Cottages at Hemet

Type of visit: Required - 1 Year

On 08/25/26 Licensing Program Analyst (LPA) Ahliah Sharp made an unannounced visit to the facility to conduct an annual required visit. LPA met with Executive Director Barbara Bogoje, where LPA explained the purpose of the visit. The facility consists of six (6) single story cottages with fifteen bedroom/bathroom units in each cottage. There is a total of four (4) cottages dedicated to assisted living residents and two (2) cottages dedicated to memory care residents. LPA conducted a review of both staff and resident record files. LPA reviewed five (5) resident files that were observed to have most of the required documents such as medical assessment, needs and services plan, but of those five (5) three (3)did not have the updated appraisals or updated Physician’s Orders; a deficiency was issued. Staff files reviewed had the Department's required training records and valid first aid/CPR certification. LPA reviewed the facility's Fire Drill logs and noted the facility's last fire drill was conducted on 5/26/2026. The kitchen, which is in the main building, was observed to be clean, and clutter free. There was plenty of cook ware, dishes and utensils to serve the residents in care. The facility was observed to have the required two (2) day supply of perishable and seven (7) day supply of nonperishable food items. All meals are prepared in the kitchen and delivered to each cottage. Each cottage has an independent dining room, which consists of a kitchenette that was observed to have food warmers, refrigerators, and pantry. In one of the memory care cottages, the laundry room was observed to be unlocked where chemicals were easily accessible to residents in care. Cont. on LIC 809C... Continued from LIC809... This posed an immediate health and safety risk to residents in care, and a deficiency was issued. Additionally, sharp items (knife) were not locked up in that same cottage. The residents’ bedrooms were observed to be clean and odor free in most of the cottages, but in one specifically, as soon as the door opened, it was a noticeably offensive odor that immediately overtook the air. Upon entering, there was water all over and the resident was frantically saying, “Help me, what is going on?”. Everywhere LPA looked, feces was present; the bed, the floor, bathroom. When speaking with staff, it was reported, that this resident has severe incontinence issues stated, “Resident just poops everywhere, no matter what we do, it doesn’t matter; it is all day every day, their spouse tries to help, but nothing works, they even refuse to shower, which makes it even worse”. In another room, it was observed to have two diapers that were full of feces in the bathroom on the floor as well. This poses health and safety concerns, and a citation was issued. The cottages were all at comfortable temperatures and within regulation. The medications are locked inside medication carts, but when randomly auditing, LPA observed a few residents to have had medication punched for days that had yet to arrive. When LPA asked MedTech about it, they were unable to provide a justification as to what occurred, therefore presenting an immediate health and safety issue. Deficiency was issued. Each cottage was observed to have fully charged fire extinguishers that were tested on 8/4/2026. An exit interview was conducted and a copy of this report, along with the 809D for each deficiency issued and the appeal rights were reviewed and provided to ED Bogoje.the state’s words, verbatim · CDSS document, Aug 25, 2026

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On 08/12/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross, arrived at the facility to issue a Case Management deficiency for Complaint Control #18-AS-20250220134327. It was determined that R1’s Needs and Services Plan dated 06/08/2024 identifies R1 as a Fall Risk, with two prior falls documented on 11/06/2024 and 01/11/2025. Facility records, including the Unusual Incident/Injury Report and chart notes dated 02/18/2025, indicate R1 was found on the floor outside the bathroom door near the closet. Review of the Personal Care Assistant (PCA) job description shows that staff are required to conduct rounds every two hours. Interviews with staff revealed, if a resident is a fall risk, then rounds should be conducted every hour. R1 was last seen after being escorted by staff to their room following dinner. Staff interviews confirmed that at approximately 10:30pm a staff walked by R1’s room; however, staff did not open R1’s door to visually check on R1. R1 was discovered by staff, calling for help at approximately 4:00am. Interviews with multiple relevant parties revealed R1 reported to the relevant parties, that the fall occurred between 10:00pm – 10:30pm after their walker became caught on something, causing them to fall backward and strike their head on the bedside. Thus concluding, R1 remained on the floor for an estimated six hours before being found due to the neglect of staff to conduct rounds in accordance with the facility’s procedures. A citation was issued and discussed with Barbara Bogoje, Executive Director and a copy of this report, and appeals rights was provided.the state’s words, verbatim · CDSS document, Aug 12, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Aug 26, 2026

The licensee shall ensure that residents receive care and supervision...requires the facility to have planned procedures and immediate capabilities to respond to medical needs....This requirement was not met as evidenced by: Based on interviews and record reviews,staff failed to conduct rounds every 1 to 2 hours for residents who are a falll risk, leaving resident unobserved and unattended for 6 hours after a fall. This posed an immediate health and safety risk for resident.the state’s words, verbatim · CDSS document, Aug 12, 2026

Plan of correction: An in-service training will be conducted with medtechs and care staff on having knowledge of residents care plans and fall risks residents, and making rounds. Documentation of this training will be provided to the Department by POC 8/26/26.

Allegation investigated: Staff did not administer Resident 1's medication as prescribed

On 04/21/2026, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility to investigate the allegation listed above. LPA met with Administrator Barbara Bogoje who was informed of the purpose of the visit. LPA toured the facility with Administrator Bogoje, conducted interviews, and obtained copies of pertinent records. Regarding the allegation, "Staff failed to administer Resident 1's medication as prescribed" it was alleged that on 02/17/2026, R1 visited their physician and it was discovered that the facility failed to administer R1's medications as prescribed. It was reported that R1 resided in the facility until 02/14/2026. LPA made multiple unsuccessful attempts to contact the reporting party for additional information. Unsubstantiated LPA reviewed R1’s admission agreement dated 08/27/2025. Administrator confirmed that R1 moved out of the facility on 02/14/2026. LPA reviewed R1’s physician’s report dated 08/27/2025 documenting R1 exhibits memory loss and the “Able to Administer Own Prescription Medications”, “Able to Administer Own PRN Medications” and “Able to Store Own Medications” categories are marked “No”. Administrator was interviewed and reported the following information. R1 was not prescribed any medications upon admission to the facility. While residing in the facility, R1 was prescribed routine medication which staff administered as prescribed. The facility has a contract with Yorba Linda Pharmacy (YLP) who is responsible for creating an electronic Medication Administration Record (MAR) profile for residents. Facility staff then use the electronic MAR to log the residents’ medication administration while residing in the facility. If a resident uses a different pharmacy, facility staff will fax YLP a request to profile the medication for MAR purposes only. If the resident is not listed in the electronic MAR, facility staff are responsible for generating a paper MAR until the resident’s electronic MAR is created by YLP. After a resident leaves the facility for thirty days, facility staff no longer have access to the resident's electronic MAR and are required to contact YLP to request a copy. Administrator contacted YLP to request a copy of R1’s electronic MAR for LPA’s review, but YLP staff was unable to locate a MAR profile for R1. Two (2) of two (2) staff interviewed refuted the allegation and reported R1 received their medication as prescribed which was documented in R1’s electronic and paper MARs. Two (2) of two (2) staff interviewed reported observing multiple paper MARs on file for R1. However, administrator was only able to locate one (1) paper MAR from September 2025. Administrator was unable to locate a paper MAR for each medication prescribed to R1 during their stay in the facility. LPA was also unable to make contact with the facility's former memory care director or R1’s responsible person for an interview. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. An exit interview was conducted and a copy of this report and Confidential Names list (LIC 811) was reviewed and provided to Administrator Bogoje.the state’s words, verbatim · CDSS document, Apr 21, 2026 · control 18-AS-20260415152534

Type of visit: Case Management - Deficiencies

On 04/21/2026, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced case management visit to address a deficiency observed while in the facility. LPA met with Administrator Barbara Bogoje who was informed of the purpose of the visit. During the course of a complaint investigation, LPA found that the paper and electronic medication administration records for Resident 1 (R1) were not properly retained in the facility after R1 moved out of the facility on 02/14/2026. As a result, a deficiency will be issued. An exit interview was conducted where a copy of this report, Confidential Names list (LIC 811) and Appeal Rights were reviewed and provided to Administrator Bogoje.the state’s words, verbatim · CDSS document, Apr 21, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: Apr 24, 2026

87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidenced by: Based on interviews conducted, the paper and electronic medication administration records for R1 were not properly retained in the facility after R1 moved out of the facility on 02/14/2026. This poses a potential health/safety/personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2026

Plan of correction: Administrator reported on 4/22/26 they will conduct a staff training regarding proper organization of resident records and quality assurance checks for proper medication management. POC will be emailed to LPA by close of business on 04/24/2026.

Allegation investigated: Resident sustained a fracture and bruising due to neglect/lack of care supervision.

On 03/05/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross made an unannounced visit to the facility to deliver the finding for the allegation noted above. LPA met with Barbara Bogoje, Executive Director and explained the purpose of the visit. The investigation consisted of interviews and records review. On 04/28/2025, Community Care Licensing received a complaint alleging resident (R1) sustained a fracture and bruising due to neglect and/or lack of care and supervision. It was reported R1 had an unwitnessed fall. Interviews were conducted with staff which revealed that on 04/21/2025, two caregivers on duty were assisting residents when they heard a loud noise and when the caregivers responded to the noise, they found R1 on the floor beside their walker. Continue on LIC 9099C... Unsubstantiated A review of records revealed that R1’s Physician Report with exam date of 08/15/2024, indicated cognitive impairment, dementia, confusion, and disorientation. The Physician’s Report, under category Able to Communicate Needs, it reads “unknown.” Facility charting notes were reviewed. The charting note dated 04/21/2025 revealed R1 was found on the floor in the hallway. Caregiver reports that R1 stated they did not hit their head and R1 was not complaining of pain or discomfort. Charting note dated 04/22/2025 revealed R1 was their normal self and was not complaining of pain or discomfort. Charting note dated 04/23/2025 revealed there were no complaints of pain or discomfort. Charting note dated 04/26/2025 revealed staff noted discoloration on R1’s left arm. The note further reads there no reports of R1 falling. This note has a time of 12:21pm. The next charting note dated 04/26/2025 with a time of 3pm, read R1’s arm was swollen and bruised and R1 was sent to the hospital. An interview with medical staff who responded to the facility, reported that during their assessment of R1’s injuries, they observed bruising and swelling on the left arm. It was described as a purple and green bruise starting on the left arm, extending to the bicep, elbow and chest area of R1. The medical staff further reported R1 complained of pain but due to their cognitive condition, R1 could not explain what happened. They added that during checks for movement, R1 could not use their arm. Based on their medical experience, the injuries appeared to have occurred a couple of days prior, based on how much bruising was sustained. R1’s medical records dated 04/26/2025 were reviewed, which revealed R1 was seen for an upper extremity injury. Medical records revealed a diagnosis of humeral fracture, possible c-spine fracture. Therefore, the allegation is SUBSTANTIATED, which means the preponderance of evidence standard has been met. A copy of this report along with 9099D, and Appeal Rights were provided to Executive Director, Barbara Bogoje. An interview with the Executive Director, Barbara Bogoje, she reports there is not a policy on timely checks. She further reported that checks should be done every one to two hours. The Executive Director explained that caregivers do not document these checks. Interviews with caregivers revealed they check on residents every hour to hour and a half. Records were reviewed. A review of R1’s Needs and Services Plan, with an effective date of 08/15/2024 was completed. The review revealed the plan was not signed by neither the resident, the resident’s responsible party nor a facility representative. The review of this document revealed relevant information under various categories. Under the category of Activities of Daily Living, it reads “Independent” and the note reads “uses walker outside of building”; under the category of Falls, it reads “No”; under the category of Ambulation, it reads “Independent”. A review of R1’s Physician Report with exam date of 08/15/2024, revealed R1 was able to independently transfer to and from the bed and was considered ambulatory for purposes of a fire clearance. The investigation did not reveal that R1 was a fall risk or was on increased supervision checks. Therefore, the allegation is unsubstantiated, meaning the preponderance of evidence standard has not been met. A copy of this report was explained and provided to Executive Director, Barbara Bogoje.the state’s words, verbatim · CDSS document, Mar 5, 2026 · control 18-AS-20250428151030

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87465(g) · Plan of correction due date: Mar 19, 2026

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 was not met as evidenced by: Licensee did not call 911 in a timely manner when immediate medical care was needed for R1's injuries.the state’s words, verbatim · CDSS document, Mar 5, 2026

Plan of correction: Licensee shall certify plan to address how the facility plans to remain in complaince with this regulation. Licensee will provide an in-service training to staff and to Med-techs to call 911 immediately when resident has any injury that requires medical attention that includes falls. Plan must be emailed to LPA Shaw-Ross by POC 03/19/2026.

Allegation investigated: Facility does not provide clean equipment for resident. Facility does not have sufficient staffing.

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Barbara Bogoje, Administrator. The Department’s investigation involved interviews with staff and residents and review of records. On June 24, 2025, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged that facility does not provide clean equipment for resident. Information received indicated that shower chair in shower room was dirty. LPA conducted interviews with eight (8) staff members, all of whom stated that shower chair has been cleaned after every shower was provided by caregivers. Those eight (8) staff members also stated that shower chairs are cleaned by housekeepers as well as night shift caregivers. Continued on LIC9099-C.... Unsubstantiated LPA conducted interviews with seven (7) residents, all of whom stated that the shower chairs have been clean all the time. LPA conducted an interview with an outside agency personnel member who stated that the facility has always appeared to be clean whenever they visited the facility for their patients. LPA’s observations of the facility corroborated the statements from the staff members, residents and the outside agency personnel. LPA conducted a tour of the facility and observed the shower room and the shower chairs to be in clean condition. Based on interviews conducted and observations, the allegation that facility does not provide clean equipment for resident is unsubstantiated. It was alleged that facility does not have sufficient staffing. Information received indicated that all cottages of the facility are short staffed. LPA conducted an interview with memory care director who stated that they have not experienced short staffing. The memory care director explained that there are 3 caregivers for 2 memory care units, one (1) medication technician for two (2) memory care units, one (1) caregiver for each assisted living unit, and one (1) medication technician for four (4) assisted living units. LPA’s interview with other seven (7) staff members corroborated the memory care director’s statement. LPA conducted interviews with seven (7) residents, all of whom stated that they have not experienced staff shortages. LPA’s review of staff schedules corroborated the statements from the memory care director and the staff members interviewed. LPA conducted a tour of the facility, observed, and verified that those stated number of staff members were on duty. Based on interviews conducted, observation, and record reviews, the allegation that facility does not have sufficient staffing is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 18-AS-20250624100701

Type of visit: Case Management - Other

On October 13, 2025, Licensee Program Analyst (LPA), Venus Mixson made an unannounced Health and safety visit in order to obtain additional information regarding information received via several Unusual Incident/Injury Reports. Information received was pertaining to an elopement. During the investigation process LPA conducted interviews, record reviews, and made observations pertaining to the elopement. LPA conducted a tour of the facility along with the Memory Care Director, Dawn Pracapio and made observations pertaining to the listed incident reported on October 10, 2025. Community Care licensing received information stating a resident eloped from the facility on two separate occasions. There were no Health and/or Safety concerns observed during today visit. LPA was informed by the Memory Care Director the facility has put a care plan in place to lessen the behavior. The plan includes relocation of resident to a more structured cottage, and a calmer atmosphere, along with higher supervision. An exit interview was conducted, and a copy of this report was given to Memory Care Director, Dawn Pracapio.the state’s words, verbatim · CDSS document, Oct 13, 2025

Allegation investigated: The Licensee is requiring the resident to execute another admissions agreement. Licensee is overcharging resident fees.

Licensing Program Analyst (LPA) Debbie Palacios conducted an unannounced visit to deliver findings for the allegation listed above. LPA met with Executive Director Barbara Bogoje where LPA explained the purpose of the visit and the elements of allegation. The investigation consisted of interviews with staff members and residents, and a review of records. It was alleged the licensee was requiring the resident to execute another Admissions Agreement when there was already an admissions agreement in place and there had been no change of condition of the resident. Per an interview conducted with the Executive Director (ED), it was reported that a new admission agreement was introduced solely to reflect the facility’s name change from Pacifica Senior Living to Cottages at Hemet. Through record review and interviews LPA verified there was no new admissions agreement signed. LPA attempted to contact both R1 and their responsible party but was unsuccessful. Unsubstantiated Regarding the allegation the licensee is overcharging resident fees, it was alleged the facility was requiring the resident to pay a second one-time Community Fee that had previously been paid in August of 2023. The ED reported a request for residents to sign a new admission agreement was introduced solely to reflect the facility’s name change. Although the new admission agreement reflected the language of the one-time Community Fee, staff were not requiring residents to pay the community fee, as it had already been paid. LPA attempted to contact both R1 and their responsible party but was unsuccessful. Additional residents were selected at random and interviewed. Three of six residents interviewed reported that their families handle the financial aspects including monthly payments and administrative matters. Additionally, the remaining three of six residents reported that facility staff have never pressured or forced them to sign any documents. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 18-AS-20250508082843

Type of visit: Required - 1 Year

On 08/28/25 Licensing Program Analyst (LPA) Debbie Palacios made an unannounced visit to the facility to conduct a 1 year required visit. LPA met with Executive Director Barbara Bogoje, where LPA explained the purpose of the visit. The facility consists of (6) single story cottages with fifteen bedroom/bathroom units in each cottage. There is a total of (4) cottages dedicated to assisted living residents and (2) cottages dedicated for memory care residents. LPA conducted a review of both staff and resident record files. LPA reviewed five (5) resident files that were observed to have the required documents such as medical assessment, needs and services plan. Staff files reviewed had the Department's required training records and valid first aid/CPR certification. LPA reviewed the facility's Fire Drill logs and noted the facility's last fire drill was conducted on 08/05/25. The kitchen which is in the main building was observed to be clean, and clutter free. There was plenty of cookware, dishes and utensils to serve the residents in care. The facility was observed to have a 2 day supply of perishable and a 7 day supply of non perishable food items. All meals are prepared in the kitchen and delivered to each cottage. Each cottage has an dining room, which consists of a kitchenette that was observed to have food warmers, refrigerators, and pantry. The resident bedrooms were observed to be clean and odor free, the cottages were at a comfortable temperature. The hot water was tested and found to be within regulatory limits measuring 105.4-114.2 degrees Fahrenheit. The medications are locked inside medication carts. The facility uses electronic Medication Authorization Records (MAR)s. Each cottage was observed to have a fully charged fire fire extinguishers. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 28, 2025

Allegation investigated: Staff did not make sure residents have their dinner. Staff left residents in soiled bedding or briefs. Staff did not make sure resident’s restroom was clean. Staff dd not answer resdients call pendants in a timely fashion.

Licensing Program Analyst (LPA) Nicol Weslety conducted an unannounced complaint visit to investigate the above allegations. LPA Wesley met with Community Relations Director Brittney Walsh to explained the purpose for todays visit. Brittney included Resident Service Director Miajoy Mc Elyea to join the visit. The investigation consisted of the following: LPA toured the community, obtained copies of staff roster, client roster, faciltiy menu, tested residents call buttons. LPA interviewed 8 out of 9 residents, and 5 staff. Regarding allegation: Staff did not make sure residents have their dinner. Dinner is served in each of cottages dining area at 4:30pm. A resident can eat in the dining area or in their room. When its time for dinner, the resident are told its dinner time and for those they are in a wheelchair and require assistance, they are taken the dining area. LPA Wesley interviewed 8 residents who said the staff makes sure they have their dinner. continued on LIC9099C. M Unsubstantiated Regarding allegation: Staff left residents in soiled bedding or briefs. LPA Wesley Interviewed 8 residents who said they are never left in soiled bedding or briefs and LPA Wesley interviewed Staff #1 who said she ensures staff meets the schedule for changing the residents briefs which is every two hours or as needed, depending on the residents level of care. Staff #1 said when a resident takes their shower their bedding is changed, some residents require more changes than the other depending on how often the bed is wet. Regarding allegation: Staff did not make sure resident’s restroom was clean. LPA Wesley interviewed staff #1 who said the residents rooms are lightly cleaned daily, they caregivers take the trash out, dust and clean the residents bathroom. LPA Wesley interviewed residents 1-8 and they did not have a problem with their bathroom being cleaned or their trash being emptied by the staff or hospice providers. One resident said she takes out her own trash to have something to do. Staff #1 said she hasn't heard any problems with the staff not doing their duties. Regarding allegation: Staff did not answer residents call pendants in a timely fashion. LPA Wesley toured 2 of the resident cottages and pressed the pendants of the residents neck and the residents night stand, and the staff answered it within a decent time frame. LPA Wesley interviewed 8 residents who said their call pendants are answered, sometimes it could take longer depending on what they are doing for other residents. LPA Wesley asked what's the longest time you had to wait, and it was under 20 minutes. LPA Wesley asked staff do they answer call pendants in a timely manner and they answered yes it is usually 30 minutes or less depending on what the resident is calling for. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. 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. A copy of the LIC 809/809C was given during the exit interview.the state’s words, verbatim · CDSS document, May 10, 2025 · control 18-AS-20240118084146

Allegation investigated: Facility issued a rate increase for a falsiflied change of condition Facility falsified paperwork

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Barbara Bogoje Resident Service Director and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 05/07/2024, LPA Delgado interviewed one (1) staff and requested and obtained copies of documentation. During today’s visit LPA Gutierrez interviewed Resident Service Director/Administrator, staff #1- Staff #3 and resident #2 -resident #9. Resident one R1 has left facility. LPA obtained copies of the following documents: staff roster, resident roster, R1’s admission agreement, physicians reports, identification and emergency information, and resident assessment. SEE LIC 9099C Unsubstantiated In regard to the allegation “Facility issued a rate increase for a falsified change of condition”, it is alleged that a change of condition was given that was not needed for R1 therefore a rent increase was issued for services not needed. During interviews with residents eight (8) out of the nine (9) residents stated that they have never received a rate increase that they didn’t know about. R7 stated that everything goes up, but they are always given notification of an increase. During interviews with Administrator and staff all four (4) stated that all residents and person responsible for residents are notified of any rate increase. Administrator stated that the nurse and physicians make the assessment if any change of condition has occurred and base the rate on the type of care residents need. During file review LPA observed that there was a change of condition for R1. In regard to the allegation” Facility falsified paperwork”, it is alleged that the signature on signed contract is falsified. During interviews with administrator and staff four out (4) out of five (5) staff state that they have never heard of any falsified documentation. During interviews with residents eight (8) out of nine (9) stated they have had no issues with their contracts to their knowledge. LPA reviewed admission agreement and resident assessment documentation and were all signed by both resident and responsible party LPA found no discrepancies. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. 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. An exit interview was conducted with Med-Tech Jocelyn Constante. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 19, 2025 · control 18-AS-20240503151502

Allegation investigated: Staff are not providing adequate food service to residents Staff speak inappropriately to residents in care Staff are not providing adequate supervision to resident

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Barbara Bogoje Executive Director/Administrator and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 09/26/2022, LPA Colvin interviewed one (1) staff and requested and obtained copies of documentation. During today’s visit LPA Gutierrez interviewed Executive Director/Administrator, staff #2- Staff #4, and resident #2 -resident #9. LPA toured kitchen and obtained copies of the following documents: staff roster, resident roster, food menu, R1’s admission agreement, physicians reports, and appraisal needs and service plan. SEE LIC 9099C Unsubstantiated In regard to the allegation “Staff are not providing adequate food service to residents”, it is alleged that residents are served hot dogs and non-nutritional meals. During interviews with Administrator and staff all four (4) stated residents are served nutritional food based on their diets. R4 stated they had an alternative food menu for residents. LPA toured the kitchen and observed a sufficient amount of food. During interviews with residents all stated that there were concerns about food. Residents stated there was enough and a different variety of food and that it was just not to their liking's. In regard to the allegation” Staff speak inappropriately to residents in care”, it is alleged that staff yells and humiliates residents in care. During interviews with Administrator and staff four (4) stated that staff does not yell at residents, and they have never witnessed yelling. During interviews with residents seven (7) out of nine (9) stated that staff does does not yell at them. R9 stated that she had been yelled at before by a staff member. In regard to the allegation” Staff are not providing adequate supervision to resident ‘it is alleged that there is not enough staff to meet the needs of residents in care causing falls. During interviews with Administrator and staff all four (4) stated that there is enough staff. S2 stated they are in the process of hiring more care givers. During interviews with residents four (4) out of nine felt that there wasn’t enough staff to meet the needs of residents. Although it may appear that not enough staff is present it was reveled during interviews that each cottage has at least one staff at all times. When assistance is needed a med-tech will provide coverage. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. 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. An exit interview was conducted with Med-Tech Jocelyn Constante. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 19, 2025 · control 18-AS-20220923153215

Allegation investigated: Facility staff dropped resident during a transfer resulting in bruising. Facility did not notify resident's family of incident. Facility did not seek timely medical attention for resident. Staff did not dispense medication according to doctor’s orders.

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced subsequent complaint investigation visit on 04/19/2025 regarding the above allegations to deliver findings. LPA Ramirez conducted subsequent complaint investigation on 3/29/25; interviews were conducted and a needs further investigation was required. LPA Delgado conducted initial complaint visit on 10/20/2023 and a needs further investigation was documented. The investigation consisted of the following: LPA Ramirez requested copies of Resident#1 (R1)- face sheet, emergency contact information, Centrally Stored Medications (LIC 622), Controlled Medications Record, Prescription Orders for R1, Physician’s Report (LIC 602), Unusual/Incident Reports for R1, Hospice care notes, Resident Assessment for R1, Interview of Resident# 2- 8 (R2-R8), Interview of Staff#1- 5 (S1-S5), Attempted Interview of R1, Attempted Interview of Staff#6 (S6), Copies of S6’s: employment application, separation form, CPR/First Aid certificates, and annual training. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: regarding the allegation- Facility staff dropped resident during a transfer resulting in bruising- It is alleged S6 dropped R1 while transporting them from their wheelchair to their bed. Five (5) out of the five (5) staff interviewed denied this allegation. Staff interviews revealed R1 had been agitated earlier that morning and staff administered a PRN to calm R1 down. Records reviewed revealed staff documented R1 was still agitated after PRN and R1’s doctor was notified. Staff interviews revealed R1 made a sudden movement forward in their wheelchair and fell out right as S6 was attempting to transfer R1 to their bed. Staff interviews did not corroborate S6 dropped R1 while transferring R1 to their bed. Eight (8) out of eight (8) residents interviewed denied this allegation. Review of hospice notes dated 9/30/2023, revealed hospice staff provided care to R1 because of a fall. Review of S6’s personnel record did not corroborate this allegation. LPA Ramirez attempted to interview R1, but R1 is no longer at the facility and unavailable for interview. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility did not notify resident's family of incident- It is alleged facility staff did not notify R1’s family when she had a witnessed fall. Five (5) out of the five (5) staff interviewed denied this allegation. Eight (8) out of eight (8) residents interviewed denied this allegation. Records reviewed revealed staff documented R1’s fall to R1’s Power of Attorney (POA), doctor and hospice were all notified on 9/30/2023. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility did not seek timely medical attention for resident- It is alleged facility staff did not seek timely medical attention for R1 after a witnessed fall sustained on 09/30/2023. Five (5) out of the five (5) staff interviewed denied this allegation. Eight (8) out of eight (8) residents interviewed denied this allegation. LPA Ramirez attempted to interview R1, but R1 is no longer at the facility and unavailable for interview. Records reviewed revealed on 9/30/2023, hospice arrived after 2pm to assess R1 due to fall. Hospice notes revealed R1 was assessed and R1’s family requested to not send R1 to the hospital but wanted to keep R1 comfortable and pain free. Hospice notes and facility staff notes documented R1 had bruising to their head, left side and hand. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff did not dispense medication according to doctor’s orders- It is alleged facility staff did not administer pain medication to R1 after witnessed fall on 09/30/2023. Five (5) out of the five (5) staff interviewed denied this allegation. Eight (8) out of eight (8) residents interviewed denied this allegation. LPA Ramirez attempted to interview R1, but R1 is no longer at the facility and unavailable for interview. Records reviewed revealed R1 had a medication order for PRN prescription for pain. Records reviewed revealed on 9/30/2023, hospice staff administered pain medication to R1 on 09/30/2023 due to a witnessed fall. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were issued for this complaint investigation. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 19, 2025 · control 18-AS-20231013131810

Allegation investigated: Staff do not ensure residents’ incontinence needs are met. Staff do not respond to resident's call button. Staff intimidated resident. Staff spoke to resident in a disrespectful manner.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Brittney Walsh – Sales Director/Community Relations Representative and the reason for the visit was explained, shortly after Executive Director/Administrator Barbara Bogojie arrived to assist with visit. The investigation consisted of the following: LPA obtained copies of staff and client rosters, toured facility, observed incontinence supplies, tested residents call buttons, and interviewed 9 residents and 4 staff. (continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff do not ensure residents’ incontinence needs are met. It is alleged that S1 does not change the residents, leaving residents soiled throughout the late evening/early morning. LPA toured facility and residents rooms, sufficient supply of incontinence supplies were observed in resident rooms and caregiver station. LPA interviewed 9 residents and 8 out of 9 residents denied the above allegation, some residents stated that although it may take time for staff to arrive for assistance it may be because they are busy assisting another resident and they would have to wait their turn. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation stating that assistance is provided in a timely manner, caregivers do rounds every 2 hours (or as needed) to ensure residents needs are being met and haven’t had any complaints about this allegation. During interview with S4, it was stated that there have been no complaints or disciplinary actions against S1 for such allegation. Allegation: Staff do not respond to resident's call button. It is alleged that S1 does not respond to residents call buttons and was seen on their phone rather than responding to call. LPA interviewed 9 residents and 6 out of 9 staff denied the above allegation, stating that they feel staff respond within a timely manner when call buttons are pressed, some residents stated that although it may take time for staff to respond at times it is due to staff assisting other residents that are also in need of assistance. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation stating that staff does their best to provide prompt care to residents when call buttons are used, responding within 15 minutes or less depending on the situation and if staff are assisting other residents. LPA tested 2 residents call buttons and staff arrived within 7-20 minutes to provide assistance, reason for delay was that staff was busy assisting a resident with incontinence care and/or getting into bed. During interview with S4, it was stated that there have been no complaints or disciplinary actions against S1 for such allegation. (Continued on LIC9099-C) Allegation: Staff intimidated resident. It is alleged R1 asked staff to lower their voices as they were speaking loudly in the hallways at night and S1 responded by intimidating resident. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation, stating that they have never nor have they ever witnessed another staff act intimidating towards residents. LPA interviewed 9 residents and 7 out of 9 residents denied the above allegation stating that they have never felt threatened or intimidated by staff. During interview with S4, it was stated that there have been no complaints or disciplinary actions against S1 for such allegation. Allegation: Staff spoke to resident in a disrespectful manner. It is alleged that S1 spoke to R2 with in a disrespectful way and in a disrespectful tone. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation, stating that they have never nor have they ever witnessed another staff raise their voice or act disrespectful towards residents. LPA interviewed 9 residents and 7 out of 9 residents denied the above allegation stating that they have never felt threatened or intimidated by staff. During interview with S4, it was stated that there have been no complaints or disciplinary actions against S1 for such allegation. Based on statements and interviews conducted with staff/residents, tour of facility and LPA observations, there was not enough supportive evidence to concur with the reported allegations. 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. Exit interview held, and a copy of this report was provided to Jocelyn Constante - MedTech.the state’s words, verbatim · CDSS document, Apr 19, 2025 · control 18-AS-20241002122520

Allegation investigated: Staff do not respond to requests for assistance in a timely manner. Staff do not ensure that resident's toileting needs are being met while in care.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Brittney Walsh – Sales Director/Community Relations Representative and the reason for the visit was explained, shortly after Executive Director/Administrator Barbara Bogojie arrived to assist with visit. The investigation consisted of the following: LPA obtained copies of staff and client rosters, toured facility, observed incontinence supplies, tested residents call buttons, and interviewed 9 residents and 4 staff. (continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff do not respond to requests for assistance in a timely manner. It is alleged that staff at facility do not respond to R4’s pendant calls leaving R4 to wait a very long time (45 minutes, 18 minutes, 1.5 hours, etc.) for assistance. LPA interviewed 9 residents and 6 out of 9 staff denied the above allegation, stating that they feel staff respond within a timely manner when call buttons are pressed, some residents stated that although it may take time for staff to respond at times it is due to staff assisting other residents that are also in need of assistance. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation stating that staff does their best to provide prompt care to residents when call buttons are used, responding within 15 minutes or less depending on the situation and if staff are assisting other residents. LPA tested 2 residents call buttons and staff arrived within 7-20 minutes to provide assistance, reason for delay was that staff was busy assisting a resident with incontinence care and/or getting into bed. Allegation: Staff do not ensure that resident's toileting needs are being met while in care. It is alleged that R4 used pendant call for assistance with toileting, staff did not respond, leaving resident no choice but to soil themselves and sitting in soiled bedding for a very long time until staff arrived. LPA toured facility and residents rooms, sufficient supply of incontinence supplies were observed in resident rooms and caregiver station. LPA interviewed 9 residents and 9 out of 9 residents denied the above allegation, some residents stated that although it may take time for staff to arrive for assistance it may be because they are busy assisting another resident and they would have to wait their turn. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation stating that assistance is provided in a timely manner, caregivers do rounds every 2 hours (or as needed) to ensure residents needs are being met and haven’t had any complaints about this allegation. Based on statements and interviews conducted with staff/residents, tour of facility and LPA observations, there was not enough supportive evidence to concur with the reported allegations. 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. Exit interview held, and a copy of this report was provided to Jocelyn Constante - MedTech.the state’s words, verbatim · CDSS document, Apr 19, 2025 · control 18-AS-20240109155246

Allegation investigated: Resident sustained injuries due to a fall Staff leave residents unattended in dirty diapers for extended periods of time Staff mismanage residents' medication Staff failed to treat residents with dignity and respect Staff do not ensure that residents are hydrated Staff handle residents in a rough manner Facility is unkempt

*This report supersedes report dated 4/5/25 to correct documents information and dates for R2's records on LIC 9099C.* On 4/5/25 Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Nidia Chavez Activities and explained the reason for the visit. The investigation consisted of the following: On 3/26/25 LPA Flores requested a copy of staff/resident roster over the phone. On 4/2/25 LPA requested documents for three residents over the phone. On 4/4/25 LPA conducted a visit at the facility interviewed administrator, 5 staff, 8 residents, and 1 staff over the phone. LPA toured the facility with Annette Harris concierge and observed 7 random resident room and common areas. LPA reviewed files for Resident #1-2(R1-R2) and requested copies of Physician’s Report, Identification and Emergency Information sheet, Needs and Care plan, medical records. (CONTINUED ON LIC 9099C) Unsubstantiated LPA requested copies of incident reports, and medication destruction logs for the past three months, medication training for 2 medication technicians(Med-Tech), personal rights training, training on dementia care and activities of daily living for 2 caregivers. LPA reviewed medication for 5 residents. On 4/5/25 LPA delivered findings. The investigation revealed the following: Regarding allegations: Resident sustained injuries due to a fall. It is alleged around December 2022, R2 sustained an unwitnessed fall which left R2 with bruises and lacerations. Interviews conducted with residents revealed 4 out of 8 residents were unable to answer due to cognitive skills. 2 out of 8 residents stated to have fallen and staff provided assistance right away and 2 out of 8 residents stated to not fallen while in care but are certain staff will assist them right away if it happens. Interviews with staff revealed facility has a protocol for residents falls. Per staff if a resident falls Med-Techs are called. Med-techs evaluate the resident and if the resident is laying on their back or hit their head they are send out to the hospital for further evaluation. Staff stated that they have staff checking on residents and are aware of residents that need assistance. Those residents that need additional assistance are maintain within supervision range. Documents review revealed the following, per physician’s report dated:12/16/21, R2 is non-ambulatory and there were no notes of being a risk fall. Per needs and care plan dated 12/22/21 R2 requires a 2 person assist escort and total assistance with transferring. Medical records reviewed revealed R2 was seen on 10/13/22 due to a hematoma. On 11/7/22 R2 was seen at the hospital due to a mechanical fall. On 12/13/22 R2 was seen by a physician due to a fall. R2 was not under hospice or home health care. Medical record dated 10/13/22 notes R2 was seen for a hematoma. However, it does not note whether the reason was a fall. There were no incident reports to review for the falls above. Therefore, although R2 did sustained 2 falls per medical records and a hematoma is unclear whether those were due to lack of supervision. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff leave residents unattended in dirty diapers for extended periods of time. It is alleged residents are left unchanged for an extended period of time. Interviews conducted with residents revealed 3 out of 8 residents do not need assistance with incontinence care and stated staff assist with care as needed. 3 out of 8 residents were unable to answer due to cognitive skills and 2 out of 8 residents stated facility staff assist residents with going to the bathroom and changing as needed. (CONTINUED ON LIC 9099C) Interviews with staff revealed 4 out of 7 staff stated caregivers who assist residents with incontinence care check residents every two to three hours and check residents as needed. 2 out of 7 staff were not aware of concerns with incontinence care. 1 out of 7 staff stated that a resident was found wet with a full pull up in the morning recent. The incident was report it to management. Administrator stated staff was given a written warning a copy of warning was reviewed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff mismanage resident’s medication. It is alleged staff mix up the residents’ medication and the facility keep the deceased residents’ medication. Interviews with residents revealed 5 out of 8 residents do not have concerns regarding medication management. 3 out of 8 residents were unable to answer due to cognitive skills. Interviews with staff revealed 4 out of 7 staff interview stated medications have not been mixed and medications are properly after a resident leaves or passes away. Medication is destroyed by placing them in a destruction container with a witness, staff destroying medication signs destruction medication log, and the destroyed medication in secure container are picked by contractor at least every three months. Medication review did not reveal errors or mismanagement of current residents’ medications. LPA observed the medication destruction container and did not observe old medications stored. LPA reviewed medication destruction logs for 7 residents were reviewed. Last medication training was provided on 4/3/25. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff failed to treat residents with dignity and respect and Staff handle residents in a rough manner. It is alleged a resident was treated with force when the resident refused to shower. Interviews with residents revealed 6 out of 8 residents stated staff treat them with respect when providing care. 2 out of 8 residents were unable to answer due to cognitive skills. Interviews with staff revealed staff have not mistreated or observed staff mistreating residents in care. Administrator and staff were unable to identify the resident in question. Administrator searched through stored records. However, there were no resident found with the name provided or incident described. Last Resident Rights training was provided to staff on 12/17/24. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.(CONT.LIC9099C) Regarding allegation: Staff do not ensure residents are hydrated. It is alleged most of the residents are dehydrated as the staff do not make sure to give the residents enough drinking water. Interviews conducted with residents revealed 6 out of 8 residents stated facility provides proper care. 2 out of 8 residents were unable to provide an answer due to cognitive skills. Interviews with staff revealed staff provide care with all activities of daily living and residents are encouraged to drink water throughout the day. During facility’s tour LPA observed large water dispensers supplied with cups in each dining area and in the admission building. Staff were last provided training on dementia care on 1/21/25. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility is unkempt. It is alleged facility is dirty and sometimes the residents have feces on their beds. Interviews conducted with residents revealed 6 out of 8 residents interviewed stated the facility its clean and their bedding is changed often. 2 out of 8 residents were unable to answer due to cognitive skills. Interviews with staff revealed facility is maintained clean and the bedding is changed at least every three days or as needed. Per Annette Harris concierge residents provide their own bedding supplies. During facility’s tour LPA observed the facility’s common areas were clean and each bed observed had clean sheets and bedding supplies. LPA observed memory care cottages had additional bedding supplies in the laundry room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Barbara Borgoje Administrator and a copy of this report was email for signature.the state’s words, verbatim · CDSS document, Apr 7, 2025 · control 18-AS-20221221141339

Allegation investigated: Resident sustained injuries due to a fall Staff leave residents unattended in dirty diapers for extended periods of time Staff mismanage residents' medication Staff failed to treat residents with dignity and respect Staff do not ensure that residents are hydrated Staff handle residents in a rough manner Facility is unkempt

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Nidia Chavez Activities and explained the reason for the visit. The investigation consisted of the following: On 3/26/25 LPA Flores requested a copy of staff/resident roster over the phone. On 4/2/25 LPA requested documents for three residents over the phone. On 4/4/25 LPA conducted a visit at the facility interviewed administrator, 5 staff, 8 residents, and 1 staff over the phone. LPA toured the facility with Annette Harris concierge and observed 7 random resident room and common areas. LPA reviewed files for Resident #1-2(R1-R2) and requested copies of Physician’s Report, Identification and Emergency Information sheet, Needs and Care plan, medical records. LPA requested copies of incident reports and medication destruction logs for the past three months, medication training for 2 medication technicians(Med-Tech), personal rights training, training on dementia care and activities of daily living for 2 caregivers. LPA reviewed medication for 5 residents. On 4/5/25 LPA delivered findings. (CONTINUED ON LIC 9099C) Unsubstantiated The investigation revealed the following: Regarding allegations: Resident sustained injuries due to a fall. It is alleged around December 2022, R2 sustained an unwitnessed fall which left R2 with bruises and lacerations. Interviews conducted with residents revealed 4 out of 8 residents were unable to answer due to cognitive skills. 2 out of 8 residents stated to have fallen and staff provided assistance right away and 2 out of 8 residents stated to not fallen while in care but are certain staff will assist them right away if it happens. Interviews with staff revealed facility has a protocol for residents falls. Per staff if a resident falls Med-Techs are called. Med-techs evaluate the resident and if the resident is laying on their back or hit their head they are send out to the hospital for further evaluation. Staff stated that they have staff checking on residents and are aware of residents that need assistance. Those residents that need additional assistance are maintain within supervision range. Documents review revealed the following, per physician’s report dated: 2/15/22, R2 is non-ambulatory and there were no notes of risk fall. Per needs and care plan dated 6/20/22 R2 requires a 1 person assist escort and total assistance with transferring. Medical records reviewed revealed R2 was seen on 10/13/22 due to a hematoma. On 11/7/22 R2 was seen at the hospital due to a mechanical fall. On 12/13/22 R2 was seen by a physician due to a fall. Hospice records show that R2 was being provided hospice services since 3/12/21, plan of care notes dated 3/12/21, note R2 must have precaution care for falls/injures. Hospice notes between September and December 2022 do not note concerns or falls. Medical record dated 10/13/22 notes R2 was seen for a hematoma. However, it does not note whether the reason was a fall. There were no incident reports to review for the falls above. Although R2 did sustained 2 falls were medical records it is unclear whether the falls were due to lack of supervision. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff leave residents unattended in dirty diapers for extended periods of time. It is alleged residents are left unchanged for an extended period of time. Interviews conducted with residents revealed 3 out of 8 residents do not need assistance with incontinence care and stated staff assist with care as needed. 3 out of 8 residents were unable to answer due to cognitive skills and 2 out of 8 residents stated facility staff assist residents with going to the bathroom and changing as needed. Interviews with staff revealed 4 out of 7 staff stated caregivers who assist residents with incontinence care check residents every two to three hours and check residents as needed. 2 out of 7 staff were not aware of concerns with incontinence care. (CONTINUED ON LIC 9099C) 1 out of 7 staff stated that a resident was found wet with a full pull up in the morning recent. The incident was report it to management. Administrator stated staff was given a written warning a copy of warning was reviewed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff mismanage resident’s medication. It is alleged staff mix up the residents’ medication and the facility keep the deceased residents’ medication. Interviews with residents revealed 5 out of 8 residents do not have concerns regarding medication management. 3 out of 8 residents were unable to answer due to cognitive skills. Interviews with staff revealed 4 out of 7 staff interview stated medications have not been mixed and medications are properly after a resident leaves or passes away. Medication is destroyed by placing them in a destruction container with a witness, staff destroying medication signs destruction medication log, and the destroyed medication in secure container are picked by contractor at least every three months. Medication review did not reveal errors or mismanagement of current residents’ medications. LPA observed the medication destruction container and did not observe old medications stored. LPA reviewed medication destruction logs for 7 residents were reviewed. Last medication training was provided on 4/3/25. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff failed to treat residents with dignity and respect and Staff handle residents in a rough manner. It is alleged a resident was treated with force when the resident refused to shower. Interviews with residents revealed 6 out of 8 residents stated staff treat them with respect when providing care. 2 out of 8 residents were unable to answer due to cognitive skills. Interviews with staff revealed staff have not mistreated or observed staff mistreating residents in care. Administrator and staff were unable to identify the resident in question. Administrator searched through stored records. However, there were no resident found with the name provided or incident described. Last Resident Rights training was provided to staff on 12/17/24. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. (CONTINUED ON LIC 9099C) Regarding allegation: Staff do not ensure residents are hydrated. It is alleged most of the residents are dehydrated as the staff do not make sure to give the residents enough drinking water. Interviews conducted with residents revealed 6 out of 8 residents stated facility provides proper care. 2 out of 8 residents were unable to provide an answer due to cognitive skills. Interviews with staff revealed staff provide care with all activities of daily living and residents are encouraged to drink water throughout the day. During facility’s tour LPA observed large water dispensers supplied with cups in each dining area and in the admission building. Staff were last provided training on dementia care on 1/21/25. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility is unkempt. It is alleged facility is dirty and sometimes the residents have feces on their beds. Interviews conducted with residents revealed 6 out of 8 residents interviewed stated the facility its clean and their bedding is changed often. 2 out of 8 residents were unable to answer due to cognitive skills. Interviews with staff revealed facility is maintained clean and the bedding is changed at least every three days or as needed. Per Annette Harris concierge residents provide their own bedding supplies. During facility’s tour LPA observed the facility’s common areas were clean and each bed observed had clean sheets and bedding supplies. LPA observed memory care cottages had additional bedding supplies in the laundry room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Brittney Walsh Sales Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 5, 2025 · control 18-AS-20221221141339

Allegation investigated: 5Staff are not mitigating the spread of scabies in the facility.

Licensing Program Analyst (LPA) Cynthia Chan conducted a follow up visit to deliver findings for the allegation above. LPA met with Brittany Walsh, the Sales Director, and explained the reason for the visit. The investigation consisted of the following: On 11/13/24, LPA Stephanie Martinez conducted the initial visit. LPA interviewed a staff, requested copies of relevant documentation, and toured two of six buildings. It was determined the allegation needed a further investigation. On 4/4/25, LPA Chan conducted interviews with the administrator, 5 staff and 9 residents. The investigation revealed the following: Allegation – Staff are not mitigating the spread of scabies in the facility. The administrator and staff interviewed stated there was an outbreak of scabies in November 2024. They stated they took action right away to prevent the spread to other residents. Unsubstantiated Staff wore gowns and gloves in the memory care unit where the outbreak occurred. They enhanced their washing and drying and separated all the residents’ clothes and beddings from others. Staff stated all the residents were given the treatment to mitigate the spread and tried to keep residents away from physical contacts as much as possible. They showered the residents more frequent during that time. Other cottages were instructed to clean and sanitize frequently and to observe for any signs of scabies. Families, visitors, and the public health department were also notified of the outbreak in the community. LPA reviewed the facility’s Infection Control Plan, and it appeared that the facility followed the procedures for any communicable disease. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Staff B. Walsh. A copy of this report along with the appeal rights was provided.the state’s words, verbatim · CDSS document, Apr 5, 2025 · control 18-AS-20241105103403

Allegation investigated: Facility staff subjected resident to multiple doctor visits due to staff refusing to accept physician diagnosis. Resident sustained an injury from an unwitnessed fall due to lack of supervision. Facility staff did not notify resident’s authorized representative of resident’s injury. Facility is not reporting contagious outbreak to residents and/or their authorized representatives.

Licensing Program Analyst (LPA) Cynthia Chan conducted a follow-up visit to deliver findings. LPA met with Staff, Brittany Walsh, and explained the reason for the visit. The investigation consisted of the following: On 12/19/24, LPA Stephanie Martinez started the complaint investigation and interviewed one staff, requested copies of relevant documentation, and toured two of six buildings. The allegations needed a further investigation. On 4/4/25, LPA Chan conducted a follow-up visit to interview the administrator, 5 Staff, and 9 residents. Resident #1 is no longer residing at the facility and was not interviewed. The investigation revealed the following: Allegation - Facility staff subjected resident to multiple doctor visits due to staff refusing to accept physician's diagnosis. It is alleged that the staff kept insisting Resident #1 (R1) had scabies. Unsubstantiated LPA reviewed R1’s facility file. Upon admission, R1 had a general body rash and dermatitis. After summary reports on file from 8/16/24 – 10/24/24 indicated that R1 had either a bacterial skin condition or dermatitis. Staff interviewed stated they suspected R1 to have scabies due to increased itch and observation of skin. R1’s family member agreed to take resident to the doctor’s appointments. The after summary reports did not mention scabies, however, it was noted that on 9/18/24, the doctor prescribed Permethrin cream to treat dermatitis. Staff indicated that the family member later called and reported that R1 has scabies while at the hospital. Allegation - Resident sustained an injury from an unwitnessed fall due to lack of supervision. It is alleged that Resident #1 (R1) fell and sustained a bruise to the hip area down to the calf. Staff and Residents were interviewed regarding this allegation. The administrator stated there are 2 care staff per shift in the memory care unit and 1 care staff and a med tech in the other cottages. Staff indicated they are frequently checking on the resident, at least 1 to 2 hours. Staff stated that when a resident falls, they contact the med tech to inform them of the fall. The med tech and Resident Care Coordinator will assess the resident and contact 911. Regarding R1, Staff stated that the resident had fallen while at the facility. However, staff attended to the resident and assessed right away. Per resident interviews, staff are always supervising residents and those who have fallen at the facility were helped immediately. Allegation - Facility staff did not notify resident’s authorized representative of the resident’s injury. LPA Chan interviewed the administrator and staff regarding this allegation. Per administrator and staff, anytime there is a fall or injury to a resident, they would contact the authorized representative to inform them of the incident. Care staff stated that they do not notify families of the incident. The administrator, resident care coordinator, or med techs are responsible for notifying the authorized representatives. Per staff, R1’s authorized representative was notified of all known falls and/or injuries. Five of the residents interviewed indicated that their families are notified if anything happens to them. (Continue on LIC9099C) Allegation - Facility is not reporting contagious outbreak to residents and/or their authorized representatives. It is alleged that the scabies outbreak was not reported to the residents and their authorized representatives. The administrator and staff stated that the scabies outbreak was reported to the public health department, licensing, residents, and authorized representatives. The outbreak occurred back in November 2024 in the memory care unit. LPA observed a line list of residents with the onset of scabies symptoms and the doctor’s diagnosis. Per the administrator, there was no letter provided by the public health department. Staff stated they notified the all the families/authorized representatives via telephone and the affected residents’ physicians. They also stated visitors were informed of the outbreak during visitations. 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. An exit interview was conducted with Staff B. Walsh. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Apr 5, 2025 · control 18-AS-20241210124228

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit regarding deficiencies found during a complaint investigation. LPA met with Brittney Walsh Business Director and explained the reason for the visit. On 4/5/25 LPA Flores conducted a complaint investigation during the investigation it was found there were no incident reports for Resident's #2(R2) sustained between October and December of 2022. On 10/13/22, R2 was taken to the hospital due to a hematoma. On 11/7/22 R2 was seen at the hospital due to a mechanical fall. On 12/13/22 R2 was seen by a physician due to a fall. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 5, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Apr 11, 2025

87211 Reporting Requirements: (a) Each licensee shall furnish...(1) A written report shall be submitted to the licensing agency ...(D) Any incident which threatens the welfare, safety or health of any resident, ... This requirement is not met as evidence by: Based on documents reviewed licensee did not ensure staff were submitting incident reports for incidents sustained while in care for R2 which poses a potential risk to the health, personal rights, and safey of the residents in care.the state’s words, verbatim · CDSS document, Apr 5, 2025

Plan of correction: Administrator will certify in writting that any incidents pertaining the residents will be submitted to the department via unusual incident report which will be submitted to the department by POC due date 4/11/25.

Allegation investigated: Staff did not administer resident's medication as prescribed.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 03/29/2025 regarding the above allegation. LPA Mixon conducted initial complaint visit on 01/13/2023 and a needs further investigation was documented. During today’s visit, LPA Ramirez was greeted by Staff-Brittney Walsh and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster (LIC 500), Staff#1 - 5 interviews (S1 – S5), Attempted interview of Resident#1 (R1) Resident#2-9 interviews (R2-R9), copies of Resident#1 (R1)- face sheet, emergency contact information, Centrally Stored Medications (LIC 622), Controlled Medications Record, Prescription Orders for R1, Physician’s Report (LIC 602), and physical plant tour. See 9099-C Unsubstantiated The investigation revealed the following. Regarding Allegation: Staff did not administer resident's medication as prescribed – It is alleged on 01/10/2023, R1’s medications were discontinued by the facility physician. Five (5) out of the five (5) staff interviewed denied this allegation. Seven (7) out of the eight (8) residents interviewed denied this allegation. LPA Ramirez attempted to contact R1 for an interview, but R1 was not available for an interview. LPA Ramirez reviewed R1’s facility file and it revealed R1 was admitted into the facility in August of 2021. Review of R1 Physician’s report dated 01/05/2023, revealed R1’s physician documented R1 was non-compliant with medication recommendations. Review of R1’s Physician’s report dated 02/21/2023, revealed R1’s physician noted R1 was “Resistant to medication management and wants to choose what medications to take and never accepts medical advice.” LPA Ramirez reviewed a prescription medication change order by R1’s physician dated 01/06/2023. On 1/6/2023, R1’s physician ordered R1 discontinued twelve (12) medications and ordered R1 be administered four (4) new medications. Staff interviewed revealed medication technician's administer and or discontinue medications according to the physician's order. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No violations were cited for this investigation. Exit interview was conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, Mar 29, 2025 · control 18-AS-20230110093308

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 03/29/2025, stemming from subsequent complaint investigation on 3/29/2025. LPA Ramirez was greeted by Staff Brittney Walsh and explained the purpose of the visit. Case Management-Incident findings: On 3/29/2025, LPA Ramirez attempted to obtain copies former resident (R1) and former staff (S1) records for an open complaint investigation. Facility staff revealed documents requested were not available to LPA Ramirez. Staff revealed documents requested are in storage and the facility will need more time to get the documents. Per Title 22, Division 6, Chapter 8, Article 9. Resident Records- 87506(d) Resident Records- All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:.LPA Ramirez will issue a Type B violation based on this observation. Per Title 22, Division 6, Chapter 8, Article 07. Personnel Records-87412(g) Personnel Records- All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. LPA Ramirez will issue a Type B violation based on this observation. Two (2) violations were observed and cited. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided.the state’s words, verbatim · CDSS document, Mar 29, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(d) · Plan of correction due date: Apr 4, 2025

Resident Records- All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement was not met as evidenced by: R1's resident record was not made available to LPA Ramirez upon demand during normal business hours.the state’s words, verbatim · CDSS document, Mar 29, 2025

Plan of correction: Licensee shall certify plan to address how the facility plans to remain in complaince with this regulation. Plan must be emailed to LPA Ramirez by 4/4/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(g) · Plan of correction due date: Apr 4, 2025

Personnel Records- All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement was not met as evidenced by: S1's peronnel record was made available to LPA Ramirez for review.the state’s words, verbatim · CDSS document, Mar 29, 2025

Plan of correction: Licensee shall certify plan to address how the facility plans to remain in complaince with this regulation. Plan must be emailed to LPA Ramirez by 4/4/25.

Allegation investigated: Resident sustained an unstageable pressure injury while in care Resident sustained injuries resulting in hospitalization due to unwitnessed fall(s) while in care Staff did not notify responsible party of resident's change in condition

Licensing Program Analyst (LPA) Seo Jeon made an unannounced visit to the facility to deliver findings. LPA Seo Jeon met with Barbara Bogoje, Administrator, and explained the purpose of the visit. The following allegations were investigated by the Department, the investigation included interviews and record review. It was alleged that resident sustained an unstageable pressure injury while in care. On 02/08/2022 Resident#1 (R1) was transported to the hospital and admitted for a fall. Medical records were reviewed. Medical records dated 02/08/2022 do not indicate any pressure injuries noted. Based on facility records, on 02/21/2022, staff called 911 for R1. A review of facility records titled Narrative Charting was completed. The Narrative Charting dated 02/21/2022 indicated R1 was sent out via 911 due to self-harm. While at the hospital, R1 was diagnosed with a pressure injury. A review of medical records dated 02/21/2022 revealed R1 was diagnosed with a wound. Continued on LIC9099-C Unsubstantiated Wound was described as wound location: left trochanter, type of wound: consistent with pressure related injury, stage was listed as unstageable and wound size was listed as 4.2 x 4 cm. The left trochanter is located at the top of the left thighbone, on the outside of the hip. Interviews with staff were conducted and 5 of 6 staff indicated they did not observe any pressure injuries on R1. The sixth staff did not reveal knowledge of any pressure injuries. During staff interviews, 4 of 6 revealed R1 would pick at their skin causing small wounds. Staff would then clean and bandage the wounds. It was not clear during interviews where the wounds were located on R1. Narrative Charting dated 02/19/2022 corroborated staff interviews. The Narrative Charting revealed care staff reported R1 is pinching their skin, causing small wounds, the wounds were cleaned and bandaged. R1 was not able to be interviewed. Based on interviews and records review the allegation of resident sustained an unstageable pressure injury while in care is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. It was alleged that resident sustained injuries resulting in hospitalization due lack of care and supervision. R1 moved into the facility on 01/13/2022. R1’s Physicians Report dated 12/17/2021 indicated R1 was ambulatory. The Physician’s Report does not list R1 as a fall risk. R1’s AL Advantage Memory Care Resident Assessment was reviewed. The assessment is neither dated nor does it include R1’s name. However, the assessment was provided by the facility staff as relating to R1. The assessment indicates R1’s level of assistance as R1 was to receive (8) eight status checks per shift. Investigation did not reveal documentation of the eight (8) status checks per shift. Staff interviews revealed R1 was found on the floor. Staff interviews further indicated R1 was transported to the hospital on 02/08/2022 due to the un-witnessed fall. Medical records dated 02/08/2022 revealed R1 was noted with a contusion to the right elbow and the back of the right hand. R1 was discharged back to the facility on 02/09/2022. Narrative Charting dated 02/21/2022, revealed R1 was sent back to the hospital due to self-harm. Medical records dated 02/21/2022 revealed R1 had a chief complaint of agitation. Medical records for the 02/21/2022 hospital visit is where it was revealed an “anticipated” diagnosis of right hip fracture. Based on interviews and records review the allegation of resident sustained injuries resulting in hospitalization due lack of care and supervision is unsubstantiated. A finding that the complaint is unsubstantiated means Continued on LIC9099-C... It was alleged that staff did not meet the needs of resident in care. Resident (R1) moved into the facility on 01/14/2022, according to records obtained R1s Physicians report indicated R1 baseline is cognitive impairment, including screaming episodes, confusion, and hallucination. R1s physician report also revealed R1 was ambulatory and not listed as a fall risk. Facility staff made several observations of R1s exhibited behaviors consisting of screaming episodes, displaying confusion, and hallucinating. In addition, staff observed R1 throw themselves out of their wheelchair on a regular basis. On 2/8/2022 R1 was transported to the hospital and admitted for a fall, supportive documents revealed R1 was in their apartment sitting in a chair when they tried getting up and then fell. R1 sustained injuries from their fall, contusion to the right hand and elbow. R1 returned to the facility from the hospital on 2/9/2022, there were no new appraisals or assessments completed by the facility staff indicating a change in R1s condition. According to information obtained through staff interviews, the facility did not provide one-on-one service to any residents. Additionally, the facility had three (3) caregivers per shift for twenty-five (25) residents. The facility also had one (1) medical technician, who would fulfill caregiver duties after passing medications. Information obtained through interviews revealed the med-tech would move the resident closer to them (med-tech) whenever the med-tech had to attend to other residents who required their assistance. Based on interviews and records review R1 was not reassessed by the facility staff after experiencing a fall and being hospitalized, therefore the allegation staff did not meet the needs of resident in care is found to be substantiated. The preponderance of the 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 9099 D. An exit interview was conducted, and a copy of this report was provided. that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. It was alleged that staff did not notify responsible party of resident's change in condition. Information obtained through interviews revealed upon R1s admission to the facility, R1 was observed in their wheelchair covered with a blanket and a lap belt on them to secure them in the wheelchair to prevent them from falling. After R1’s admission, the facility staff removed the lap belt due to the lap belt being a form of restraint. According to staff’s observations R1 would then proceed to throw themselves out of the chair on a regular basis. R1 was provided with a recliner by R1s daughter however this was identified as another form of restraint. In addition, R1 began to exhibit behaviors, picking at their skin on a regular. Staff would treat R1s wound by cleaning and bandaging R1 each time R1 would pick at their skin. Evidence gathered during this investigation confirms the facility staff and R1s power of attorney (POA) were in constant communication via in-person visits, phone calls, and or text messages regarding R1s activities of daily living (ADL’s). Based on interviews and records review the allegation of staff did not notify responsible party of resident's change in condition is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.the state’s words, verbatim · CDSS document, Feb 26, 2025 · control 18-AS-20220722151836

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463 · Plan of correction due date: Mar 7, 2025

Reappraisals: The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented. This was not met by: Based on record review and interviews, the Licensee did not comply with the above regulation with R1. R1 was hospitalized due to a fall, after being discharged from the hospital R1 was not reassessed to determine level of care for R1. This was an immediate safety risk to R1.the state’s words, verbatim · CDSS document, Feb 26, 2025

Plan of correction: Administrator will send documentation that all staff have received new traning on reporting residents' change of condition, list of procedures to follow when observed, and updating all parties involved.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Mar 7, 2025

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided...licensee shall ensure that such changes are documented and brought to the attention of...physician and ... responsible person ...This was not met by: Based on record review and interviews, the Licensee did not comply with the above regulation with R1. R1 exhibited throwing themselves out of their wheelchair on a regular basis. R1 was hospitalized due to a fall. This was an immediate safety risk to R1.the state’s words, verbatim · CDSS document, Feb 26, 2025

Plan of correction: Administrator will send documentation that all staff have received new traning on reporting residents' change of condition, list of procedures to follow when observed, and updating all parties involved. A new procedure will be created for a updated care plan for residents.

Allegation investigated: Facility staff are not ensuring resident is thoroughly cleaned Facility staff are not assisting resident with toileting Resident does not have pendant/call button Resident is not provided assistance in a timely manner

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation in regards to the allegations noted above. LPA met with Executive Director Barbara Bogoje and explained the purpose of the visit and the elements of the allegation. The allegations were investigated, which consisted of observations, interviews and records review. On February 22, 2022, Community Care Licensing received a complaint alleging that facility staff are not ensuring resident is thoroughly cleaned, facility staff are not assisting resident with toileting, resident does not have pendant/call button and resident is not provided with assistance in a timely manner. Regarding the allegation of facility staff are not ensuring resident is thoroughly cleaned. It was alleged that Resident #1 (R1) was observed to be covered in feces while at an appointment in or around March 2022. Interview conducted with R1 revealed that R1 believes they are given “the red-carpet treatment” and admitted that there are times when they can be difficult with the staff. R1 further stated that they get angry with staff and tell them to get out of their room, and it does not matter the task that is being completed, they will tell staff to leave, and staff comply. Staff interviews revealed that staff are not always able to finish providing the care Unsubstantiated that R1 was being provided with because R1 sometimes instructs the staff to get out of the room. Staff do not want to violate R1s personal rights, so they abide by R1’s wishes. LPA conducted a records review of narrative charting for R1 which revealed that on 3/10/22 staff was trying shave R1 when they attempted to bite staff. On 02/17/22 when staff was conducting a check on R1, R1 reportedly told staff to get out and tried to kick and punch the staff. A further review of resident’s shower sheet form dated 2/28/22 revealed that R1 stated that “nobody here knows how to give a shower”. The form also noted that R1 had forgotten that staff already cleaned their head and hair, so staff repeated the task. Per an interview with current Executive Director the residents have a shower schedule and depending on the resident, the days assigned can range from 1-3 times a week and as needed. The staff make charting entries for showers completed, refused and if laundry was needed to be cleaned. Due to insufficient evidence to corroborate or refute the allegation of facility staff are not ensuring resident is thoroughly cleaned is unsubstantiated. Facility staff are not assisting resident with toileting. It was alleged that although R1 wears adult briefs, R1 is reported to be able to use the bathroom with staff assistance, as well as communicate the need to use the restroom, but staff do not provide them assistance. Per an interview with R1, R1 stated that there are times when they are being assisted with toileting and getting their adult brief changed and that if they want staff out, they will instruct staff to leave them alone. Per a review of narrative charting dated 02/17/22 R1 is noted as being aggressive with staff when staff was attempting to conduct a check on them. R1 is noted as telling staff to get out and tried to kick and punch the staff. Per an additional review of the end of shift reports from February 2022 it is noted that staff conducted checks as well as provided R1 with toileting assistance. Per interviews conducted with the current executive Director Barbara Bogoje, the residents are checked at beginning of shifts, throughout the shifts and during last rounds. Due to insufficient evidence to corroborate or refute the allegation of facility staff are not assisting resident with toileting is unsubstantiated. Resident does not have pendant/call button It was alleged that R1 did not have a pendant/call button. LPA conducted a review of narrative charting which revealed that R1 did not have a pendant from 2/3/22 to 2/10/22. A further records review revealed that R1 noted to have allegedly destroyed (4) pendants, which included R1 putting their pendant inside a cup of water on separate occasions. It was further alleged from a third-party witness the directive was given to not issue R1 another pendant, and to increase the checks on R1. LPA conducted a records review of narrative charting which indicated staff had increased checks on R1 every 30 minutes beginning 02/06/22. Per an interview with R1, R1 admitted to breaking their pendant, and they use the alarm cord in the bathroom or yell when they need assistance. Per an interview with current Executive Director “If a pendant becomes lost or stolen, a replacement is given to the resident, and there is no limit to replacing the pendants”. Based on observations interviews and records review the allegation of resident does not have a pendant/call button is unsubstantiated. Resident is not provided assistance in a timely manner It was alleged that R1 is not being provided assistance in a timely manner. Interview R1 revealed that staff have a difficult time understanding them and that frustrates them and R1 will demand staff to leave their room. During LPA interview with R1, R1 was observed to be difficult to understand as they were speaking in a low voice and mumbling. It was further alleged from a third-party witness to not issue R1 another pendant, and to increase the checks on R1. R1 was reported to often yell and scream at staff while demanding they leave them alone. LPA conducted a records review of Narrative charting that revealed staff had increased checks on R1 every 30 minutes, beginning on 02/06/22. Interview with R1 revealed they use the alarm cord in the bathroom or yell when they need assistance. R1 further stated that they are given the “red carpet treatment”. Based on observations, interviews and records review the allegation of resident is not provided assistance in a timely manner is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted and a copy of this, and LIC811-confidential names list was provided to Executive Director Barbara Bogoje .the state’s words, verbatim · CDSS document, Feb 21, 2025 · control 18-AS-20220222133113

Allegation investigated: Facility is in disrepair

Licensing Program Analyst (LPA) Abdoulaye Zerbo made an unannounced follow-up complaint visit to the facility to deliver findings on the above allegations. LPA met with Executive Director (ED) Barbara Bogoje, explained the purpose of the visit, and was granted entry into the facility. It was alleged that the facility is in disrepair. All six (6) cottages, including the kitchen area, were toured during the inspection. The kitchen was observed to be clean and fully functional. Five (5) of the six (6) cottages were in good condition. One cottage in memory care had a hole in the ceiling in the laundry room. Maintenance and the Executive Director (ED) acknowledged the issue and confirmed that repairs were underway. Based on the evidence, the allegation mentioned above is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the preponderance of the evidence standard has been met. Deficiencies were cited on an LIC9099- D page. Substantiated It was alleged that the staff did not ensure a safe environment was provided to residents in care. Five (5) of five (5) staff members interviewed stated all staff working during the outage took fast action to make sure all the residents were safe. In the memory care cottages, staff stated they were provided with flashlights, and residents were provided with extra blankets. LPA also observed a box containing multiple lanterns to be available. The staff also stated all the residents were gathered in the dining area and did activities with them. They also stated one (1) staff was positioned at each exit to ensure no clients were going out unsupervised. At the Assisted Living cottages, LPA observed the call button to be battery operated and in good repair. staff stated they were provided with flashlights to ensure care and supervision would not be interrupted and or jeopardized due to the power outage. LPA observed a few rooms to have lanterns. The ED stated all the families, as well as hospice companies, were notified during the power outage. Based on the evidence, the allegation mentioned above is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.the state’s words, verbatim · CDSS document, Feb 21, 2025 · control 18-AS-20250109093446

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 7, 2025

87303 Maintenance and Operation (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 is not met as evidenced by: Based on observation and interview, the ceiling in the laundry room of one(1) of the memory care cottage had a hole, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 21, 2025

Plan of correction: The licensee must ensure repairs are made with proof of repair to licensing by the POC due date

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct a Case Management visit regarding an update of an incident that took place on June 2, 2024. LPA spoke with Barbara Bogoje, Executive Director and obtained the information. LPA conducted a health, safety and welfare check of residents in care, there are no issues at this time per ED. There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, a copy of this report were provided to the Executive Director, Barbara Bogoje.the state’s words, verbatim · CDSS document, Feb 19, 2025

Allegation investigated: Facility staff disclosed confidential medical information of resident to an unauthorized party.

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Executive Director (ED), Barbara Bogoje, and informed her of the purpose for the visit. A report was received by the Department alleging Staff One (S1) provided Resident One's (R1's) medical information to an unauthorized family member on 10/03/2024. The LPA conducted staff interviews, reviewed records, and obtained copies of relevant documentation. R1 was not available for an interview prior to the delivery of the investigation findings. S1 was interviewed and reported the individual, who was the alleged unauthorized family member, has visited R1 at the facility on at least one occasion. S1 denied providing the individual with R1's medical information. The LPA interviewed the alleged unauthorized family member; the individual reported they have visited with R1 on occasion and were denied medical information about R1 when requested. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. This report was reviewed with RSD, Miriam Issa, and a copy was provided. NOTE: The LPA was off of the premises from about 12:20 PM to 12:50 PM. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 19, 2024 · control 18-AS-20241210124228

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct a Case Management visit regarding an update of an incident that took place on June 2, 2024. LPA spoke with Barbara Bogoje, Executive Director and obtained the information. LPA conducted a health, safety and welfare check of residents in care, there are no issues at this time per ED. There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, a copy of this report were provided to the Executive Director, Barbara Bogoje.the state’s words, verbatim · CDSS document, Dec 9, 2024

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct a Case Management visit regarding an update of an incident that took place on June 2, 2024. LPA spoke with Barbara Bogoje, Executive Director and obtained the information. LPA conducted a health, safety and welfare check of residents in care, there are no issues at this time per ED. There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, a copy of this report were provided to the Executive Director, Barbara Bogoje.the state’s words, verbatim · CDSS document, Nov 18, 2024

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct a Case Management visit regarding an update of an incident that took place on June 2, 2024. LPA spoke with Barbara Bogoje, Executive Director and Mariam Issa, Resident Services Director and obtained the information. LPA conducted a health, safety and welfare check of residents in care, there are no issues at this time per ED. There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, a copy of this report were provided to the Executive Director, Barbara Bogoje.the state’s words, verbatim · CDSS document, Oct 9, 2024

Type of visit: Required - 1 Year

*Amended report* 08/29/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA met with Terri Harris, Concierge, where LPA explained the purpose of the visit. The facility is licensed to serve residents age range 60 and over, 110 non ambulatory, of which 12 may be bedridden. The facility has an approved hospice waiver for 20, and for delayed egress. There are 13 residents receiving hospice services. The facility consists of (6) single story cottages with fifteen bedroom/bathroom units in each cottage. There is a total of (4) cottages dedicated to assisted living residents and (2) cottages dedicated for memory care residents. Below is a summary of what was observed during today's visit: LPA conducted a tour of the interior and exterior areas of the facility, there are no pools or bodies of water on the premises. LPA conducted a review of both staff and record files. LPA reviewed (6) resident files that were observed to have the required documents such as medical assessment, needs and services appraisal. Regarding staff files, all staff present at the facility were observed to have obtained criminal record clearance, and to be associated to the facility however, there was no proof of valid CPR certification in the (6) files reviewed deficiency cited. The staff files reviewed were not observed to have any updated required training. In addition LPA observed for the facility to have a change of administrator. LPA discussed that a request should be submitted for the facility administrator to be updated with the regional office. The kitchen which is in the main building was observed to be clean, and clutter free. There was plenty of cookware, dishes and utensils to serve the residents in care. The facility was observed to have a 2 day supply of perishable and a 7 day supply of non perishable food items. All meals are prepared in the kitchen and delivered to each cottage. Each cottage has an dining room, which consists of a kitchenette that was observed to have food warmers, refrigerators, and pantry. The resident bedrooms were observed to be clean and odor free, the cottages were at a comfortable temperature. The hot water was tested and found to be within regulatory limits measuring 105.4-114.2 degrees Fahrenheit. The medications are locked inside medication carts. The facility uses electronic Medication Authorization Records (MAR)s. Each cottage was observed to have a fully charged fire extinguisher. The smoke and carbon monoxide detectors were unable to be tested at the time of LPAs visit as there was not a staff on grounds that knew how to test the devices. LPA conducted a review of the fire inspections log and observed that there is no record that the facility has been conducting emergency disaster drills on a quarterly basis. The last drill documented was an elopement drill that was conducted on 5/19/22. deficiency cited. Based on today's inspection citations were issued on the attached 809D in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted and a copy of this report, 809D, appeal rights, and LIC9098-Proof of Corrections form was reviewed and provided to Terri Harris.the state’s words, verbatim · CDSS document, Aug 29, 2024

Allegation investigated: Resident fell while in care

Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conclude the investigation into the allegation listed above. LPA met with Continuous Improvement Specialist Kim Henson and explained the purpose of the visit. Regarding allegation “Resident fell while in care”, it was reported Resident One (R1) had fallen while in care due to lack of supervision by staff and sustaining an injury as a result of the fall. Interview with staff revealed Staff One (S1) observed R1 in the living room in their wheelchair. S1 returned to the living room from the kitchen and found R1 on the floor. S1 attempted first aid to the back of the head and contacted two (2) staff for assistance. Records review of staff schedule revealed two caregivers and one MedTech were scheduled to work the PM shift on 08/11/2021. Records review of facility’s Narrative Charting revealed R1 sustained a laceration to the back of the head and R1 was transported to the hospital. R1 was admitted to the facility on 08/10/2021 with resident assessment of ambulation with one (1) person total assist or wheelchair escort to and from activities, meals, etc. Unsubstantiated Interview with R1 was not conducted due to R1’s passing in August 2021. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Continuous Improvement Specialist Kim Henson.the state’s words, verbatim · CDSS document, Aug 5, 2024 · control 18-AS-20210816150952

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility regarding the department receiving an SIR of an incident that took place on June 2, 2024 of medications that were taken during a robbery. LPA spoke with Administrator Mark Pacia and obtained additional information. LPA toured the area accompanied by the Administrator. LPA conducted a health, safety and welfare check of residents in care and Administrator confirmed that no residents were identified that were victimized, injured or harmed during the incident. Administrator confirmed the staff that were present and victimized have been offered resources by the facility. LPA received an inventory of medications that were taken. Administrator confirmed the medications that were taken have been replaced and no resident had a lapsed in receiving their medications on time. Administrator confirmed that emails and letters were sent to resident's family or responsible parties regarding the incident. Administrator confirmed that the police were notified and investigation is on going. Administrator confirmed with LPA that preventative measures are going to be implemented for the safety of all residents, staff and visitors. There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, a copy of this report were provided to the Executive Director, Marc Pacia.the state’s words, verbatim · CDSS document, Jun 5, 2024

Type of visit: Case Management - Deficiencies

On April 23, 2024, Licensing Program Analyst (LPA), Venus Mixson conducted an unannounced Health and safety visit in conjunction with a case management visit with deficiencies. LPA Mixson met with Marc Pacia, introduced herself and stated the purpose of the visit. LPA Mixson conducted a tour of the facility, along with the Administrator, and made observations pertaining to the information obtained via unusual incident/injury report (SIR). On April 15, 2024, the Department received an SIR stating a resident received the incorrect medication. There were no Health and/or Safety violation observed during this visit. LPA Mixson observed the facility utilities operating without issues. Food supply is sufficient. There are no immediate health or safety concerns for residents in care observed currently at the time of this visit. There are deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22, Division 6, for the SIR dated April 15, 2024, for the incorrect medications to a resident in care, that occurred on April 11, 2024. An exit interview was conducted, a copy of this report, along with the 809-D and Appeals rights, were provided to the Executive Director, Marc Pacia.the state’s words, verbatim · CDSS document, Apr 23, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80075(b) · Plan of correction due date: Apr 29, 2024

80075(b) Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:the state’s words, verbatim · CDSS document, Apr 23, 2024

Plan of correction: Licensee stated that they shall conduct an in-service training for all staff members that assist in administering medication. Licensee stated they will FAX proof of training completion by the POC date to the Department.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087(a) · Plan of correction due date: Apr 29, 2024

Based on records reviewed, the Licensee did not ensure that medication was properly administered to a resident in care. This poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Apr 23, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20231013131810 to check on the health, safety, and welfare of residents in care. LPA met with Executive Director Marc Pacia and explained the purpose of today's visit. Seventy-Eight (78) of (78) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. One (1) deficiencies were cited CCR87211(a)(1)(D) during today's visit. An exit interview was conducted and a copy of this report, LIC809D and Appeal Rights was to provide Pacia.the state’s words, verbatim · CDSS document, Oct 20, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 23, 2023

REPORTING REQUIREMENTS: a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (D) Any incident which threatens the welfare, safety or health of any resident...This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not being met as evidenced by: During interview with ED on 10/20/2023, ED verbally stated that one resident had a fall and ED failed to report the resident had fall that resulted in bruising on temple and forehead on 09/30/2023. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 20, 2023

Plan of correction: ED stated that they will report all incidents and falls to Licensing according to requirements.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced case management visit to the facility to follow up on additional information for resident's death that occurred on 9/14/2023. LPA spoke with RSD, Yolanda Garcia and gathered documentation. No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report LIC 809 were provided to Yolanda Garcia.the state’s words, verbatim · CDSS document, Oct 20, 2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced case management visit to the facility. On 9/14/2023, CCLD received report of a resident's death. The visit was to follow up on resident #1 (R1)s death. LPA met with Executive Director Mark Pacia and Resident Services Director Yolanda Garcia and explained the purpose of today's visit. During LPA's visit, LPA reviewed and obtained copies of pertinent documentation and interviewed two (2) staff. LPA was informed by Resident Services Director regarding the events that led up to R1's death whom passed away on September 14, 2023. LPA was informed that R1 had not been feeling well since the morning prior to her passing and R1 refused to be sent out to the hospital when asked by staff. The preliminary cause of death is unknown at this time. LPA advised Mark Pacia and Yolanda Garcia to send a copy of the death certificate to the department as soon as it is available. No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report (LIC 809) and LIC 811 (confidential names list), were provided to Mark Pacia and Yolanda Garcia.the state’s words, verbatim · CDSS document, Oct 9, 2023

Allegation investigated: Facility does not have hot water

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to the facility to initiate an investigation into the allegation list above. LPA met with Executive Director (ED), Marc Pacia and explained the purpose of the visit. LPA interviewed three (3) staff, three (3) residents, toured the facility, and obtained copies of pertinent documents. On September 26, 2023, Community Care Licensing received information which stated the facility did not have hot water.” It was reported that Aspen Cottage at the facility was without hot water for approximately three (3) weeks from September 13, 2023 to September 26, 2023. Interviews conducted revealed the facility's hot water heater could not be repaired but need to be replaced. As a result, Rooms 1-8 (CONTINUED ON LIC9099-C) Substantiated (Continued from LIC 9099) and 10-15 were without hot water. The facility made other accommodations for Residents to use the Birch building for showers. ED Marc reported the water heater was repaired on September 26, 2023 and hot water has now been restored in rooms 1-8 and 10-15. LPA observed the hot water to be operational at the time of the visit. Based on LPA’s observations, interviews conducted, and records reviewed, the time frame for completing the corrections were not reasonable, 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, Section 87303(a), is being cited on the attached LIC 9099 D. An exit interview was conducted. A copy of the report, LIC 9099-D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 18-AS-20230926082804

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 28, 2023

Maintenance and Operation- (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 was not met as evidenced by: Licensee did not ensure hot water was available for all residents. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: Facility has repaired the hot water and LPA verified hot water is operational during this visit today.