Country Place Assisted Living

Allegation investigated: Staff communicated inappropriately with resident

On 07/14/26 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver amended findings of above allegations. LPA explained the purpose of the visit with ADM. This is an AMENDMENT to original report dated 06/16/26. During investigation, LPA conducted interviews with staff, random residents and obtained the following documents from ADM: Personnel record (LIC500), Residents roster, incident reports. Continued on next page, LIC9099-C Unsubstantiated This is an AMENDMENT to original report dated 06/16/26. Allegation: Staff communicated inappropriately with resident Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP), staff (Administrator) and resident (R1) and reviewed R1’s documents. On 06/26/26, LPA interviewed ADM who stated that she failed to communicate with R1 in a timely manner on several occasions the morning of 06/01/26 because she was busy attending to other matters. However, ADM denied speaking inappropriately with R1 on 06/01/26. LPA was unable to verify the details of the incident because there were no other witnesses when R1 tried to talk to ADM again in front of her office to the point of becoming physically aggressive. Review of written statement from R1 dated 06/26/26 showed he felt disrespected because ADM failed to communicate with him in a timely manner. ADM confirmed with LPA that she did not speak inappropriately with R1 on 06/01/26 when he was experiencing behavioral expressions. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff communicated inappropriately with resident was found to be unsubstantiated. No deficiency cited during visit. Exit interview conducted and a copy of this report providedthe state’s words, verbatim · CDSS document, Jul 14, 2026 · control 15-AS-20260616143035

Allegation investigated: Staff did not follow reporting protocols

On 07/14/26 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver amended findings of above allegations. LPA explained the purpose of the visit with ADM. This is an AMENDMENT to original report dated 06/16/26. During investigation, LPA conducted interviews with staff, random residents and obtained the following documents from ADM: Personnel record (LIC500), Residents roster, incident reports. Continued on next page, LIC 9099-C Substantiated This is an AMENDMENT to original complaint report dated 06/16/26 Allegation: Staff did not follow reporting requirements Investigation Finding: Substantiated During investigation, LPA conducted interviews with reporting party (RP), staff (Administrator) and resident (R1) and reviewed R1’s documents. RP stated that while on a visit at the facility on 06/01/26, R1 stated that he tried to talk to ADM several times on the morning of 06/01/26 which made him upset when she did not communicate properly with him. RP stated ADM failed to notify law enforcement and complete the required SOC 341 until she instructed her to do so. On 06/26/26, LPA interviewed ADM who stated that she did not fill out any incident report because nothing happened between R1 and herself. On 06/29/26, ADM recalled filling out an SOC341 on 06/02/26 after receiving instructions from RP on 06/01/26. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not follow reporting requirements was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Technical Support on reporting requirements with ADM scheduled at a later date. Exit interview conducted, appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 15-AS-20260616143035

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jul 31, 2026

A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by staff did not follow reporting requirements which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: On or before POC due date, ADM agrees to complete and submit to CCL in-service staff retraining certifications on reporting requirements in compliance with Title 22 Section 87211 regulations.

Allegation investigated: Staff are retaining a resident that requires a higher level of care Staff do not ensure that resident's needs are met

On 02/18/2026 at 03:05pm, Licensing Program Analyst (LPA), Carol Fowler arrived unannounced to deliver complaint findings for the allegations above. LPA met with Yvonne Golden, Medication Technician (MT) and explained the reason for the visit. LPA spoke with Sherry Richardson via phone call. During the investigation LPA interviewed W1, S1, S2, S3, and R1. LPA reviewed facility and Staff Roster, C1 face sheet, preplacement appraisal information, progress notes, Medical Administration Records (MAR). C1 Physicians Report is missing from the file. CONTINUE ON LIC9099C Unsubstantiated CONTINUE FROM LIC9099 Allegation: Staff are retaining a resident that requires a higher level of care Investigation Finding: unsubstantiated. During the investigation, the LPA interviewed W1,S1, S2, S3 and R1. Interview with W1 revealed that W1 was concerned with R1 needing a higher level of care, W1 stated that the facility has clients that have mental illnesses and R1 has dementia. Interview with S1 revealed that R1 has been a resident at the facility for 9 years and has been diagnosed with dementia before being placed at the facility. S1 also stated that R1 was placed at the facility by San Francisco Department of Public Health which is a placement agency. S1 stated that R1 was living in SRO (single residence occupancy) housing and R1 became forgetful before moving to the facility S1 also stated that R1 has not had any altercations with any of the other residents living at the facility and that R1 knows and recognize the faces at the facility, R1 has had the same roommate for a very long time. Interview with S2 revealed that R1 had dementia prior to moving into the facility and R1 likes to walk a lot and R1 will work around the building and talk with other residents, there has not been any altercations with any other residents, R1 also like to talk with the residents. Interview with S3 reveals that R1 likes to walk and talk with the other residents around the facility. S3 also stated that if R1 is talking and a resident doesn’t want to talk they will just call R1s name and redirect R1. Interview with R1 revealed that R1 likes living at the facility and R1 likes to walk and sing. R1 stated that R1 likes the food, and the people are okay. THEREFORE, THIS ALLEGATION IS UNSUBSTANTIATED. CONTINUE ON LIC9099C CONTINUE FROM LIC9099C Allegation: Staff do not ensure that residents’ needs are met Investigation Finding: unsubstantiated. During the investigation LPA interviewed W1, S1 and S3. W1 expressed concerns about R1s needs at the facility being met due to the facility type. Interview with S1 revealed that R1 has help with ADLs (activities of daily living) and sometimes if R1 needs to be prompted to eat, facility staff have been trained on dementia care. Interview with S3 revealed that S3 has had dementia care and has been working with dementia care residents for many years. S3 also stated that S3 works with R1 directly and assists with R1s ADLs and that sometimes R1 likes to sometimes shower R1s self and S3 will be there if assistance is needed. S3 also stated that R1 feeds R1 self and only sometime R1 might need staff to prompt R1 by putting the spoon in R1s hand and R1 will then feed R1s self. LPA interviewed and observed R1 eating and drinking a snack, LPA also observed R1 singing and was able to answer some interview questions. THEREFORE, THIS ALLEGATION IS UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 15-AS-20241014211018

Type of visit: Required - 1 Year

On 12/31/2025 at 8:30AM, Licensing Program Analyst (LPA) Andrew Christy arrived unannounced to conduct the 1-Year Annual Required inspection. LPA met with Administrator, Shani Edwards, and explained the purpose of the visit. The facility currently houses 46 residents with a max capacity of 49 residents. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. No bodies of water were observed. A comfortable indoor temperature is maintained at 70.0 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 108.4 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 01/16/2025. At 10:00AM, LPA reviewed five (5) resident files and four (4) staff files. The emergency disaster plan was last reviewed 12/31/2025. A review of resident medications and the Medication Administration Record (MAR) found no outstanding errors. Continued on LIC809C..... Continued from LIC809..... The following deficiencies were cited during the inspection: At 10:00AM during file review, it was noted the residents were not getting yearly updates for the Appraisal Needs and Services Plan. At 10:30AM, it was discovered that quarterly emergency drills were not being conducted. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and a copy of this report was made available to the administrator.the state’s words, verbatim · CDSS document, Dec 31, 2025

Allegation investigated: Staff did not provide designated smoking areas for the residents Staff did not have planned activities for the residents

On 07/16/25 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit, met with administrator (ADM). LPA conducted interviews & record reviews and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM. On 06/05/25 at 2:38 PM, LPA conducted interviews with staff, random residents and obtained the following documents from ADM: Personnel record (LIC500), Residents roster, incident reports. Continued on next page, LIC 9099-C Substantiated Allegation: Staff did not provide designated smoking areas for the residents Investigation Finding: Substantiated During investigation, LPA confirmed with staff (ADM) and reporting party (RP) that all 43 residents (7 positive and 32 negative residents) were confined to their rooms due to a COVID-19 outbreak lockdown which started on 05/08/25 until 06/05/25. Approximately 11 to 12 residents who smoke cigarettes had their right to smoke taken away from them by staff as part of the COVID-19 lockdown period (05/08/25 until 06/05/25). Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not provide designated smoking areas for the residents was found to be substantiated. Allegation: Staff did not have planned activities for the residents Investigation Finding: Substantiated During investigation, ADM and third-party witness (W1) confirmed with LPA that due to the COVID-19 outbreak that started on 05/08/25, staff suspended all common area activities for all 43 residents (7 positive and 32 negative residents) which included smoking in the smoking post outside areas, watching TV and relaxing in the living room / garden areas. Staff confined all 43 residents inside their rooms with no planned activities offered while in isolation from 05/08/25 until 06/05/25. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not have planned activities for the residents was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided. Allegation: Staff yell and mistreat the residents while in care Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP), random residents (R1, R2, R3) and staff (ADM). RP stated that several residents (names unknown) expressed fear of asking anything other than their daily meals and medications due to staff yelling at them and treating them indifferently. LPA interviewed random residents (R1, R2, R3) who stated that staff are OK and do not mistreat or yell at them. ADM stated that she has not observed any staff mistreat or yell at any residents at the facility. During unannounced visits on 12/10/24, 06/05/25, 07/16/25, LPA observed staff did not yell or mistreat any residents when assisting them with their activities of daily living (ADLs). Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff yell and mistreat the residents while in care is unsubstantiated. Allegation: Staff use inappropriate language towards the residents Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP), random residents (R1, R2, R3) and staff (ADM). RP stated that several residents (names unknown) said that staff are rude and curse at them when requesting assistance. LPA interviewed random residents (R1, R2, R3) who stated that staff assist them with their needs, give them their daily meals/snacks/drinks and medications without cursing at them. ADM stated that she has not observed any staff curse at any resident at the facility. During unannounced visits on 12/10/24, 06/05/25, 07/16/25, LPA observed staff did not curse at residents when assisting them with their activities of daily living (ADLs). Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff use inappropriate language towards the residents is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 16, 2025 · control 15-AS-20250605093548

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 11, 2025

To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by staff did not provide designated smoking areas for the residents which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2025

Plan of correction: By POC due date, Administrator agreed to complete and submit to CCL in-service staff re-trainings b a CCLD approved vendor on residents’ personal rights in compliance with Section 87468.2(a)(4).

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(5) · Plan of correction due date: Aug 11, 2025

To have the freedom to attend religious services or activities of their choice either in or outside the facility and to have visits from the spiritual advisor of their choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. This requirement was not met as evidenced by staff did not provide planned activities for the residents during COVID lockdown which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2025

Plan of correction: By POC due date, Administrator agreed to complete and submit to CCL in-service staff re-trainings b a CCLD approved vendor on residents’ personal rights in compliance with Section 87468.1(a)(5).

Allegation investigated: Staff mismanaged resident's medication

On 07/16/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit, met with administrator (ADM). LPA conducted interviews & record reviews and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM. On 06/05/25 at 3PM, LPA conducted interviews with staff, random residents and obtained the following documents from ADM: Personnel record (LIC500), Residents roster, admission agreement, reappraisals, needs & services plan, physician's report, centrally stored medication logs, medication administration records, incident reports. Continued on next page, LIC 9099-C Substantiated Allegation: Staff mismanaged resident’s medication Investigation Finding: Substantiated During investigation, staff (ADM) and reporting party (RP) confirmed with LPA that staff failed to timely pick-up resident’s prescribed medication (Mavyret) and timely administer the medication to the resident (R1). Review of R1’s centrally stored medication logs dated October 2023 showed R1’s prescribed medication started on 02/23/24 and was discontinued on 04/19/24. Witness (W1) also stated that facility staff failed to timely pick-up and administer R1’s prescribed medication (Mavyret). Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff mismanaged resident’s medication was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided. Allegation: Staff threatened resident in care Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (ADM), responsible party (POA) and resident (R1). ADM denied threatening R1 with eviction. Review of R1’s 30-day eviction notice dated 07/01/24 showed that R1 was given written notification of the 30-day eviction due to failure to comply with facility guidelines wherein he walked into the medication office, took a staff’s wallet, removed money, credit cards/ driver’s license and then bragged to other residents about it. Responsible party (POA) stated that she convinced ADM to rescind R1’s written 30-day eviction in July 2024 and let R1 stay at the facility. During unannounced visits on 12/10/24, 06/05/25 and 07/16/25, LPA observed (R1) still residing at the facility. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff threaten resident in care is unsubstantiated. Allegation: Staff did not provide proper transportation services to resident in care Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with staff (ADM), reporting party (RP). resident (R1) and reviewed R1’s documents. Review of R1’s signed admission agreement dated 11/11/22 showed the facility is not responsible for R1’s transportation requirements. LPA also reviewed R1’s medical records which showed his audio appointment on 01/08/25 was rescheduled at a later date due a scheduling conflict with his oncology radiation treatments. ADM confirmed with LPA that R1’s transportation was provided by a third party as arranged by R1’s case manager and R1’s family member to and from his doctors’ visits. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not provide transportation services to resident in care is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 16, 2025 · control 15-AS-20250605132237

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Aug 11, 2025

The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by staff mismanaged resident’s medication which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2025

Plan of correction: By POC due date, Administrator agreed to submit to CCL completed in-service staff re-trainings on residents’ medication administration in compliance with Section 87465 (a)(1).

Type of visit: Case Management - Infectious Disease Outbreak

On 06/05/25 at 2:38PM, LPA D Panllio conducted an unannounced case management visit to discuss the facility's COVID mitigation plan with administrator (ADM). Prior to the 2PM visit, around 11:30AM, LPA spoke with ADM on the phone who confirmed that there were 2 residents that tested COVID positive on 05/08/25. All staff and residents were tested and results showed that on 05/16/25, 7 residents were COVID positive. Continuous rounds of COVID testings were done on 05/12/25, 05/16/25, 05/20/25. Last COVID testings done on 05/27/25 on all residents and staff showed only 1 resident still COVID positive. On 06/02/25, 1 staff tested COVID positive. ADM stated all residents' activities were temporarily suspended and facility is on lock down due to COVID positive residents. ADM confirmed with LPA that no incident report (LIC624) was submitted to CCLD when the 2 residents first tested positive for COVID-19. Deficiency is cited for violation of reporting requirements per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, Jun 5, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Jun 25, 2025

(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidenced by facility staff failiing to notifiy CCLD of COVID outbreak and timely submit a written report LIC 624 which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: ED agreed to complete and submit written incident report to CCLD on or before POC due date. ED also agreed to complete and submit in-service staff retraining on implementing current COVID mitigation plan in ocmpliance with COVID infection control procedures.

Type of visit: Required - 1 Year

On 12/10/24 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM1) and explained the purpose of the visit. ADM has a current administrator certificate # 6024408740 which expires 01/25/2025. LPA toured the facility including but not limited to the front entrance, screening station, hand washing stations, kitchen, bathrooms, bedrooms and common areas. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand washing signs were observed posted in common areas. Facility has a 30-day supply of PPEs, paper, medications locked in medication room cabinets. Comfortable temperature was observed at 73 deg F per thermostat reading. Hot water temperature was measured at 111 deg F. Fire extinguishers were observed fully charged. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 5 staff and 5 resident files. The following deficiencies were observed during inspection: Absence of a screening station for COVID-19 symptom checks. Four (4) expired fire extinguishers re-inspection tags Emergency/Disaster quarterly fire drills documentation missing Continued on next page, LIC 809-C Updated copies of the following documents were obtained from administrator:  LIC500- Personnel Report  LIC9020 - Resident Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 10, 2024

Allegation investigated: Facility staff refused to accept resident back into care from hospital.

On 10/29/2024 at 9:00 AM, Licensing Program Analysts (LPAs) James Sampair and David Doidge conducted an unannounced complaint visit. Upon arriving, the LPAs explained the purpose of the visit to Administrator (ADM) Shani Edwards. The complaint alleges that facility staff refused to accept resident back into care from hospital. The LPAs interviewed the ADM and reviewed documentation for Resident R1. The data collected from those sources supported the actions of the staff not to accept R1 as resident in the facility. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove them; therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 29, 2024 · control 15-AS-20241021101209

Type of visit: Case Management - Deficiencies

On 10/15/24 at 4:37PM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to open a 10 day initial complaint on an unrelated matter and conducted a case management deficiency. LPA met with Yvonne Golden, Lead Med Tech, and explained the purpose of the visit. During the initial 10 day complaint opening, LPA observed that R1 Physician Report (LIC602) is missing from R1's file. Staff contacted the Administrator via phone call and Administrator stated that R1 doesn't have a current Physician Report. Regulations are cited from California Code of Regulations, Title 22, are being cited on the attached LIC809D. Therefore, this allegation is Substantiated. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 15, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458 · Plan of correction due date: Oct 29, 2024

Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. ...LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Based on observation, licensee failed to ensure that resident has a medical assessment maintained in records, which poses a potential risk to the health and safety of resident in care.the state’s words, verbatim · CDSS document, Oct 15, 2024

Plan of correction: LPA observed the record file of R1 missing a medical assessment. Administrator agreed to get an updated medical assessment for R1 and provide a copy to the Department by the POC date via email.

Type of visit: Case Management - Other

On 11/08/23 at 2:30PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct a case management visit pertaining to an incident which occurred on 10/31/23 wherein 41 residents were left unsupervised during a fire alarm at 4AM set off by a resident. Fire responders confirmed with LPA that they observed no staff was present inside the facility when they deactivated the fire alarm at 5AM on 10/31/23. An immediate civil penalty of $500 is being assessed for absence of supervision on 10/31/23 which is in violation of Title 22 Section 87415 (a)(2) Night Supervision. Exit interview conducted, Appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, Nov 8, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87415(a)(5) · Plan of correction due date: Nov 8, 2023

In facilities required to have a signal system, specified in Section 87303, Maintenance Operation, at least one night staff person shall be located to enable immediate response to the signal system. If the signal system is visual only, that person shall be awake. This requirement was not met as evidenced by absence of supervision on 10/31/23 which posed an immediate health & safety risk to residents in carethe state’s words, verbatim · CDSS document, Nov 8, 2023

Plan of correction: Immediate civil penalty of $500 is assessed today for absence of supervsion. Administrator corrected deficiency on 11/01/23. S1 was terminated due to work negligence and S2 suspended without pay until retrained on proper care and supervision of residents.

Type of visit: Required - 1 Year

On11/08/23 at 3PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. LPA toured the facility including but not limited to the front entrance, screening station, hand washing stations, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, additional face masks and hand sanitizer were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand washing signs were observed posted in common areas. Facility has a 30-day supply of PPEs, paper, medications locked in medication room cabinets. Comfortable temperature was observed at 75 deg F per thermostat reading. Hot water temperature was measured at 118 deg F. Fire extinguishers were last inspected on 12/01/22 and observed fully charged. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 5 staff and 5 resident files. LPA also conducted 3 staff and 3 resident interviews during visit. The following deficiency were observed during inspection: Ants in room #7 Open trash bins in residents' rooms & bathrooms Continued on next page, LIC 809-C Updated copies of the following documents were obtained from administrator:  LIC500- Personnel Report  Resident Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 8, 2023

Allegation investigated: Facility is unsanitary

On 11/01/23 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM1) to deliver the finding of above allegations. LPA explained the purpose of the visit with ADM1. During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, admission agreement, physicians report, needs & services plans, physicians’ orders, showering schedules, housekeeping schedules, incident reports. Allegation: Facility is unsanitary Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Continued on next page, LIC 9099-C Substantiated Allegation: Facility is unsanitary Investigation Finding: Substantiated Continuation Staff (ADM1) confirmed with LPA that the main couch in the living room had urine/feces stains due to frequent usage by residents. LPA observed living room couch had urine stains on fabric during visit on 07/14/23. ADM stated that in August 2023 that she purchased a cleaning machine that staff use regularly to remove the stains and odors from the faux upholstered and suede covered living room couches. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) facility is unsanitary was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Facility is odiferous Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. On 07/14/23 at 10:30AM, LPA toured the facility with staff (S1) including but not limited to the main dining area, kitchen, storage areas, living room, common hallways, bedrooms, bathrooms and activity room. LPA observed no odiferous odors from the areas inspected. LPA also observed S3 cleaning the common hallways while touring with S1. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the facility is odiferous and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that the facility is odiferous is unsubstantiated. Allegation: Staff do not accord residents with dignity while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff (S1, S2) who denied not treating residents with dignity while providing care and supervision. Staff (S1, S2) stated they do not tell residents to “go away” or “go sit down” when they need help. During visit. LPA observed staff assisted residents with their prescribed medications, meals without yelling or screaming at them and responded to their requests for help in a friendly manner. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff do not accord residents with dignity while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not accord residents with dignity while in care is unsubstantiated. Continued on next page, LIC 9099-C pg2 Allegation: Staff do not accord residents with privacy while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff (ADM1,S2) who stated that most residents know their prescribed medication schedules and would go to the medication room daily to take their prescribed or over the counter medications. S2 stated staff rarely dispense medications in front of other residents in the dining room. LPA interviewed residents (R1, R2, R3, R4) who confirmed they take their daily medications from staff inside the medication room. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff do not accord residents with privacy while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not accord residents with privacy while in care is unsubstantiated. Allegation: Staff do not ensure that residents have the ability to request assistance when needed Investigation Finding: Unsubstantiated During investigation, LPA toured the facility with staff (ADM1) including but not limited to the main dining, kitchen, living room, bedrooms, bathrooms, activity room. LPA observed each bedroom has an emergency call/pull cord situated against the wall next to the residents’ bed. ADM stated residents can pull the cord when necessary to alert staff for assistance. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff do not ensure that residents have the ability to request assistance when needed and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not ensure that residents have the ability to request assistance when needed is unsubstantiated. Continued on next page, LIC 9099-C pg 3 Allegation: Facility does not have sufficient amount of staff to meet residents’ care needs Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed staff records. Review of personnel records dated 07/2023 showed the facility had sufficient staffing including on call staff available for scheduled AM, PM and NOC shifts to provide care and supervision to residents in care. LPA interviewed residents (R1, R2, R3, R4) who stated that staff met their care needs. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the facility does not have a sufficient amount of staff to meet residents’ care needs and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that the facility does not have a sufficient amount of staff to meet residents’ care needs is unsubstantiated. Allegation: Staff do not ensure that residents get a sufficient quantity of food while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed scheduled meal deliveries and records. Staff (S1) stated they order and receive deliveries of groceries (variety of meats, breads, fresh fruits, vegetables, cereals, eggs, canned goods, potatoes, pancakes) every week. If residents do not like the food, they are given sandwiches that they can eat plus 2 snacks per day. S1 stated there are a few residents that need to follow a special diet as prescribed by their doctors to control their diabetes, high blood pressure, mechanical soft diet for some with digestive issues. Residents on a regular diet are given second helpings upon request. Staff serve residents breakfast, lunch, dinner, snacks in between meals and drinks daily. LPA observed staff preparing snacks and drinks for residents during visit. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff do not ensure that residents get a sufficient quantity of food while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not ensure that residents get a sufficient quantity of food while in care is unsubstantiated. Continued on next page, LIC 9099-C pg 4 Allegation: Staff did not ensure that resident’s diapering needs were met while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. On 07/14/23 at 11:30AM, LPA interviewed resident (R1) who stated that staff helped her with changing her diapers daily. During visit, LPA interviewed other residents (R2, R3, R4) who stated that staff assisted them with their activities of daily living such as showering, toileting, grooming, dressing, changing diapers, medications and meals. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure that resident’s diapering needs were met while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure that resident’s diapering needs were met while in care is unsubstantiated. Allegation: Staff did not ensure that resident’s showering needs were met while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of resident’s (R1) functional assessment dated 07/01/23 showed R1 required total assistance with bathing (helping residentl in and out of the tub, complete washing and drying of the body). During visit, LPA interviewed R1 who stated that staff assists her with bathing, hygiene, toileting, dressing, eating, medications, changing diapers, telephone use and transportation to outings and shopping. LPA observed R1 was clean and odor free. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure that resident’s showering needs were met while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure that resident’s showering needs were met while in care is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 1, 2023 · control 15-AS-20230705153014

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 1, 2023

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 unsanitary furniture which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 1, 2023

Plan of correction: Deficiency corrected August 2023. Administrator purchased new cleaning machine to remove the stains and odors from the faux and suede upholstered couches in the living room area to ensure the furnitures are sanitary in compliance with Title 22 Section 87303 (a).

Allegation investigated: Residents were left unsupervised while in care

On 11/01/23 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit , met with administrator (ADM1) and delivered investigation finding to ADM. LPA explained the purpose of the visit with ADM1. During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, emergency/disaster plans, incident report. Continued on next page, LIC 9099-C Substantiated Allegation: Residents were left unsupervised while in care Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident records. Witness (W1) confirmed with LPA that on 10/31/23 at 4AM the fire department responded to a fire alarm which has been activated at the facility for 30 minutes. When fire responders arrived, they opened the front gate with a key and a resident opened the front entrance of the facility. Fire responders stated no staff was awake and on hand to actively supervise the residents. W1 stated they forced opened the office and called the administrator (ADM) who rushed to the facility and arrived around 5:30AM. Staff (S1, S2) were found by police and fire responders sleeping in their cars at the parking lot. Review of incident report dated 10/31/23 confirmed that staff (S1, S2) were asleep inside their cars at the parking lot while on night shift and were not inside the facility when the fire alarm was set off by a resident at 4AM. FIre alarm was blaring at the facility for 30 minutes and was deactivated by fire responders when they arrived at 5AM. ADM stated all residents were safe and no injuries were observed. ADM1 stated S1 was terminated 10/31/23 due to negligence and S2 was placed on unpaid leave while facility schedules mandatory in-service staff retraining on proper care and supervision of residents while on duty. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that residents were left unsupervised while in care was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, Nov 1, 2023 · control 15-AS-20231031160632

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87415(a)(2) · Plan of correction due date: Nov 10, 2023

In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes This requirement was not met as evidenced by unsupervised residents during a fire alarm which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 1, 2023

Plan of correction: By POC due date, administrator agreed to complete and submit to CCL staff re-training certifications regarding night shift supervision (one staff awake & on duty with one staff on call capable to respond within 10 minutes) in compliance with Title 22 Section 87415 (a)(2).