non-complaince. The letter stated their concerns and said "As such, we will be issuing an official eviction notice." The letter does not state it was an eviction notice but rather one will be issued. Continued on LIC 9099C. Unsubstantiated The facility allowed R1 to return after discharge from the hospital. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Wellness Director, Camille Nero whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1].the state’s words, verbatim · CDSS document, Oct 14, 2025 · control 08-AS-20251006121233

Allegation investigated: Facility staff did not meet resident's care needs

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit regarding the above-mentioned allegation(s). LPA met with Wellness Director, Camille Nero. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged the facility staff did not meet resident's care needs regarding Resident #1 (R1). It was reported that on May 5, 2025, R1 fell at the facility, sustained injuries, and did not report the incident to facility staff. R1’s Physician’s Report dated July 18, 2024, indicated R1 was ambulatory and independent with bathing, dressing/grooming, feeding, toileting, medication management, laundry and able to leave the facility unassisted. On May 7, 2025, R1 was observed by staff with a bump the size of a quarter on R1’s forehead and a black eye. An outside source reported staff never saw the injury when it occurred due to not properly checking on R1. The outside source also indicated the facility staff initial their names on the residents’ "check in" log for the entire day without checking on R1. Continued on LIC 9099C. Unsubstantiated Staff interviews confirmed they conducted status checks on R1. However, R1 was independent and did not like staff entering their room. Staff explained they would stand at the door and ask R1 is they were okay and/or needed anything. Staff stated R1 would respond no, and they would initial the check-in log and depart. Staff added R1 usually was in bed or sitting in their chair reading, and they would call out to R1 to check on them. R1 confirmed they did not like staff checking in on them and would refuse services. R1 also stated they tried to hide their injuries from staff by hiding their face during their check-ins and leaving the facility without stopping by the front desk to check out. R1 continued to report to staff they were fine, when checked on. A review of facility records verified the room checks conducted by staff were also supported by room check logs initialed by staff. The facility’s check-in log sheet for May 11, 2025, reflected R1 was checked on and staff confirmed R1 did not complain of pain or show signs of symptoms. R1 admitted they were able to hide their injuries and avoid staff. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Wellness Director, Camille Nero whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Sep 26, 2025 · control 08-AS-20250610103152

Allegation investigated: Licensee did not seek medical care for resident

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit regarding the above-mentioned allegation(s). LPA met with Wellness Director, Camille Nero. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged that the licensee did not seek medical care for a resident. Resident #1 (R1) fell on May 5, 2025, and sustained a bump/cut on their forehead, and a right black eye. R1’s Physician’s Report dated July 18, 2024, indicated R1 was ambulatory and independent with bathing, dressing/grooming, feeding, toileting, medication management and able to leave the facility unassisted. R1’s interview confirmed they fell while walking to the bathroom at nighttime and slipped on some magazines in their room. R1 reported they fell to the ground striking their head against their bed frame. Continued on LIC 9099C. This is an amended version of the original report created on 09/26/25. Substantiated R1 also reported they cleaned themselves up and changed their clothing after the fall and did not call for assistance. Staff interviews confirmed on May 6, 2025, R1’s room was cleaned, and blood was observed by staff on R1’s bed sheets. Staff also confirmed R1 reported to them on May 6, 2025, that R1 suffered a fall the previous day and were experiencing back pain. Facility staff are trained to notify administrators or the on-duty med-tech if a resident complains of pain. However, the staff did not report the incident causing R1 to suffer undo pain until R1’s injuries were discovered the following day May 7, 2025, around 12:00 PM, by another staff member. The administrator stated that R1’s room was normally dark, and that staff will normally enter the room and check on R1 from the doorway because R1 does not want or like being checked by staff. The room checks conducted by staff were initialed by staff on May 5, 2025, and May 6, 2025, Staff confirmed R1 does not like it when staff come into their room and check on R1. Therefore, staff will open the door and either observe R1 in bed or on their couch. Staff explained they will stand in the doorway and call out to R1 and ask if R1 is okay. R1 would always respond by saying they are okay and do not need anything. Staff added R1 always keep their lights off and curtains closed so it is dark in the room and hard to see. Once R1 reported to staff they were not well, the facility did not seek medical treatment until the following day resulting in delayed medical care. The Wellness Director’s interview confirmed R1 had to be transported to the hospital due to R1 suffering a head injury, as that was the facility’s procedure. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Wellness Director, Camille Nero whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]. Although R1 lived independently and did not require any assistance with their Activities of Daily Living, staff would do status checks on R1 in their room two times per shift. R1 corroborated with a staff statement stating staff checked on R1 often and offered to provide assistance, which R1 refused. R1 did not require line of sight supervision and was independent. Therefore, when R1 fell and did not report the incident, the injury was not due to neglect. The room checks conducted by staff were also supported by room check logs initialed by staff on 05/05/25 and 05/06/25. Staff confirmed R1 does not like when staff come into their room and check on R1. Therefore, staff will open the door and either observe R1 in bed or on the couch. Staff explained they will stand in the doorway and call out to R1 and ask if R1 is okay. R1 would always respond by saying they are okay and do not need anything. Staff added R1 liked to keep their lights off and curtains closed so it is dark in the room and hard to see. It was also alleged that neglect resulted in dehydration. An outside source reported that R1 was not eating upon their return from their hospital visit on 05/07/25. The outside source also reported R1 was malnourished and dehydrated. R1 was seen at the hospital on 05/07/25 and returned to the facility the same day. R1 returned to the hospital on 05/11/25 due to the pain worsening and shortness of breath. R1 was discharged back to the facility on 05/16/25. R1’s medical records for hospital visits dated 05/07/25 and 05/11/25 were reviewed. There was no diagnosis or documentation of R1 being malnourished or dehydrated during R1’s examinations. R1’s interview indicated R1 did not like the food served at the facility and had a refrigerator in their room with a variety of food items. R1 indicated they go to the grocery store independently to purchase their food items. R1 reported they preferred to eat the food from their refrigerator and never felt they were not eating enough. R1 also stated that staff would offer R1 water, but R1 did not like water and would make themselves lemonade. R1 also reported they made a mistake telling the paramedics they hadn’t eaten in five days. R1 clarified that they meant they hadn’t been to the dining room to eat for five days. R1 denied not receiving enough to drink or eat. Staff reported they would ask R1 if they wanted staff to heat their food and R1 refused their help and said they would do it themselves. liked to keep their lights off and curtains closed so it is dark in the room and hard to see. It was also alleged that neglect resulted in dehydration. An outside source reported that R1 was not eating upon their return from their hospital visit on 05/07/25. The outside source also reported R1 was malnourished and dehydrated. R1 was seen at the hospital on 05/07/25 and returned to the facility the same day. R1 returned to the hospital on 05/11/25 due to the pain worsening and shortness of breath. Continued on LIC 9099C. R1 was discharged back to the facility on 05/16/25. R1’s medical records for hospital visits dated 05/07/25 and 05/11/25 were reviewed. There was no diagnosis or documentation of R1 being malnourished or dehydrated during R1’s examinations. R1’s interview indicated R1 did not like the food served at the facility and had a refrigerator in their room with a variety of food items. R1 indicated they go to the grocery store independently to purchase their food items. R1 reported they preferred to eat the food from their refrigerator and never felt they were not eating enough. R1 also stated that staff would offer R1 water, but R1 did not like water and would make themselves lemonade. R1 also reported they made a mistake telling the paramedics they hadn’t eaten in five days. R1 clarified that they meant they hadn’t been to the dining room to eat for five days. R1 denied not receiving enough to drink or eat. Staff reported they would ask R1 if they wanted staff to heat their food and R1 refused their help and said they would do it themselves. Lastly, it was alleged that the licensee did not report a change of condition for R1. On 05/07/25, R1 was transported to the hospital and diagnosed with a fractured rib. On 05/11/25, R1 complained of pain and shortness of breath to an outside source and was transported to the hospital. On 05/11/25, R1 was diagnosed with fractured ribs and Pneumonia. A review of R1’s medical reports indicated R1 had a history of Pneumonia. A review of the hospital’s final summary reflected that shortness of breath was more consistent with splinting and atelectasis in the setting of known rib fractures. The facility did not report a change in condition as there was no change in condition. R1’s shortness of breath may have been a result of the fractured ribs but was not documented as a change of condition. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Wellness Director, Camille Nero whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Sep 26, 2025 · control 08-AS-20250626090416

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Sep 27, 2025

Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by: Based on interviews, the licensee did not contact 911 upon learning that 1 out of 74 [R1] residents fell and had complained of pain, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2025

Plan of correction: The Wellness Director stated In-Service training will be conducted with staff to review contacting 911, emergency protocols, and chain of command. The Wellness Director will schedule the training by POC due date and provide proof of training within 2 weeks.

Allegation investigated: Staff did not accord resident safe accommodations

Licensing Program Analyst (LPA), Natasha Persaud contacted the facility via telephone, to conclude the complaint investigation regarding the above-mentioned allegation. LPA spoke with Executive Director, Rajni Kharbanda. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged that staff did not accord resident safe accommodation. It was reported that on 06/08/25, Resident #1 (R1) was lying on their bed fully clothed with shoes on and a pillow over their face. R1 had a medical condition that required medical attention. Staff called 911 and R1 was transported to the hospital. R1 also has a Major Neurocognitive Disorder and didn’t recall the incident, when interviewed. R1 confirmed they sleep in their bed, on top of their covers, fully clothed, and wearing shoes. R1 also confirmed they do not sleep with a pillow over their face or feel they are in harm. Continued on an LIC 9099C. Unsubstantiated Staff interviewed confirmed that R1 was not found with the pillow over R1’s face but to the side of R1’s face, very close, but not to interfere with R1’s breathing. There are no corroborating statements or evidence to support the allegation. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were emailed to Executive Director, Rajni Kharbanda.the state’s words, verbatim · CDSS document, Sep 2, 2025 · control 08-AS-20250609134506

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA met with Executive Director, Rajni Kharbanda and Maintenance Manager, Luis Ibarra-Medina. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured between 108 - 110F.. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per the Executive Director, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The reviewed files contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An advisory note was issued regarding Personal Rights documentation. An exit interview was conducted with Executive Director to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Aug 28, 2025

Allegation investigated: Licensee did not administer medications as prescribed. Licensee did not follow resident's care plan. Licensee did not provide services agreed upon in the admissions agreement.

Licensing Program Analysts (LPAs) Ramin Hashemi, Nacole Patterson and Janet Ngallo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPAs introduced themselves and disclosed the purpose of the visit to Wellness Director Camille Nero. On 03/17/2025 it was alleged Licensee did not administer medications as prescribed, Licensee did not follow resident's care plan, and Licensee did not provide services agreed upon in the admissions agreement. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Licensee did not administer medications as prescribed", it was alleged that multiple medication administrations were missed for Resident 1 (R1). Staff interviews revealed the medication in question was tied to a vitals parameter which the facility could not administer without a twenty-four hour nurse. (Continued on LIC9099 Page 2) Unsubstantiated (Continued from LIC9099 Page 1) This was communicated to all involved parties, including R1's responsible party upon admission. R1 had twenty-four hour private caregivers (PC) and it was agreed upon that they would be responsible to administer medications with parameters. Staff informed that the accuracy of medications and timings were difficult due to Medical Technicians (MTs) needing to confirm what medications had been given each day. In addition, staff were informed by R1's physician that the PCs were to administer blood pressure medications. Staff informed that while the medication administration system caused confusion, no medication errors occurred with this resident based on the agreement. Staff informed that medications with parameters were locked inside R1's room and the MTs did not have access to R1's parameter medications at all times. An outside medical provider familiar with R1 (OS1) revealed that the facility would not be allowed to administer parameter medications without the help of a RN or another medical professional allowed to make medical decisions for residents. This was explained in full in a meeting between R1's family, the Executive Director of the facility, and OS1. It was determined that the PCs would have to administer parameter medications. Records Review revealed that on the Physician Communication & Progress Form, Dated 03/04/25: "[Power of attorney] POA doesn't want to discontinue parameters for Chlortalidone 25mg", "Chlortalidone to be given by caregiver." A review of the Medication Administration Record (MAR), Dated March, 2025 revealed: "Lisinopril: suspended 26 February 2025 to 31st March 2025: ON HOLD, Resident is on another BP Med with parameters private caregiver administering." A number of medications were not administered during the required prescription time, however each of those times had reasonable explanations such as: "Waiting for pharmacy to refill," "Withheld per DR/RN orders," "Given to family to give later", and "physically unable to take." The MAR did not indicate any medication errors or unexplained missing administrations. Regarding the allegation, "Licensee did not follow resident's care plan.", it was alleged that blood pressure checks were a part of the agreed upon care plan to which the facility was not consistently performing. Staff interviews revealed the process of admitting new residents and developing a care plan which did not include BP checks. The facility's New Admissions Care Plan can include but is not limited to: Oxygen order, LIC602, diet modifications, POLST, pharmacy information, etc. Staff informed that R1's care plan did not say that Blood Pressure (BP) checks were required. Staff informed that the care plan was made based on what R1's care needs were when they were first assessed by the facility and R1's Physician. Staff were to follow the care plan as directed whether the PC was there or not. (Continued on LIC9099 Page 3) (Continued from LIC9099 Page 2) Outside Source Interviews revealed no concerns for the facility's ability to follow R1's agreed upon care plan. Coronado Retirement Village Resident Assessment & Care Plan/ Functional Capabilities, Dated 2/17/25 stated that R1 had as part of their main diagnosis HTN (Hypertension). HTN was a recorded condition of R1 during the admission process. Review of the Coronado Retirement Village New Admission Care Plan, Dated 2/17/2025 revealed no mention of Blood Pressure checks required in the care plan which corroborates staff statements. Regarding the allegation, "Licensee did not provide services agreed upon in the admissions agreement.", it was alleged that meal and tray services were not received by R1. Staff interviews revealed that R1 was never charged for the agreed upon tray service in the admissions packet and this was documented and removed from the final bill. Staff informed that the responsible party wanted R1 to eat in their room; however R1 was often away from the facility with PC during the day. Due to this arrangement, the pattern was inconsistent of when staff were to conduct tray service. R1's family gave their Sixty (60)-day notice and terminated their lease. Upon receiving the notice, the facility removed all charges that were not basic rent. Staff informed that R1's family was charged basic rent for April and May sans tray service. On the 11th of March, R1 moved out and the rent was totaled and prorated as final billing. Records review revealed on the Customer Payment History from 02/04/2025 - 05/01/2025: "February, March, and May are prorated; April, rent only. Prorated to exclude tray services and meal tickets. This corroborates staff statements. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are all UNSUBSTANTIATED. An exit interview was conducted with Wellness Director Camille Nero, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 08-AS-20250317093152

Allegation investigated: Staff are not safeguarding resident's personal possessions

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegation. LPA met with Wellness Director, Camille Nero. Executive Director, Rajni Kharbanda arrived during the visit. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, resident, and outside sources. It was alleged staff are not safeguarding resident's personal possessions. It was reported Resident #1 (R1) was missing $150 dollars in April 2025. Staff were interviewed and denied taking R1's money and were not aware of what happened to R1's money. Staff also stated R1 does not leave the facility unless transported by their PACE program. Therefore, they were not aware R1 withdrawled cash as they are not responsible for R1's cash resources. A review of the Resident Property and Values sheet dated 04/17/24, did not indicate $150 dollars was to be safeguarded by the facility. R1's interview indicated they kept their money in their wallet and it was stolen while they were asleep. The Executive Director explained an internal investigation was conducted and R1 reported their roommate took their money. Continued on an LIC 9099C. Unsubstantiated The Executive Director explained an internal investigation was conducted and R1 reported their roommate took their money. R1's roommate was interviewed and denied taking the money or observing anyone taking it. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Rajni Kharbanda whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 08-AS-20250408110439

Allegation investigated: Staff did not give medication as prescribed

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegation. LPA met with Wellness Director, Camille Nero. Executive Director, Rajni Kharbanda arrived during the visit. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, resident, and outside sources. It was alleged staff did not give medication as prescribed. It was reported Resident #1 (R1) had a PRN order on file for Desitin paste to be applied for skin irritation. Outside source #1's (OS1) interview revealed on 04/15/25, R1 complained of pain twice in the same day and the Desitin was brought to R1 but not applied. An interview with a Medication Technician (med tech) stated only the med tech's are allowed to administer the cream. Another med tech stated that the med tech dispenses the cream into a cup and the caregivers apply the cream. Staff interviews revealed conflicting statements. Caregivers stated they report the PRN is needed to the med tech and it's applied by the med tech. Continued on an LIC 9099C. Substantiated Caregivers also stated if they already have their gloves on they will apply the cream, once brought by the med tech. Staff also reported R1 is verbal and expresses any concerns to them. The Wellness Director explained when there's a PRN medication, the resident will verbalize their need and the med tech will administer the PRN and document it. A review of the Medication Administration Record indicated the Desitin was not dispensed on 04/15/25, when requested. The Executive Director explained the med tech's follow the orders and they are the only one's to apply creams. However, some caregivers are cross trained on administering medications/creams. R1's interview confirmed they asked for the Desitin twice on 04/15/25 due to pain. R1 also stated the med tech brought the cream in a little cup but did not administer it. Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. California code of Regulations,(Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Rajni Kharbanda whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 08-AS-20250418130533

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Aug 12, 2025

Incidental Medical and Dental Care. If the resident's physician has stated in writing...need for nonprescription PRN medication...shall be permitted to assist the resident...are met: Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on interviews and record review the licensee did not give Desitin paste as prescribed for 1 out of 74 [R1] residents, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: Executive Director stated they will have In-Service training on medications and provide proof of training by POC due date.

Allegation investigated: Staff did not give medications as prescribed Due to insufficient staff, residents’ needs are not being met Licensee did not abide by admissions agreement Staff are not properly trained

Licensing Program Analysts (LPA) Arian Golbakhsh and Amy Rodgers conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPAs were welcomed by, identified themselves to, and discussed the purpose of their visit with Administrator Elizabeth Najera. On 05/18/2021, it was alleged that staff did not give medications as prescribed, residents’ needs were not being met due to insufficient staff, Licensee did not abide by admissions agreement, and staff are not properly trained. The Department’s investigation consisted of an unannounced facility visit, records review, and interviews with staff, residents, and outside sources. Unsubstantiated (Continued from 9099) Staff interviews did not indicate that medications were not being given to residents as prescribed. All resident interviews and those with outside sources corroborated that they received their medications in a timely manner. An attempt for a copy of the Medication Administration Record (MAR) was done, however the facility switched over to a new recording system and are not obligated to retain records after three (3) years. All staff interviews acknowledge issues with being short staffed, but most do not believe it directly caused resident needs to go unmet. Resident interviews revealed that their needs were being met. File reviews of documents from May 2021 indicate that the average wait time for a call button response was 4 minutes and 39 seconds, facility census was 48 residents, and an average of 4-6 staff members were scheduled per shift. Interviews with residents, outside sources, and file reviews revealed that the admissions agreement was followed by the Administrator. Concerns discussed in interviews were explicitly listed as excluded responsibilities by the facility as per the Admissions Agreement. Staff interviews indicate that staff do receive adequate training. Staff were able to recall specific trainings completed, and the thoroughness of the staff training logs when conducting file reviews corroborated that. Furthermore, interviews with residents and their responsible parties did not reveal any concerns about staff being properly trained. Based on interviews and records review, while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred – therefore the allegations have been determined to be UNSUBSTANTIATED. An exit interview was conducted with Administrator Najera to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Dec 20, 2024 · control 08-AS-20210518135552

Allegation investigated: Facility was unsanitary.

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced visit in response to the above-mentioned allegation to deliver an amended report. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Elizabeth Najera. It was alleged that the facility was unsanitary. The Department's investigation consisted of LPA observations, record review, and interviews with staff, residents, and outside sources. LPA observed a housekeeper cleaning a lobby restroom. Resident rooms were clean and hallways, elevator, dining room, and resident rooms were sanitary and in order. Staff, residents, and outside sources interviewed said the facility is clean. Outside sources preferred to use their loved one's restroom. LPA reviewed housecleaning schedules and staffing levels were sufficient. Completed tasks were signed off on a daily checklist. According to records and interviews there is insufficient evidence that the alleged violation occurred. Therefore, this allegation is deemed unsubstantiated. This amended report and Licensee/Appeal Rights (LIC9058 03/22) were provided to Administrator Elizabeth Najera at the end of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 20, 2024 · control 08-AS-20241218165603

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Elizabeth Najera . According to the facility’s license, the facility has a maximum capacity of (120) residents, seven (7) of whom may bedridden. During today’s inspection, there were a total of eighty-four (84) residents in care. This facility features a delayed egress for dementia residents. LPA, accompanied by Najera, toured the interior and exterior of the facility, and inspected residents' rooms. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant. There was at least 2 days supply of perishable food, and at least seven (7) days of non-perishable food was present. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters observed available to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per Najera , no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Confidential records were stored in locked area. Najera also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Najera, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 30, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Daniel Pena conducted a Case Management - Incident visit at the Coronado Retirement Village (CRV). LPA met with Administrator, Elizabeth Najera, after identifying himself and providing the purpose of the visit. On May 28, 2024, Community Care Licensing Division (CCLD) received a self-reported Death Report, involving the death of Resident #1 (R1). During the visit, LPA conducted interviews with CRV staff and obtained copies of pertinent facility and resident records. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator Najera, whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, May 29, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Daniel Pena, conducted an unannounced Case Management visit. The LPA introduced himself and disclosed the purpose to Wellness Director, Maria Moellman. Liz Najera, Administrator, later joined LPA and was briefed on the visit. Today's visit was in response to an Incident Report submitted to the Department, for Resident 1 (R1). Per facility reporting, R1 sustained a fall on 04/06/2024 which resulted in two (2) spinal fractures. Reports indicate R1 was transported to the hospital and underwent surgery. Per Ms. Moellman, R1 was transferred to a rehabilitation facility after hospitalization and the facility is awaiting notice as to whether R1 will return to the community. LPA conducted a review of R1's pertinent records and interviewed staff. No health and safety concerns were identified and no deficiencies were cited during today's visit. An exit interview was conducted with Administrator Najera, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 1, 2024

Allegation investigated: Staff dropped resident resulting in multiple fractures. Staff did not seek medical attention for resident in a timely manner.

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced complaint visit at the facility to close out a complaint. LPA gained access to the facility and met with Administrator, Liz Najera, and explained the purpose of the visit which was to deliver findings for the above allegations. The Department’s investigation consisted of record reviews, interviews with staff, residents and outside sources. It was alleged that staff dropped resident resulting in multiple fractures. Interviews revealed that on July 23, 2020, on or about 1:00 PM Staff 1 (S1) indicated they were transferring Resident 1 (R1) from the wheelchair to their bed by themself. R1 became combative and S1 believed they were going to lose control of R1, so S1 assisted R1 to the floor. Interviews revealed R1 slid between S1’s legs and R1’s legs twisted as they slid. S1 conducted a body check and observed a skin tear with blood on their left knee and during the check, R1 complained of left knee pain. A review of the facility training protocol for a Manual Transfer, Lifting and Repositioning instructions stated, “Do not attempt to lift or transfer residents by self; If a coworker is not available, ask additional assistance from Med-Tech or Supervisor.” During the interview with the Med-Tech, they confirmed that training policy/protocol mandates “two-person assist” when transferring residents. Interviews revealed they have observed caregivers transfer R1 in and out of bed by themselves because R1 is small and does not weigh much. However, interviews revealed that S2 has always advised other staff to use two-person assist when transferring R1 per facility policy/protocol. Hospital records dated July 20, 2020, revealed that R1 suffered fractures of their Bilateral Hips and Femur and had surgery on July 25, 2020 for repair. Substantiated Interviews revealed that the caregivers are responsible for ensuring water is always available for the residents and encouraging them to drink water. Staff would give R1 their medication in the dining area during breakfast and lunch. R1 always requested a glass of water to take their medications. Interviews revealed several staff members would always make water available to R1 and encourage them to drink it during their visits. However, R1 did not like water and would often refuse. Interviews revealed a cup of water was kept on a night stand next to R1’s bed. R1 in addition to water was also provided Ensure protein drinks several times a day to supplement for their lack of fluid intake and juice during meals. Interviews revealed that R1 liked Ensure and they normally finished the drink when it was provided to them. After a review of Medical Records from Sharp Memorial from R1’s visit on 7/23/2020, there was no indication/mention of dehydration. Dehydration was first reflected in Scripps Green Hospital medical records after R1 was transferred on 7/24/2020. Interviews with outside sources stated they did not believe facility staff would be able to adequately evaluate a resident for dehydration due to their lack of training. The allegations of staff neglected resident resulting in a urinary tract infection and neglect/lack of care and supervision by facility staff resulting in dehydration is unsubstantiated. Based on the evidence obtained from interviews, and records review, the complaint allegations are unsubstantiated. An exit interview was conducted with Liz Najera, Administrator and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit. On August 6, 2020, R1 passed away due to Failure to thrive and Granulomatous disease. The death report also stated that other significant conditions contributing to the death were injuries sustained from a fall on July 23, 2020 and Cardiac Disease. Based on records and interviews conducted, R1’s fall may have been prevented if S1 was following facility policy/protocol when transferring R1; therefore, the allegation of neglect resulting in R1’s fall and subsequent death is substantiated. It was alleged that staff did not seek medical attention for resident in a timely manner. Interviews revealed R1’s neighbor (R2) was returning from dinner, and they walked to R1’s room to visit them. Upon arrival, R1’s door was open and R1 was lying in bed. Interviews revealed R2 observed R1 to have a distressed look on their face and they reached up toward R2 with their hand. Interviews revealed R1’s hand was very clammy. R1 expressed that they were in a lot of pain and R1 begged R2 to get them some help. Interviews revealed R2 immediately went to the nurse’s station and advised a nurse that R1 was in pain and needed to go to the hospital. Staff called for an ambulance and R1 was transported to the hospital. A review of records reviewed from the ambulance company show that they received the call from Cornado Retirement Village at 7:40 PM and immediately dispatched an ambulance to the facility. The ambulance arrived at the facility at 7:51 PM and transported R1 to the hospital. The ambulance arrived at the hospital at 8:33 PM. A review of the Ambulance Service Incident/Response report revealed that facility staff were unsure if R1 hit their head and that R1 was given Tylenol for pain, but they weren’t able to state the time that the medication was given. The report also revealed that staff advised Emergency Medical Technicians (EMT) that the resident was observed increasingly lethargic since their fall at 1:00 PM. The report also documented that staff described R1 as normally talkative and polite, but on this day R1 was refusing to let staff touch them. When EMTs assessed R1, R1 displayed 10/10 sharp pain in right hip and bilateral lower extremities that worsened significantly upon movement or palpitation and yelped in pain. EMTs asked R1 what happened but R1 couldn’t recall the fall. The report documents bilateral bruising on anterior aspect of R1’s shins. R1 also had a skin tear on the right knee, covered with a band aid. The facility’s Training/Policy states the following: … emergencies include, but are not limited to: Shortness of breath, bleeding, trauma, chest pain or other notable pain, fainting, fall, stroke, unconsciousness, suicide thoughts/action, severe dehydration/weakness, dizziness, delirium, aggressive behavior, or any life-threatening situations, Do Not delay in guessing or assuming; The Med-Tech on shift or attending staff must immediately call 911. Based on staff and resident interviews, a review of the Ambulance Service Incident/Response report, and review of the facility’s Training/Policy, the allegation of staff neglecting to immediately telephone 9-1-1 for an injury is substantiated. Deficiencies are being cited in accordance with the California Code of Regulations, Title 22, Division 6, Chapter 8, and are noted on the attached LIC9099-D. An immediate civil penalty of $500 was assessed for the following violation: Incidental Medical and Dental Care. Incidental Medical Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health… At this time, per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division Based on the evidence obtained from interviews, and records review, the complaint allegations are substantiated. An exit interview was conducted with Liz Najera, Administrator and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 12, 2024 · control 08-AS-20200807104355

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Mar 22, 2024

87411(a) Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: Based on interviews and records review, the licensee did not retain competent personnel to provide the services necessary to meet resident needs in 1 of 86 persons in care [R1] which posed an immediate Health, Safety, and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: Licensee stated that S1resigned on 12/26/2022. Licensee stated they will provide staff training from an outisde source on two person transfer assists, combative residents, and staff compentency. POC due to CCL by 03/22/2024 with sign in sheet and training materials.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Mar 22, 2024

Incidental Medical and Dental Care Incidental Medical Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health… Based on interviews and review of records, the licensee did not immediately telephone 9-1-1 for the injury R1 sustained in 1 of 86 persons in care which posed an immediate Health risk to persons in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: Licensee stated they conduct mid week trainings every week on procedures and safety checks. Licensee will provide training from an outside source on Responding properly to residents care needs. POC due to CCL by 03/22/2024 with sign in sheet and training materials.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Elizabeth Najera. Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 02/05/2024). According to the LIC624, during the early morning of 02/01/2024, Resident #1 (R1) had an unwitnessed fall. [See LIC 811 Confidential Names List for a description of R1.] Staff observed R1 on the floor and was assessing them for injuries when R1 had a seizure episode. 911 was called and R1 was hospitalized. During today’s visit, LPA performed a brief facility tour. As of the date of LPA’s visit, R1 had not yet returned to the facility. LPA collected copies of and reviewed pertinent care records. LPA also interviewed relevant staff. No deficiencies were cited during today's visit. LPA issued one (1) Technical Violation (TV) regarding reporting requirements (see LIC9102-TV). LPA also issued Technical Assistance (TA) regarding medical assessment and reappraisal (see LIC9102-TA). An exit interview was conducted with Reyes, to whom a copy of this report, the LIC9102-TV, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Feb 28, 2024

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

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Administrator Liz Najera and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of records review, interviews with facility staff and outside sources. It was alleged that staff did not provide resident records to resident's authorized representative It was reported to CCL that as of December 13, 2023 no facility records have been produced for Resident 1 (R1) (an LIC 811 Confidential Names List was provided to the facility representative to identify the resident) Interview with Administrator revealed they have been in frequent contact with R1's responsible party as well as R1's authorized representative for many months. Unsubstantiated Administrator further stated that the Licensee advised her on approximately September 2023 that she would compile all of R1's facility records and the Licensee would be in charge of sending out any facility records request for R1. Licensee stated that on September 23, 2023 they received a subpoena from R1's authorized representative to send them "all of the documents." On September 28, 2023 Licensee emailed the facility records to the authorized representative. On December 27, 2023 an employee of the authorized representative called the licensee and stated that they were missing some of the resident's documents from January 1, 2022 through December 23, 2023. Licensee stated that they would resend the requested attachments to the authorized representative. LPA records review revealed that a declaration of custodian of records was signed and dated on September 28, 2023 by the Licensee. Records review further revealed that over 400 pages of resident records were emailed to the authorized representative on September 28, 2023. The records emailed spanned from 2021 through 2023 and included; resident assessment and care plans, admission agreement, physicians reports, medication orders, incident reports, hospital discharge forms, medication refill orders and professional communication notes, etc. Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid. An exit interview was conducted with Liz Najera. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Liz Najera whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Jan 25, 2024 · control 08-AS-20231227093312

Allegation investigated: Lack of supervision resulted in resident physical abuse by another resident which resulted in serious injury

On 1/5/2024, at about 8:20 AM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to conclude a complaint investigation. LPA identified himself and discussed the allegations mentioned above with Erika Avalos, Office Manager. On 06/27/2023, the Department received a complaint, alleging lack of supervision resulted in resident physical abuse by another resident which resulted in serious injury. The Department’s investigation consisted of LPA observation, record reviews, and interviews with residents, staff, and outside sources. Resident 1 (R1) and Resident 2 (R2) were both admitted to Memory Care, have a diagnosis of dementia and suffer from severe cognitive impairment. Both residents have shown signs of aggression toward staff and or other residents, but the last documented incident occurred in March of 2023 when R1 punched a staff member and attempted to hit several residents. Both R1 and R2 had medication changes or increases to calm them and make them less aggressive. Prior to this incident, there were no prior incidents between R1 and R2. Unsubstantiated Closed-circuit television system evidence was reviewed as part of this investigation. On the day of the incident, there was one staff member in the dining room supervising four residents. R1 was talking to another resident while R2 was standing on the other side of the room. R1 left talking to the resident and casually walked toward R2. The security video is blurry, but it appears that R1 tried to grab R2 by the arms and R2 pushed R1 away in a startled or defensive move. R1 fell to the ground. Caregiver 1 (CG1) responded immediately and called for assistance on their handheld radio. Medication Technician (MT1) responded to the call for assistance. MT1 assessed R1 for injuries and called 911 to have R1 transported to the hospital to be evaluated. According to CG1, they did not see the incident between R1 and R2 that caused R1 to fall. CG1 did not hear the conversation or any argument between them. Video review showed, R1 casually walked toward R2 without obvious signs that R1 was upset and an altercation between R1 and R2 was imminent. In fact, the video shows that R1 approached R2 and R2 was most likely defending himself from R1. Based on the Department’s investigation, the allegation of Neglect/lack of supervision and care resulted in physical abuse of a resident by another resident, resulting in serious injury is Unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Office Manager, Avalos, whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jan 5, 2024 · control 08-AS-20230627133539

Allegation investigated: Resident hit by unknown adult while in care, resulting in injury

On 12/7/2023, at about 8:55 AM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to conclude a complaint investigation. LPA identified himself and discussed the allegations mentioned above with Erika Avalos, Office Manager. On 6/29/2022, the Department received a complaint, alleging a resident was hit by an unknown adult while in care, resulting in injury. The Department’s investigation consisted of LPA observation, record reviews, and interviews with residents, staff and outside sources. Record reviews showed that the incident was reported by facility staff as an unwitnessed fall. Resident 1 (R1)’s records showed that they have Mild Cognitive Impairment (MCI), history of falls, and visual impairment. The facility records indicate staff reported an incident involving this resident on 6/22/22 where the resident experienced an unwitnessed fall. The resident was transported to the hospital where they were diagnosed with a bruise to the forehead. None of the records associated with the 6/22/22 incident Unsubstantiated reflect R1 was or reported being assaulted. The alleged incident occurred in the CRV Memory Care Unit. A sample of Memory Care Unit residents were interviewed but due to their medical/physical conditions could not serve as qualifiable witnesses. In their interview, R1 said they were in bed and were asleep when "a man hit me." R1 did not know who the man was. R1 never saw the person before. R1 said the man struck them in the forehead once. R1 told a family member but did not report the incident to CRV employees. R1 said they were seen by a doctor but received no injury. R1 has not seen the man again. When asked, R1 said they felt safe at CRV. When asked, R1 said no CRV staff or another resident hit them. R1 said there was no witness to the incident. Staff interviews yielded no conclusive evidence to support the allegation. Staff generally said they were familiar with R1 and knew they had Dementia. None of the staff witnessed any person strike R1 at any time. Interviews with outside sources did not produce information to corroborate the allegation. LPA observation during a walk through of the facility did not show evidence that R1 had been assaulted. A law enforcement officer responded to the facility, but no arrest was made. The Department has investigated the allegation that a resident was hit by an unknown adult while in care, resulting in injury. Based on interviews and record reviews the investigation failed to produce sufficient evidence to support the allegation. The preponderance of evidence standard was not met; therefore, the allegation is deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Office Manager, Avalos, whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Dec 7, 2023 · control 08-AS-20220629133454