Country Club Manor

Allegation investigated: Staff mismanaged resident's medications Staff stole from residents in care

On August 06, 2026, at 2:06 PM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Kathryn Nevin during today’s visit and explained the purpose of the visit. Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, and reviewed resident records. Based on resident 1's (R1) medication administration record review and file review, there was no evidence to show that R1 was administered the wrong medication. R1 also reported that they have not been administered the wrong medication. Additionally, facility records show that facility staff were managing R1's refill requests, and contacting R1's primary physician to obtain medication in a timely manner. Five out of six staff reported there have been no medication errors. Continued... Unsubstantiated In addition, LPA Martinez interviewed five out of five residents. Four out five residents reported that none of their property have been stolen by staff. One out of five residents informed LPA Martinez that they did not want to be interviewed. Six out of six staff reported that they are not aware of staff stealing from residents. Due to the above noted information, 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, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 6, 2026 · control 27-AS-20260417151128

Allegation investigated: Staff are not abiding by the terms and conditions of Admission Agreement. Staff do not ensure that resident's room is clean.

On August 4, 2026 at 11:30am, Licensing Program Analyst (LPA) Sulma Lopez and Licensing Program Manager (LPM) Arielle Pascua arrived unannounced at the facility to conduct a complaint investigation regarding the above allegations. LPA met with Facility Administrator (FA) Kathryn Nevin and explained the purpose of the visit. During the visit, LPA toured the facility including resident rooms, interviewed staff and reviewed resident files. LPA reviewed admission agreements, housekeeping checklists, and maintenance logs. It was learned that Resident 1 (R1) resides in the Independent Living section of the facility. Therefore, is not under Title 22 Regulations and is not licensed by Community Care Licensing. The above allegations are unfounded because the evidence shows it could not have happened, is false, or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to the facility. Unfoundedthe state’s words, verbatim · CDSS document, Aug 4, 2026 · control 27-AS-20260726191356

Type of visit: Required - 1 Year

On August 4, 2026, at 9:00AM, Licensing Program Analyst (LPA) Sulma Lopez and Licensing Program Manager (LPM) Arielle Pascua arrived unannounced at the facility to conduct an annual inspection. LPA met with Facility Administrator Kathryn Nevin and explained the purpose of the visit. The facility has a capacity for (112) residents over 60 years old and is approved for (30) hospice residents. The current census is 59 total residents. There are currently (4) residents on hospice, and (5) dementia residents. During the inspection, LPA reviewed (6) staff files, and (6) resident files. The files are maintained current. The administrator holds a current Administrators Certificate #6077502740 with an expiration date of 05/26/2027. The facility holds a current Infection Control Plan. At 10:30AM, LPA began a tour of the facility with the Administrator. LPA observed the facility sunroom and hallways which were free of debris and tripping hazards. The hallways are equipped with various carbon monoxide and smoke detectors in good working condition. LPA observed the fire extinguishers have been annually inspected on 09/26/2025. LPA observed the living room area which contained ample seating for resident use. Residents were participating in chair exercise with staff instruction. LPA also inspected resident bedrooms which contained furnishings in good repair. The bedrooms were clear of debris and hazards. At 10:45AM, LPA observed the laundry room which contained extra clean linens. LPA observed the medication room and reviewed the first aid kit which contained all the required components. Continued... LPA proceeded to review the dining hall and kitchen area. LPA observed the facility contained at least a 7-day supply of non-perishable foods in the pantry, and 2- day perishable food supply in the walk-in refrigerator. Cleaning supplies were locked, and the kitchen was in sanitary condition. LPA observed the weekly menu was posted on various locations throughout the kitchen and dining hall. There was an updated Activities Calendar for the month of August. At 10:50AM, LPA toured the courtyard which was free of tripping hazards. LPA observed a covered patio with a seating area available for resident use. No bodies of water were present. The following documents were requested: LIC 500 LIC 308 LIC 610E No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to the administrator.the state’s words, verbatim · CDSS document, Aug 4, 2026

Allegation investigated: Staff did not provide medical attention to resident in a timely manner. Staff mismanaging resident’s medication.

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint findings. LPA Valerio met with Administrator Kathryn Nevin, and explained the purpose of the visit. Allegation: Staff did not provide medical attention to resident in a timely manner. According to the RP, R1 requested to go to the hospital. RP asked staff to call 911. RP saw staff make a call. RP waited outside with R1 for paramedics to arrive. RP stated 10 minutes later a staff member (name unknown) came out and informed RP they would not call 911 and refuse to call. Staff closed and locked the door. RP then flagged down paramedics who then called 911 for R1. Based on review of an interview conducted by LPA Viarella, the RP did not disclose the date of this incident. LPA Valerio attempted to contact RP but was unsuccessful. LPA Valerio requested from the facility all incident reports regarding R1. Continues on LIC 9099 -C... Unsubstantiated According to an interview with S1, S1 stated that R1's RP wanted R1 to go to the hospital because R1's bed was uncomfortable. S1 stated that it was not a medical emergency so we could not send R1 out. S1 checked the video footage and S1 did not see anyone ever ask the staff to send R1 out. LPA Valerio reviewed two incident reports received from the facility. Incident 1, dated 10/01/2025, stated R1's POA dropped resident off at the facility after R1 being out for the day. POA then came barging into the med room about R1 not sleeping in R1's bed. POA then started hollering at the med techs accusing them of not doing their job and stating R1 needed a new bed right now or R1 needs to go to the hospital. Med techs kindly explained to POA that they are not able to switch beds and to reach out to the administrator. POA was noted to take R1 to the emergency room. R1 came back at 7:52AM on 10/02/2025 from the hospital with a dx of pain in lower extremities and physical deconditioning. Staff noted on the incident report that the R1's bed has been switched out 3 times, 2 different hospital beds, and a regular bed, which R1 did not like. R1 has been up and about today. No complaints of pain or discomfort in R1's legs. LPA Valerio reviewed hospital after visit summary dated 10/01/2025. LPA Valerio confirmed the information that was relayed on the incident report was also stated on the after summary. Incident 2, dated 10/02/2025, stated R1's POA stated POA was coming down to the facility to pick up the resident to take R1 to the hospital since POA did not feel comfortable leaving R1 at the facility due to the lack of a comfortable bed and feels POA would be neglecting R1 if R1 is left at the facility. POA took R1 out of the facility at 7:00 PM. On the incident report, staff indicated that there were no medical needs mentioned. According to staff, "resident prefers to sleep in recliner and PCP sent [doctors] orders for resident to sleep in recliner on 10/03/2025." Staff indicated that R1's case manager reached out to the facility stating the ER wants to discharge R1 but are holding R1 until alternative placement is found." Continues on LIC 9099 - C, page 3 Allegation: Staff mismanaging resident’s medication. According to records review, R1 is able to determine need and communicate need clearly for PRN medications and has a service plan of full assistance with medication management. LPA Valerio reviewed the Medication Administration Record (MAR) for September and October of 2025. LPA Valerio did not observe any discrepancies for the September or October MAR. Based on all the information collected by the Department, although the allegation may have happened or is valid, here is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Jul 20, 2026 · control 27-AS-20251007110723

Allegation investigated: Facility rails are a hazard to residents.

Licensing Program Analyst (LPA) Christina Valerio and LPA Reza Jamaly arrived to the facility unannounced to conduct a complaint investigation and deliver complaint findings. The following has been determined as it relates to aforementioned allegation: Facility rails are a hazard to residents. On 10/13/2025, LPA Viarella conducted an interview with the Reporting Party (RP). The RP informed LPA Viarella that the handrail by the medication room has chunks missing and could cause a skin tear or splinters for residents. On 10/15/2025, LPA Viarella conducted an unannounced visit. LPA Viarella inspected the hand railing that travels the walls around the interior of the facility. According to LPA Viarella's observation notes, LPA Viarella obtained a splinter in her right hand after running her hand along the railing to test if it was a danger to residents. Continues on LIC 9099 - C... Substantiated On 07/07/2026, LPA Valerio conducted an unannounced visit. LPA Valerio inspected the hand rails around the interior of the facility. LPA Valerio observed many handrails to have chunks of wood missing from the handrail. One handrail was observed to have a piece of the hand rail missing, which exposed two needles or staples. Based on interview and observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility. On 07/07/2026, LPA Valerio conducted an unannounced visit. R1 no longer lives at the facility and therefore, the room was unoccupied. LPA Valerio conducted an inspection of four (4) resident bedrooms. LPA Valerio observed clean linens and bedsheets in each bedroom. LPA Valerio observed a supply closet that was fully stocked with bed sheets, comforters, towels, and pillow cases. Staff does not keep resident’s room free from pest. According to the RP, the R1's bedroom was full of dead bugs. There were dead bugs in the closet and in the bathroom. During LPA Viarella's unannounced visit on 10/15/2025, LPA Viarella did not indicate the observation of pest or bugs in R1's room. LPA did not see any insects (alive or dead) and the entire room did not look like it had been vacuumed in some time as evidenced by the dust and debris. During this visit, Pest Control Invoices were collected for review. LPA Valerio observed the facility to received pest control services on 08/11/2025, 09/08/2025, and 10/02/2025. According to an interview with Staff 1 (S1), the pest control service provider, Aantex Pest Control, continues to service the facility monthly. In addition to this pest control provider, they have an additional pest control service that services individual rooms when requested by the facility. According to an interview with Staff 2 (S2), the facility will be having the pest control service come out to spray the rooms. There is not a specific bug/pest they are targeting and it is more for maintenance. Staff not keeping resident’s room free from odor// Staff did not properly dispose urine. According to an interview with the RP, the RP stated that R1's room had an odor due to two buckets of old urine under R1's bed. During LPA Viarella's unannounced visit on 10/15/2025, LPA Viarella did not indicate the observation of odors. LPA observed that the carpet was heavily stained and was in the process of being pulled up from the baseboard; however, there were no odors. During LPA Viarella's unannounced visit on 10/15/2025, LPA Viarella did not indicate the observation of buckets of urine located under the bed. However, it should be noted that R1 was removed from the facility by R1's LPA Valerio conducted an unannounced visit on 07/07/2026. LPA did not observed buckets of urine under any bed in the bedrooms inspected during the tour. Continues on Page 3 Staff not maintaining resident’s hygiene. According to the RP, R1 was not provided a shower for weeks and the bathroom door stated that the bathroom could only be used for room 41, which wasn’t R1's room. According to LPA Viarella's observation the bathroom located inside of R1's room was a shared bathroom. The bathroom did not have a shower and it was solely a toilet. According to an interview with S1, they had one resident diagnosed with scabies and that specific shower room was being used by that individual until they were clear of scabies. According to S1, R1 would have been provided a shower that was not utilized by the individual diagnosed with scabies. According to R1's care plan dated 09/15/2025, R1's bathing service showed the following: hands -on help with bathing, assistance with bathing 2x per week, needs a shower chair, and the frequency is as scheduled and completed by a caregiver or med-tech. Staff does not provide nutritious meals/Staff does not offer fresh fruits and vegetables. According to the RP, the facility did not offer fresh fruit or vegetables. On 10/15/2025, LPA Viarella took pictures of Clementine's, pineapples, bananas, oranges, asparagus, cucumbers, and boxes of more vegetables being unloaded as it was their delivery day. On 07/07/2026, LPA Valerio observed strawberries, fruit cups, oranges, mandarins, asparagus, celery, salad, fruit cocktail, and plates of cobb salad. According to Consultant Dietitian Report Cards dated July and November of 2025, the facility scored 100% in the category Nutrition Care. According to the report dated July 2025, "lunch meal Swedish meatballs, parsley noodles, buttered carrots, roll and whipped gelatin parfait. The two mechanically altered diets were prepared according to residents preferences.". According to the report dated November 2025, "lunch meal - meatballs with marinara, spaghetti, tossed salad, garlic bread, sherbet. Residents were very happy with meal. Tasted and temperature were good. Puree diet texture appropriate" Continues on Page 4 Staff does not provide comfortable sleeping arrangement for resident. According to the RP, R1 had been "sleeping up" for the last two months and was tired. The RP reported that the facility had a mattress but it went missing. According to an interview with S1, S1 stated they provided many options for R1; however, R1 did not like the hospital bed and preferred to sleep in a reclining chair. We offered R1 different beds but R1 did not like them. According to facility records, R1 moved out of the facility in October and is no longer a resident of the community. Based on all the information collected by the Department, although the allegation may have happened or is valid, here is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 27-AS-20251007110723

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 7, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on observations on 10/15/2025 and 07/07/2026, the facility handrails were not in good repair, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Licensee stated the facility will have the maintenance staff inspect the handrails and repair as needed and remove any hazards. LPA Valerio to receive pictures of repaired handrails by POC due date.

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Facility is not kept free of pests. Facility is in disrepair.

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on June 30, 2026, at 9:00 AM to deliver complaint findings, LPA Martinez met with Kathryn Nevin and explained the purpose of the visit. Throughout the course of the investigation, LPA Martinez conducted interviews and inspected resident bedrooms and maintenance/cleaning supply room. LPA Martinez inspected resident 1's (R1) bedroom. LPA Martinez observed twenty-three dead cockroaches behind R1's recliner chair. In addition, LPA Martinez observed twenty-seven dead cockroaches in resident 2's (R2) bathroom. LPA Martinez also interviewed resident 3 (R3). R3 reported they took pictures of cockroaches that they found throughout the facility. R3's shared the photos with LPA Martinez during the interview. Resident 4 (R4) also confirmed having cockroaches in their bedroom. LPA Martinez also inspected the maintenance/cleaning supply room on June 30, 2026. LPA Martinez observed that there were holes in the wall and baby cockroaches were walking around and near the holes on the wall. Continued... Substantiated As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D page, per Title 22 Regulations. An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights document were provided to the facility. An exit interview was conducted, and a copy of this 9099 report, 9099-D Page, and appeals rights document were provided to the facility.the state’s words, verbatim · CDSS document, Jun 30, 2026 · control 27-AS-20260417151128

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 14, 2026

87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidence by: based on observation and interviews, the Licensee did not ensure the facility was kept free of pests. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 30, 2026

Plan of correction: Facility staff agrees to conduct a pest treatment and repair maintenance/cleaning supply room wall by poc date July 14, 2026. Staff agrees to email documentation to LPA Martinez by POC Date: July 14, 2026 by 5:00 PM.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Lack of supervision resulting in resident sustaining fractures. Staff left resident in soiled in clothing for a period of time.

On 3/20/26, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to complete and close the investigation into an allegation noted above. LPA met with Medication Technician, Nickolas Townsend(S3), and Resident Care Coordinator, Karla Celina Rosete Ayala (S2) and stated the purpose of this visit. An entrance interview was conducted Allegation: Lack of supervision resulting in resident sustaining fractures. This investigation focused on Resident 2 (R2) Throughout the process, LPA conducted facility observations interviewed on duty staff and residents, collateral interviews, and reviewed all relevant documents related to R2. Per R2's LIC 602, physicians’ report dated 8/2025, R2 is noted as ambulatory. R2’s care plan dated 9/11/2024 they are noted as “Independent with transferring” as well as independent with changing and toileting. Additionally, it indicates R2 needs assistance with bathing - 2x per week with use of a Shower chair and assistance with medications. CONTINUED ON 9099-C Unsubstantiated Hospital records confirm R2 obtained two broken ribs and was admitted on 1/31/26. It was also reported that R2 was stiff when staff tried to assist them with repositioning. Administrator, Kathryn Nevin (S1) stated that R2 fell on 1/31/26, 2/5/26, and 12/13/26. S1 stated that R2 was not utilizing any assertive devices for walking prior to 1/31/26 and did not have a history of falls, they were not a fall risk. Per incident report (SIR) received on 1/31/26, R2’s was immediately sent to the hospital upon R2 reporting that they had fallen the night prior but did not request assistance until medication pass around 8:00AM. Staff 3 (S4) reported that R2 was covered with their blankets so they were unable to see if R2 was soiled. On 3/20/26, Med tech, S4 stated on shift on 1/31/26 stated they went into R2’s room in the morning to give him his medications and that is when R2 reported they fell at 2:00AM on 1/31/26 and was able to get himself up so they did not call for help. staff called the paramedics to have R2 be evaluated at the hospital as he was complaining of pain, S4 stated R2 stayed in their bed covered by their blankets until the paramedics arrived. Discharge paperwork received for R2's hospital visits on 1/31/26 and 2/5/26. The facility created a new care plan/appraisal on 2/5/26 done due to the change in condition. R2 started. receiving physical therapy and get more assistance since. The updated plan stated “Safety checks - 4 times per shift” and R2 now uses a walker in which they need verbal reminders and cuing to use. S2 stated R2 fell on 1/31/26, 2/5 and 2/13, in which a re-assessment of needs was made for this change of condition. On 3/202/6, R2 stated they don’t like to use the call button unless they really need it, their needs are being met at this facility, and they feel safe. Per Department led record review of R2s care plan and incident reports it was found that R2 does not have a history of falls. 3 out of 3 staff interviewed sated R2 did not require constant supervision as they were mostly independent prior to falling on 1/31/26 and there is increased supervision ever since February 2026. S2 stated that R2 has a new care plan effective 2/18/2026 and currently receives skilled nursing, physical therapy, and occupational therapy, 2 hours checks by care staff, shower assistance, and uses a walker. S1 stated R2 is using their walker more often as staff encourages them to do so. R2 confirmed they are using a walker "for long distance" and have a working call button. On 3/20/26, LPA Tamayo observed a care staff arrived to R2's bedroom within four minutes of the button being pressed (12:41PM -12:45PM). Authorized representative for R2 stated they have no concerns about the facility, they are “grateful” for the care and supervision provided by the facility. LPA observed the call button is fixed to the wall behind a chair and night stand. S3 stated that staff tried to rearrange their room to make the call button more accessible, however R2 did not want their room rearranged. CONTINUED ON 9099-C2 S2 plans to talk to maintenance to get a longer pull string for the call button or if it can be relocated. S3 is also seeing if a hospital bed is possible to obtain to allow for the call button. S2 stated that wearable pendant buttons is not currently a service offered at the facility but S3 will look into whether they can get one for fall risk residents. The new care plan involves more supervision with more frequent checks, every two hours. S1 stated an incident report was sent in on 2/17/26 to the Regional Office for another witnessed fall on 2/13/26 in which there was a diagnosis of closed fracture above inner left wrist (distal radius). A fall risk assessment was completed by the facility on 2/18/26. Facility provided the Department with fall risk assessment. Based on interviews and record review of the LPA and review of records the allegation that "Lack of supervision resulting in resident sustaining fractures", is unsubstantiated. Allegation Staff left resident in soiled in clothing for a period of time. This investigation focused on Resident 1 (R2) Throughout the process, LPA conducted facility observations interviewed on duty staff and residents, collateral interviews, and reviewed all relevant documents related to R2. It was alleged that R2’s "clothing was soiled and dirty, his shirt had vomit from over 24 hours and had not been changed". Per incident report received on 1/31/26, R2’s was sent to the hospital upon R2 reporting that they had fallen the night prior but did not request assistance or tell staff they had a fall until medication pass around 8:00AM. Medication Technician Staff 4 (S4) reported that R2 was covered with their blankets so they were unable to see if R2 was soiled. 3 out of 3 staff stated R2 was complaining of pain and they stayed in bed until the paramedics arrived, there was no observation of R2 being in soiled. R2 stated their hygiene needs are met, although they want to be independent, staff assisted with bathing and laundry. On 3/20/26, LPA observed that R2s room was clean and free from odor and R2s clothing was clean and did not have any odors. LPA conducted a collateral interview with R2's family member (R1), they stated that R2 does not have any concerns about resident being left in soiled in clothing for a period of time. Based on interviews and record review of the LPA and review of records and the allegation was not corroborated and the allegation "Staff left resident in soiled in clothing for a period of time" is unsubstantiated. Based on the interview statements and record review obtained during the investigation process, there is not a preponderance of the evidence to prove that the alleged violation that staff did not ensure staff coverage documentation accurately reflects the actual hours worked by staff occurred and is unsubstantiated. Although the Department has determined that the allegations above are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies cited per California Code Regulation, TITLE 22. Exit interview was conducted with the S2. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 20, 2026 · control 27-AS-20260202111051

Allegation investigated: Staff are mishandling the residents medications

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived to the facility unannounced to conduct a complaint investigation into the above allegation. LPA met with administrator Kathryn Nevin, and explained the purpose of the visit. Through record review and interview and observation by the LPA, it was learned that the facility medication administration documentation is not detailed in the specific ways outlined by regulation, or left undetailed. 5 MAR records chosen at random, one MAR record showed a clients refusal documentation reasoning as "ref" mean refused, which is not useful in determining the reasoning for the refusal. For 2 MAR records, it is marked that the facility is unable to disperse a medication by flag "other" or "medication not availible", but a readily availible Notes coloumn does not describe the reasoning of the medication not being availible or whats being done about it or what will be done about it. In interview, some staff are reporting not enough time on shifts with less Med Techs assigned to stay on top of documentation tasks. On two occassions LPA observed alerts in the MAR that were unanswered for marking down PRN dispersal results timely, one of the alerts was observed for a medication given 3 hours earlier. continued on C page Substantiated LPA gave guidance that the reason for refusal should be documented as outlined in regulation, PRN response fields of documentation should be completed timely, any staffing concerns should be raised in the internal grievance process, and documentation should be filled out with the goal to reduce reliance on verbal reporting not to make it mandatory. Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, is being cited on the attached LIC 9099D. citations issued, a copy of the appeal rights was left with the administrator. a copy of the report was read and given to the administrator. Exit interview conducted. documented, or with the client refusing or accepting a medication. Over three med pass observations, LPA did not witness the staff withold a medication, based on the blood pressure reading or not. By interview with staff/clients, and a record review of MARs and the facility menu, and meal observation, it was learned that medication is confiscated by staff when they arrive to the facility if it is not on the medication orders list. In at least one instance, a client reported the staff taking a medication perscribed to her and not dispersing it. It was learned from the mar that a discontinue order for that medication was issued 2 days before the client arrived. The facility staff do not have a response as to what happened to the medication after it was confiscated, if it was destroyed, if it was kept secure as property of the client. LPA gave guidance that kind of confiscation policy should be more obvious to the incoming clients in the form of an addendum to the admission agreement and the issue should be resolved internally as a loss of property if it cannot be produced by the facility. As a related issue, some clients (a mixed population of nonassisted living, and assisted living) report not being given the option of adequately nutritious alternatives if they have a perscribed alternative diet. LPA reviewed the menu and observed the lunch service on two occasions, the lunch service is meeting the nutritional requirement of 1/3 of servings of the various groups in the regular and alternative meals, LPA is concerned about anybody repeatedly choosing the house salad option not getting an adequate amount of protein. LPA gave guidance that the salad can easily have servings of nuts, cheese, eggs, or chicken added to it to shore up any nutritional concerns and improve the variety for the hypertensive/diabetic folks. cheese cant be used as a source of protien if its also being used as a source of dairy for the purposes of menu design. by interview with staff/clients, it was learned that holds are given of the clients medication. some clients report unease with the facility issuing medication in general and specificly the practice of holding the medication. The staff report that they do not give out medication belonging to other residents, or give out medication that is ordered by a doctor to be withheld, and destroy medications as necessary when a client has a new order/leaves the facility permanently. The practice of holding medication is specificly for unplanned absences from the facility. LPA gave guidance that medication is the clients property and should go with the client if they have a planned absense from the facility, they or a responsible party (as applicible) can sign out their medication with a affidavit that they will adhere to the schedule of the medication. The facility has a responsibility to take measures to ensure medications are delivered on schedule, and medications are not to be used to restrict the movement of the clients. Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. no citation issued, A copy of the report was read and given to the administrator, appeal rights provided. exit interview conductedthe state’s words, verbatim · CDSS document, Feb 3, 2026 · control 27-AS-20251214210439

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80075(b) · Plan of correction due date: Feb 10, 2026

80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by: Record review and interview and observation by the LPA, where 3 of 5 records requested at random had incomplete or unusable documentation, 1 unusable reasoning of refused medication and 2 missing PRN reasoning. This posed a potential risk to the health, safety or personal rights of the clients in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Licensee will review current documentation practices, propose a strategy in writing to the LPA that addresses the concerns, by the poc date. noel.wolfpetersen@dss.ca.gov LPA is suggesting better and consistant use is made of the "notes" feature on the online mar.

Allegation investigated: Staff are inappropriately locking facility doors.

On 09/18/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Kathryn Nevin and explained the purpose of the visit. The purpose of this visit was to inform the facility and it's representative that a complaint has been filed against it at this time. Current census was 55. A brief interview with FDA Nevin was conducted. It was alleged that facility staff are inappropriately locking facility doors. Based on interviews conducted, it was denied that the facility staff are inappropriately locking facility doors. It was stated that the facility doors are closed after 8:00pm, however, the facility residents have access to go through the doors. In addition, LPA Pascua reviewed facility video recordings and did not find that the facility staff was locking the facility doors. LPA Pascua observed the doors to be easily accessible to the residents in care. Based on the information gathered, there is not sufficient evidence to show that the facility staff inappropriately lock facility doors. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 was provided to the facility at the end of this visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 18, 2025 · control 27-AS-20250912124600

Allegation investigated: Resident felt pressured to sign a payment plan.

On 09/04/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to open an investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director (ED). LPA met with ED Kathryn Nevin and a brief interviewed followed. Documents requested: Admission Agreement for resident (R1) signed and dated 08/27/22 Eviction notice for R1 dated 08/28/25 Payment Agreement signed by R1 dated 04/09/25 Regarding the allegation: Resident felt pressured to sign a payment plan. Over the course of 11 months, from 10/01/24 - 08/01/25, the R1 incurred charges that Unsubstantiated amounted to $29,345.00. As of, 08/04/25, R1 paid $19,601.98 of that amount but still owed $9,743.02. The Designated Facility Administrator/Executive Director (ED) Katherine Nevin, met with R1 in early April of 2025. LPA was provided a copy of an agreement signed by R1 which stated that R1 would pay an additional $300.00 a month on top of the monthly charge of $2695.00 in order to bring R1's account up to date. R1 also signed an agreement with payee service , Helping Hearts, on 04/04/25 which went into effect on 05/01/25. The agreement with Helping Hearts stated that they would pay $2,117.00 and R1 was responsible for paying the remaining $878.00. LPA interviewed R1 who stated that they knew they were behind in their payments and was afraid that they were going to be evicted so they signed the payment plan even though they knew they were not going to be able to pay the extra $300 dollars a month on top of their monthly fee of $2,595.00. This LPA learned in a conversation with the business office manager that when the facility asked R1 to contract with a payee service, the facility waived late fees which were in excess of $1,000.00. LPA interviewed the 3 individuals present at the payment plan meeting: The ED, the Business Office Manager and the Regional Director (RM). R1 stated that they felt pressured because they were asked to sign a payment plan. The RM was surprised to learn that R1 felt pressured. They went on to state that oftentimes residents are hesitant to sign payee agreements but that R1 did so willingly. R1 also stated that the ED had a conversation with R1 where they requested that R1 increase their payment from $300 to $400 because they were not keeping up with their payments. Another written agreement was not drafted because R1 continued to pay less than the monthly base charge for services. During a meeting conducted today with R1 and the ED, the ED stated that they would assist R1 in finding a residence within their budget and also stated that they would connect R1 with a care coordinator to assist as well. R1 stated that they have begun to explore their options and mentioned a facility they had previous experience with. R1 also agreed to have a care conference which would include other parties who have assisted R1 with their financial responsibilities in the past. Regarding the allegation: Resident felt pressured to sign a payment plan. R1 knew they owed over $9,000.00 in fees. The facility followed their protocol for when a resident falls behind in their payments; a payee organization is offered to assist with consistent payments and a payment plan agreement is suggested to assist in bringing accounts up to date. Based on interviews and information that was gathered during this investigation, the standard for the preponderance of evidence to support the above allegation was not met. As a result, this LPA has determined that the above allegation to be UNSUBSTANTIATED. A complaint allegation finding of 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. There were no deficiencies observed or cited at this time. A copy of this report was provided along with a copy of the appeal rights and an exit interview was conducted with Nevin.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 27-AS-20250902093942

Type of visit: Required - 1 Year

Unannounced annual visit made out to this facility on 06/30/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility Business Office Manager, Jennie Tello, who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator, Kathryn Nevin, to inform her that CCL was present at this time for an annual visit. It was learned that this facility currently has (3) residents under the care of hospice at this time. This facility does have an approved hospice waiver to be able to accept and retain up to (3) hospice residents at any given time. It was learned that there were 37 residents diagnosed with dementia at this time. It was learned that there were (4) residents receiving services through a home health agency at this time. It was learned that there was (1) resident deemed to be bedridden but was currently under the care of hospice at this time. Current census was 89 residents. Tour of the facility was conducted. Living area, dining area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient, in good repair, and able to meet the needs of the residents at this time. Kitchen area was toured. Cabinets and drawers were opened and the contents were reviewed at this time. Items for preparing, cooking, and serving meals unto the residents were observed to be sufficient and in compliance at this time. Cleaners and cleaning agents were observed to be locked and made inaccessible to the residents at this time. Fire extinguishers, located hanging on the walls throughout this facility, were observed to have been annually inspected on 09/26/2024 by the local fire extinguisher company, Sentinel Fire Equipment Co., and was in compliance at this time. Medication room was observed to be locked and made inaccessible to the residents at this time. An interview was conducted with the facility medication technician and a brief review of the narcotics count log was conducted at this time. First aid kits were observed to be present and contained all of the required components at this time. Food supply, and food storage units, were observed to be sufficient and able to meet the needs of the residents at this time. This facility was observed to have, on hand at all times, a sufficient supply of 2-day perishable and 7-day nonperishable food quantities at this time. A tour of the facility bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. A tour of the facility restrooms was conducted. Grab bars, non skid mats, and toiletries were observed to be sufficient and able to meet the needs of the residents at this time. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees at this time. A review of the laundry room was conducted. Bleach, detergent, and all other laundry supplies were observed to be locked and made inaccessible to the residents at this time. Exterior grounds of this facility were toured. Facility perimeter fence, side gates, and all other exits were reviewed at this time. Administrator certificate for the facility designated Administrator, Kathryn Nevin, was observed to be present with certificate number 6077502740 and set to expire on 05/26/2027. A review of (5) facility personnel files was conducted and noted on the following LIC 859. A review of (5) facility resident files was conducted and noted on the following LIC 858. The following forms and documents were requested to be updated and submitted into CCL: LIC 308 LIC 400 LIC 500 LIC 610 There were no deficiencies observed or cited during today's annual visit. Exit Interviewthe state’s words, verbatim · CDSS document, Jun 30, 2025

Allegation investigated: Facility did not notify the responsible party of an incident. Due to a lack of supervision, resident was assaulted by another resident multiple times while in care. Facility did not put a plan in place to protect a resident from being physically attacked by another resident.

On 12/06/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings for this complaint investigation into the above allegations. The LPA identified herself upon arrival, stated the purpose of her visit and asked to meet with the Executive Director (ED). LPA met with ED Josef Dunham and a brief interview followed. Regarding: Facility did not notify the responsible party of an incident. * This allegation was previously addressed as part of a case management on 08/02/24 and the faciity was cited under California Code or Regulations, CCR 87207. An incident occurred in the dining room on 07/24/24 during dinner: a resident (R1) was stabbed in the face with a fork by another resident in care (R2). Community Care Licensing (CCL) and the Ombudsman's office were notified of the incident by the facility, however, this LPA learned through interviews with S2, S3, and S5, that the responsible party for R1 was not. R1's responsible party was notified by the Ombudsman (O1) when O1 called to follow up on the incident report that was received. The standard for the preponderance of evidence was met and the department found the above allegation SUBSTANTIATED. According to the California Code of Regulations, Title 22, this deficiency was cited on the LIC 9099D page. Substantiated Regarding: Due to a lack of supervision, resident was assaulted by another resident multiple times while in care. R1 was assaulted by R2 on 07/24/24 in the dining room with a fork. The two sat together at a specific table and were regular dining companions. In order to prevent future incidents, the ED removed their dining table and had staff redirect the two residents to sit with different dining companions. The second assault occurred at 7:30 AM on 08/04/2024. The following was learned through interviews conducted by this LPA and the Ombudsman (O1). This second assault was witnessed by kitchen staff (K1). K1 stated that a dietary aid (D1) saw R2 and R1 arguing at a table. D1 said they moved R2 to another table and as R2 did so, R2 hit R3 in the head. R3 went to the lobby to tell someone in charge and another member of the kitchen staff (K2) took R2 to a table in the back of the dining room. The responsible party (RP) for R1 was notified of this incident at approximately 9:39 AM by S7. The RP was told R1 was moved to the Sun Room and that they were doing fine. The RP said that they were on their way. RP and their spouse arrived at approximately 10:30ish and found that R1 was in the Sun Room with 5 other residents, one of them being their attacker. There were no staff present in the room. According to an interview with O1 on 08/07/24, when O1 spoke to the ED regarding the monitoring of R2, the ED stated that no one was assigned one-on­one to watch R2 despite his assurance R2 would be monitored. When asked why no staff was in the dining room where and when the assaults occurred, the ED stated they were outside the room getting residents ready to go into the dining room. When this LPA interviewed the ED on 08/05/24 as part of a case management regarding the first assault, the ED stated that they would increase monitoring of R1 and R2 and keep them separated. For meals, he said that most residents were escorted to the dining room. Because care staff were assisting residents from their rooms to the dining room, the residents in the dining room were left unsupervised resulting in multiple assaults of R1 and R3. The standard for the preponderance of evidence has been met and the department finds the above allegation to be SUBSTANTIATED. According to the California Code of Regulations, Title 22, this deficiency was cited on the LIC 9099D page. Regarding : Facility did not put a plan in place to protect a resident from being physically attacked by another resident. During the case management visit that took place on 08/02/24, regarding the first assault that occurred on 07/24/24, the ED's plan was to separate R1 and R2 by ensuring that they were not seated at the same table during meals and to increase monitoring. The ED removed the table entirely and used its absence as a justification for seating the two residents at separate locations with new dining companions. When this LPA visited the facility on 08/05/24, kitchen staff had replaced the table to the original floor plan. The ED immediately removed the table. On 08/07/24, R1 was assaulted by R2 again in the dining room. This LPA learned through a review of records that R2 had 4 "Stop and Watch" communications on file for the following dates: 12/08/23, 12/09/23, 01/21/24, and 02/19/24. They described various incidents and/or attempts of aggressive behavior by R2 towards other residents. Based on the documentation reviewed, R2 required additional monitoring in order to maintain the safety of the residents in care. After the assault on 7/24/24, the ED stated that the facility would increase monitoring. If there had been a monitoring plan put in place, then the assaults on R1 and R3 would not have occurred, however the dining room was left unattended by care staff and 2 residents were struck by R2. The standard for the preponderance of evidence has been met and the department finds the above allegation to be SUBSTANTIATED. According to the California Code of Regulations, Title 22, this deficiency was cited on the LIC 9099D page. No other deficiencies were observed or cited during today's visit. A copy of this report along with APPEAL RIGHTS were provided. Exit interview.the state’s words, verbatim · CDSS document, Dec 6, 2024 · control 27-AS-20240805120016

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jan 6, 2025

Reporting Requirements (a) Each licensee shall furnish...the following: (1) A written report to the licensing agency and to the person responsible for the resident...(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. The above requirement was not met as evidenced by: Based on interviews with S2, S3, and S5, the responsible party for R1 was not notified of the incident with R2. This posed a potential threat to the health, safety, and personal rights of the residents in care.the state’s words, verbatim · CDSS document, Dec 6, 2024

Plan of correction: A training on incident reports and reporting requirements was conducted by the clinical regional specialist for Allen Flores and submitted to Licensing as part of the POC for the deficiency cited during the case management on 08/02/24, which was during the same time period as this complaint. This POC has been cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 7, 2024

Personal Rights of Residents in All Facilities - (a) Residents...shall have following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. The above requirement was not met as evidenced by: Based on a review of records, as well as through interviews with K1, K2, and R3, R1 was attacked on 07/24/24, 08/04/24, and R3 was struck on 08/04/24 as well. This posed an immediate risk to the health, safety, and personal rights of the residents in care.the state’s words, verbatim · CDSS document, Dec 6, 2024

Plan of correction: The ED stated that he will sign an attestation stating that in the future, if a resident is being targeted/assaulted by another resident, increased monitoring will be initiated up to and including 1-1 supervision if necessary to ensure resident safety.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.2(c) · Plan of correction due date: Dec 7, 2024

1569.2 Definitions - (c) “Care and supervision” means the facility assumes responsibility for...ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. The above requirement was not met as evidenced by: Based on a review of records, R2 had a history of aggressive behavior. Based on interviews, residents in the dining room were left unsupervised. This posed an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Dec 6, 2024

Plan of correction: The ED stated that an attestation will be signed by all care and dining staff stating that all staff understand that residents must be monitored while in the dining room at all times. This document will be submitted to CCL at kimberly.viarella@dss.ca.gov by 12/07/24.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced case management visit to this facility on 08/05/24 to amend a section of the LIC 809 D page regarding the evidence described in the report for type A deficiency cited on 08/02/24. The LPA identified herself upon arrival, stated the purpose of the visit, and asked to speak with the Designated Facility Administrator/Executive Director, Josef Dunham. A brief interview followed. On 07/24/24, R2 stabbed R1 in the face with a fork during dinner. Staff, (S1) observed the incident and separated the two residents. S1 left R1 at the table and moved R2 across the room to another table. When S1 returned to check on R1, S1 asked if R1 was okay and R1 replied, "Why wouldn't I be?" S1 explained that they had just been stabbed in the face with a fork. According to S1, R1 replied, "I don't remember that." S1 notified the MedTechs and the Resident Services Coordinator. LPA met with R1 during today's visit and there were no visible marks on R1's face at the present time. LPA learned through interviews that the MedTech on duty (S2) completed an incident report for R2 and contacted R2's responsible party and primary care physician. S2 should have also completed an incident report for R1 and notified their responsible party and primary care physician as well. However, according to the California Code of regulations Reporting Requirements, 87211(a)(1)(D) "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in... (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." The incident report for R1 was completed on 07/25/24 by S2 as requested by the Resident Care Coordinator. The report stated that there was a small mark under the resident's eye and that R1 was not bleeding or complaining. The resident was not sent out for further evaluation. The responsible party and primary care physician for R1 were not notified although the boxes indicating that they were, had been checked off. Through interviews with S1, this LPA observed that additional training was needed in the area of reporting to ensure mistakes in documentation and communication do not happen in the future. This deficiency was cited on the LIC 809D page. LPA requested the following documents for both residents: LIC 602s, Physicians Reports LIC 603s Pre-appraisals LIC 625s Care Plans LIC 624s Incident Reports LPA found that the last LIC 602 for R1 was completed on 12/20/23 and the annual exam was not due at this time. LPA found that the last LIC 602 for R2 was completed on 9/21/22 and was overdue. This deficiency was cited on the LIC 809 D page. The Resident Care Coordinator have been in communication with R2's responsible party and requested assistance in scheduling an annual exam for R2. During today's walkthrough of the facility, this LPA observed 2 med techs, 4 caregivers, 2 housekeepers and 1 maintenance worker assisting a resident with a TV installation. LPA observed lunch being served in the dining room. In order to prevent any other altercations between R1 and R2 in the dining room, the table at which they sat was relocated and each resident was redirected to another table with a different dining companion. This LPA met both R1 and R2 and each displayed a calm and friendly affect. According to the California Code of Regulations, Title 22, all deficiencies were cited on the LIC 809D pages and a copy of this report along with Appeal Rights, was provided. Exit interview.the state’s words, verbatim · CDSS document, Aug 2, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Aug 16, 2024

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. The facility did not comply with the above requirement as evidenced by the fact that their documentation (LIC 624) indicated that the responsible party and the primary care physician of R1 had been notified and they had not. This posed a posed a potential threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Aug 2, 2024

Plan of correction: Administrator stated that additional training on incident reporting will be completed and an incident report checklist will be created to ensure that all steps are completed in the appropriate order and time frame. A copy of the participant signature sheet and the checklist will be emailed to licensing at: kimberly.viarella@dss.ca.gov.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(c) · Plan of correction due date: Aug 3, 2024

87463(c) Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative...when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. The facility did not comply with the above requirement as evidenced by a records review showing that R2's LIC 602 was dated 09/21/22. R2 had a listed diagnosis of dementia in her medical reports and a reappraisal should have been done by 09/21/23.the state’s words, verbatim · CDSS document, Aug 2, 2024

Plan of correction: The Administrator will ensure that the Primary Care Physician's office as well as the responible party will be contacted by the close of business to schedule and annual examiniation for R2. A copy of the FAX transmittal sheet and /or emails to these parties will be submitted to Licensing at: Kimberly.viarella@dss.ca.gov.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio was met by Administrator Josef Dunham, and explained the purpose of the visit. LPA Valerio and Administrator Josef Dunham toured the physical plant to ensure compliance with Title 22 regulations. Resident bedrooms were observed to be fully furnished and free from odors. Resident bathrooms were observed to have hygiene supplies, grab bars, skid mats, hand soap, and toilet paper. Resident common shower rooms were occupied during the time of visit. Common areas, including the activities area, dinning room, and front lobby, were organized, clean, and fully furnished. Residents were observed eating breakfast, inside their rooms, walking in the hallway, and being assisted with ADLs. Staff were observed. Medications, cleaning supplies, and sharp objects were locked and inaccessible to residents in care. The facility temperature was at a comfortable temperature and within regulatory range. No health or safety concerns observed during today's visit. LPA Valerio reviewed six (6) resident files and five (5) staff files. Resident files were observed to be current with required documents. Staff files were complete and observed to have required annual training. Administrator J. Dunham was observed to have an active administrator certificate. LPA Valerio requested the following annual documentation be sent via e-mail to christina.valerio@dss.ca.gov for the Regional Office facility file: LIC 500, LIC 308, LIC 610D, and copy of Liability Insurance Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited today. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 5, 2024

Allegation investigated: Staff are not providing residents with a comfortable environment

Unannounced complaint visit made out to this facility on 06/25/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the Resident Services Director, Sarah Nichols, who was briefly interviewed at this time. This LPA requested that she go ahead and inform the facility designated Administrator Josef Dunham to inform him that CCL was present at this time. The facility designated Administrator, Josef Dunham, arrived later to this facility while this LPA was conducting this complaint visit. Current census was 67 residents. The purpose of this visit was to deliver the findings of this investigation to this facility and it's representative at this time. Based on interviews conducted during this complaint investigation, it was learned that there were two residents, R1 and R2, who resided as roommates in this facility. It was learned that one of the roommates was unable to use the pull chord effectively since this particular resident had impairment issues with their vision. It was learned that there was only one pull chord present in the room and it was centrally located. Substantiated It was observed that there were no other pull chords present in the restroom or other parts of the resident bedrooms at this time. It was learned that this resident, R1, who was unable to properly see the singular pull chord would call out when assistance was needed instead of attempting to use the emergency pull chord system. The roommate, R2, would also join in on this call for help and call out loudly for facility care staff. It was learned that this behavior took place about 4 to 5 times during normal business hours and another 2-3 times during after hours for a total of up to 8 times in a 24 hour time period. These outbursts could last from anywhere from a minute or two up to 5 minutes or more depending on how swift facility staff responded. Based on interviews conducted, it was learned that this ongoing behavior by R1 and R2 made it very difficult for nearby residents to relax and stay in their rooms without feeling annoyed or agitated. The level, and consistency, of the outbursts from R1 and R2 interrupted their regular day to day activities and interfered when residents were trying to sleep at night as well. This made it difficult for residents to feel comfortable with this type of behavior taking place everyday and on a regular basis as well. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jun 25, 2024 · control 27-AS-20240522123224

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 26, 2024

Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This facility was found to be deficient as evidenced by the presence of facility residents who infringed on the personal rights of nearby residents on a daily basis making them uncomfortable in their living spaces and environment. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Jun 25, 2024

Plan of correction: The facility designated Administrator stated that a plan will be constructed to deal with the ongoing outbursts of the (2) residents. This plan will involve the roles and responsibilities of this facility, the involvement of the responsible parties, and input from licensed medical professionals in assessment and possible relocation if warranted at this time. A statement of correction, along with this updated plan will be completed and submitted into CCL by the due date.

Allegation investigated: Staff mismanaged resident's medication Staff refused to provide proper bedding for resident in care Staff did not assist resident in a timely manner

Unannounced complaint visit made out to this facility on 03/14 2024 by Licensing Program Analyst (LPA) Charlie Yang was met by the facility designated representative Sarah Nichols. A brief interview was conducted with the facility designated representative at this time. This LPA requested that this facility representative go ahead and contact the facility designated Administrator, Josef Dunham, that CCL was present at this time. It was learned that the facility designated Administrator was unable to be present at this time for this complaint visit. Current census was 66 residents. The purpose of this complaint visit was to deliver the findings of this investigation to this facility and its representative at this time. Based on a review of the facility medication administration records, and a copy of a recent medication audit conducted by a third party vendor, it was observed that this facility was following physician's orders when dispensing, documenting, and handling resident medications at this time. The third party vendor audit reviewed 26 facility resident medications and observed that there weren't any Unsubstantiated components that were out of compliance at the time of the review. Based on a review of the facility personnel schedule and interviews conducted, it was learned that housekeeping staff were responsible for cleaning and maintaining the facility resident rooms on a weekly basis. It was learned that resident rooms were cleaned on a weekly basis, or as needed, if additional cleanings were necessary. This facility employed staff solely dedicated to housekeeping and staff dedicated solely for laundry services that were provided on a weekly basis as well. Based on interviews conducted, it was learned that the housekeeping and laundry staff were efficient in their tasks and there weren't any concerns at this time. Based on interviews conducted, it was learned that pull cords were installed in the resident rooms and restrooms. It was learned that the facility staff were expected to respond to alerts when the residents activated their pull cords. It was learned that a reasonable response time was to be within 5 minutes of pull cord activation while anything that went over the 5 minute mark was deemed to be unreasonable. It was learned that facility residents did not have any issues with the staff responding to pull cords and requests from the facility staff at this time. Facility staff were responding accordingly and within the reasonable amount of time. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited during this complaint visit. Exit Interviewthe state’s words, verbatim · CDSS document, Mar 14, 2024 · control 27-AS-20230927083554

Allegation investigated: Staff did not meet resident's hygiene needs.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Joe Dunham and explained the purpose of the visit. This investigation consisted of interviews and record review. LPA Moleski interviewed five residents (R1, R2, R4, R6, and R9) and eight staff members (S1, S5, S6, S7, S8, S13, S14, and S15). All staff members interviewed said that two-hour continence checks are performed. In interviews, S1, S5, S7, S13, and S14 had no concerns regarding continence care. S8 said residents sometimes refuse continence care. S15 said R6 sometimes refuses continence care. S6 said that R6 has been left in dirty garments and is not always changed when needed. [continued on 9099-C] Unsubstantiated In interviews, R1, R2, R4, and R9 did not share concerns regarding continence care. R6 said R6 is “never” left in dirty garments, and said that staff clean her frequently. LPA Moleski reviewed R6’s file. According to R6’s LIC 601, R6 is self-responsible. According to R6’s LIC 602, dated 5/18/23, R6 uses pull-ups. According to the LIC 602, R6 does not have dementia. LPA Moleski reviewed daily notes regarding R6 dating between March 2023 and October 2023. LPA Moleski observed a note written by S8 and dated 9/21/23 which describes an incident wherein S8 was passing out medications when R6 asked to be changed. S8 called for a caregiver to help R6, according to the note. R6 was “upset” because R6 could not get immediate assistance, but a caregiver did arrive and assisted R6, according to the note. The department has determined the following as it relates to the allegation that staff did not meet a resident’s hygiene needs: Based on interviews and record review, the above allegation is UNSUBSTANTIATED, which 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. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Dunham.the state’s words, verbatim · CDSS document, Dec 11, 2023 · control 27-AS-20231106124359

Allegation investigated: Staff are not ordering resident's medication in a timely manner Staff do not wear gloves when preparing foods Residents are not provided adequate food service Staff mismanaged resident's narcotic medication

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint. LPA Moleski met with facility administrator Joe Dunham and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed 13 staff members, including four kitchen staff (S3, S4, S11, S12) four caregivers (S5, S6, S14, S15), and four medication technicians (S7, S8, S9, S10). LPA Moleski interviewed 10 residents R1-R10. LPA Moleski reviewed six residents’ (R1-R5, R9) medication administration records (MARs) for a period of at least three months each. LPA Moleski observed instances where medications were not given to residents R1, R2, and R5 due to running out of medications. According to S7, family members and/or residents ordered these medications, rather than medication technicians. [continued on 9099-C] Unsubstantiated R1, R2, and R5, confirmed that they or their family members order their medications. R9 said that R9 had run out of a medication. LPA Moleski reviewed eight months’ worth of MARs for R9 and did not observe that R9 had run out of this medication at any point since starting it, according to the MARs. During interviews, all four medication technicians (S7, S8, S9, S10) said there were no issues with staff ordering medications. During a visit on 11/14/23, LPA Moleski observed staff count out all narcotic medications. LPA Moleski observed an accurate count and did not observe any irregularities. During interviews, all four medication technicians (S7, S8, S9, S10) said there were no issues with the narcotic count that were not otherwise accounted for. During a visit on 11/27/23, LPA Moleski observed portions of lunchtime and dinnertime meal preparation. LPA Moleski observed staff taking appropriate hygienic measures, including glove use. During interviews, all four kitchen staff (S3, S4, S11, S12) described proper hygiene procedures. During interviews, residents did not voice concerns regarding hygienic procedures. LPA Moleski observed postings in the kitchen containing special dietary information and documentation of doctors’ orders for special dietary restrictions. During interviews, no staff members were aware of issues with regard to special dietary orders. During interviews, one resident (R10) said that R10’s dietary orders were not being followed. LPA Moleski observed R10’s correct dietary information posted conspicuously in the kitchen. The department has determined the following as it relates to the allegations that staff are not ordering resident's medication in a timely manner, staff do not wear gloves when preparing foods, residents are not provided adequate food service, and that staff mismanaged resident's narcotic medication: Based on interviews, observations, and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Dunham.the state’s words, verbatim · CDSS document, Nov 27, 2023 · control 27-AS-20231017104548

Allegation investigated: Staff do not properly sanitize the facility grounds Staff do not properly maintain a resident's room Staff do not keep a resident's room free from pests Staff are not addressing a resident's change in medical condition

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct an investigation of the above mentioned allegations on 11/17/23 at 2:45pm. LPA met with Sarah Blane McClain, Resident Care Coordinator and stated the purpose of the visit. Sarah Blane McClain, Resident Care Coordinator contacted the Administrator regarding todays visit. LPA toured the facility which included the kitchen, a random amount of resident rooms and bathrooms, and conducted interviews of residents and staff during this visit. Regarding allegation, Staff do not properly sanitize the facility grounds, LPA observed housekeeping and maintenance performing duties during this visit. LPA obtained information that the carpet throughout the facility has been recently cleaned on 11/6/23 by First Class Carpet Cleaning. LPA did not observe a foul odor in the facility during this visit. Unfounded Regarding allegation, Staff do not properly maintain a resident's room, LPA observed a random amount of rooms and conducted interviews of residents and staff who confirmed that the residents have a laundry scheduled day and are asked if they want bedding to be cleaned and there is additional laundry conducted when there is incontinence issues. LPA observed a housekeeping schedule which indicates which rooms and which days are assigned for staff to clean on a weekly basis which includes the bathrooms, windows, and common areas. LPA observed a laundry schedule that indicates a designated staff who does laundry for 8 hours Monday through Friday and on the weekends the PM shift staff are assigned to do the laundry. Regarding allegation, Staff do not keep a resident's room free from pests, LPA observed a random amount of rooms and did not observe evidence and/or droppings of roaches, and bedbugs, nor ant trails. Residents and staff interviewed confirmed that residents do not have bugs in their rooms. Aantex Pest Control conducts treatment and pest activity inspection of the kitchen, outside foundation, spot and crevasse and selected trees. LPA observed that the most recent pest control fumigation was conducted on 10/31/23. Regarding allegation, Staff are not addressing a resident's change in medical condition, LPA obtained information through interviews that resident #1 had a rash that began on 11/8/23 which was being treated by a physician. The rash was not due to bedbugs bites. Based on interviews and observation, the allegation(s) are deemed UNFOUNDED. The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint. Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided.the state’s words, verbatim · CDSS document, Nov 17, 2023 · control 27-AS-20231115162214

Allegation investigated: Staff did not ensure that facility trash bin lids are tightly secured. Staff financially abused residents in care. Unqualified staff are administering medications to residents. Staff is not ensuring that resident is dressed in clean clothing

On 10/31/2023 at 12:15 PM Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Interim Resident Coordinator, Editha Mccullough and Resident Care Coordinator, Sarah Nichols and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 59. A brief interview with conducted with Editha Mccullough and Sara Nichols. LPA Lee toured the facility at 2:00 PM, and observed resident in the living room with a guest singer and his guitar singing. Drinks and snacks was offered to residents. The living room was filled with residents. Residents appeared to be in clean clothing and enjoyed the guest singer and each other. Allegation: Staff did not ensure that facility trash bin lids are tightly secured. It was alleged that staff did not ensure that facility trash bin lids are tightly secured. This investigation consisted of observations and interviews with staff and residents Continued LIC 9099-C Unsubstantiated LPA Lee interviewed 10 out of 10 residents and it was learned that 6 out of 10 residents had no concerns with the facility trash bin lids are not tightly secured. Furthermore, 6 out of 10 residents have not witnessed other residents digging through the facility garbage. During complaint investigation visit on 09/07/2023 and 10/09/2023 LPA Lee did observe one garbage in the sun room, one garbage in the activity room, one garbage in the front entry of the facility, one garbage in the dining room and three big garbage in the hallway. All the garbage’s observed on both days throughout the facility had fitted tight lids on them. Furthermore, LPA Lee did not observe any residents digging through the facility trash bins. Based on information provided through interviews, observations and records reviewed, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff did not ensure that facility trash bin lids are tightly secured. Allegation: Staff financially abused residents in care. It was alleged that staff financially abused residents in care. This investigation consisted of records review and interviews with staff and residents. LPA Lee interviewed 10 out of 10 residents and it was learned 10 out of 10 residents have no concern and have not experienced or witness staff financially abused resident in care. Throughout the investigation it was learned that the resident will pay rent by writing a check and then giving the check to the front desk. The front desk then gives the resident a receipt and makes a copy of the resident check and file for record. The front desk then drops the checks into the office locked box. Regional Director Robert Godfrey then picks up the check from the locked box in the office. Furthermore, 5 out of 5 facility staff denies staff are financially abusing residents in care. Based on information provided through interviews and records reviewed, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff financially abused resident in care. Allegation: Unqualified staff are administering medications to residents. It was alleged that unqualified staff are administering medications to residents. This investigation consisted of records review and interviews with staff and residents. LPA Lee interviewed 10 out of 10 residents and it was learned 6 out of 10 residents are receiving their prescribed medications and have no concerns. LPA Lee also reviewed 3 facility Med-Tech facility files and training records. It was learned that 3 out of 3 Med-Techs files are complete and has the required training documented in their files. Continued LIC 9099-C Based on information provided through interviews and records reviewed, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff is not ensuring that resident is dressed in clean clothing. Allegation: Staff is not ensuring that resident is dressed in clean clothing It was alleged that the staff is not ensuring that residents are dressed in clean clothing. This investigation consisted of observations and interviews with staff and residents. LPA Lee interviewed 10 out of 10 residents and it was learned that 10 out of 10 residents had no concerns with the staff not ensuring that resident is dressed in clean clothing. Ten residents that were interviewed were observed to be in clean clothing. Furthermore, during the complaint investigation visit on 09/07/2023, 10/09/2023 and 10/31/2023 LPA Lee did not observe any resident in dirty or unclean clothing. Based on information provided through interviews and records reviewed, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff is not ensuring that resident is dressed in clean clothing. An exit interview was conducted with Editha Mccullough and Sara Nichols and a copy of this report was given to Editha Mccullough and Sara Nichols. Per facility, LIC 500 Personnel Report it shows that administrator, Rico Foz is at the facility from Monday to Friday from 9:00 AM to 5:30 PM. On 09/07/2023 LPA Lee was at the facility from 9:44 AM to 3:40 PM and did not see administrator at the facility; therefore, the facility is not adhering to facility LIC 500 Personnel Report. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met Allegation: Staff did not ensure that residents were eating meals. It was alleged that the staff did not ensure that residents were eating meals. This investigation consisted of recorded reviews and observations and interviews with staff and residents. LPA Lee interviewed 10 out of 10 residents and it was learned that 5 out of 10 residents did not receive their meals delivered to their room when residents don’t come to the dining room. Throughout the investigation, it was learned that residents go to the dining room for all meals. It was also learned that residents can choose to pick up their meals and eat in their room or if resident choose to have meal deliver to their room with no fees. LPA Lee reviewed meal logs and record review revealed that on 09/06/2023 meal logs, 6 breakfast was left black, 3 lunch was left blank and 1 dinner was also left blank. On 09/07/2023, meal logs 5 breakfast was left blank and 2 lunch was left blank. On 10/27/2023 meal logs, 1 breakfast was left blank, 1 lunch was left blank and 66 dinner was left blank. Moreover, on 10/30/2023, meal logs 7 breakfast was left blank, 5 lunch was left blank and 68 dinner was also left blank; therefore, it is unclear if the residents received their meals. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Editha Mccullough and Sara Nichols and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Oct 31, 2023 · control 27-AS-20230831114400

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Nov 10, 2023

87405(a) Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours… This requirement is not met as evidenced by: Based on interviews, records review and observations, the licensee did not comply with the section cited above. The administrator did not ensure that administrator is at the facility for sufficient number of hours, which poses/posed a potential health, safety or personal rights to person in care.the state’s words, verbatim · CDSS document, Oct 31, 2023

Plan of correction: Administrator agrees to read regulation 87405(a) and submit a signed declaration of understanding. The administrator will review LIC 500 Personnel Report for accuracy and ensure the administrator is present at the facility for a sufficient number of hours. The administrator will email POC to LPA Lee by POC due date 11/10/2023 by 5:00 PM end of day (pang.lee@dss.ca.gov)

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(1 · Plan of correction due date: Nov 10, 2023

87555(b)(1) General Food Service Requirements (b) The following food service requirements shall apply: (1) Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day. Exceptions may be allowed on weekends and holidays providing the total daily food needs are met. Not more than fifteen (15) hours shall elapse between the third and first meal. This requirement is not met as evidenced by: Based on interviews and records review the administrator did not comply with the section cited above. The licensee did not ensure that resident is provided with three meals per day. Meal logs reviewed reveals discrepancies; therefore, it is unclear if residents received their meals.the state’s words, verbatim · CDSS document, Oct 31, 2023

Plan of correction: Administrator agrees to read regulation 87555(b)(1) and submit a signed declaration of understanding. The administrator will audit meal logs and ensure that all residents are receiving breakfast, lunch and dinner at all times. The administrator will email POC to LPA Lee by POC due date 11/10/2023 by 5:00 PM end of day (pang.lee@dss.ca.gov)

Allegation investigated: Staff are not adhering to resident's care plan. Staff did not ensure that resident in care was provided their medication(s). Staff retaliated against resident for filing a complaint.

On 10/13/23, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator Josef Dunham and explained the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on LPA observations of facility, record reviews, and staff and resident interviews there has been no direct knowledge of facility staff not adhering to resident’s care plan. Residents who were interviewed did not express any concerns with care being provided. Regarding the allegation that staff did not ensure that resident in care was provided their medication(s), LPA reviewed resident's medication log and observed no irregularities. Based on resident interviews, residents stated that they do receive their medications. Continued on 9099-C Unsubstantiated Based on staff interviews, staff stated that all residents receive their medications timely and there have been no incidents in recent months. It was learned that LPA Johnson substantiated Staff mismanaging resident medication on 4/6/2023 by Complaint Control Number: 27-AS-20230224163937. It was learned that were no other incidents pertaining to medications since. Regarding the allegation that facility staff retaliated against resident for filing a complaint, there is not a preponderance of evidence to prove that it occurred. As a result of the investigation, LPA finds the allegations above to be 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 occurred. An exit interview was conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 13, 2023 · control 27-AS-20230906163745