Covenant Living of Turlock

Allegation investigated: Financial abuse Facility staff did not adhere to admission policy procedures

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to conduct a complaint investigation into the above allegations. LPA met with administrator Ryan Hust to explain the purpose of the visit. The LPA was unable to determine the identity of the residents who were allegedly financially abused and/or were affected by nonadherance with the admission policy procedures with the information provided. LPA was also unable to identify the complaintant to obtain aditional information. At this time further investigation would be unfocused and speculative, not to say the alleged violations did not occur but unless and until more information is provided to CCLD the investigation will be closed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. A copy of the report was read and given to the administrator, a exit interview was conducted. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 22, 2026 · control 27-AS-20260504092017

Type of visit: Case Management - Incident

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to conduct a case management regarding a recent incident involving two residents, where one resident(r1) would flick the ear of the other resident(r2) to let him know where she was. R2 has a significant degree of cognitive impairment, and was making other kinds of claims(that r1 was pregnant, that r1 would slap r2 when r2 would mention the pregnancy). The department has concerns this behavior would lead to a more serious physical altercation or accusation of one. Per the administrator, around March 5th, the residents had their living arrangement separated where one was resident moved to the assisted living side after the incident on Mar 30th, and since then there has not been any physical abuse type events reported by either party during visits of the other parties. The LPA interviewed a staff familiar with the incident and the two residents, who corroborated the statements of the administrator. Both residents were observed to be responding positively about their care. The departments has no more questions about a potential serious physical altercation. the action taken by the facility seems like appropriate and timely intervention to the LPA. no citations were given as a result of this visit. a copy of the report was read and given to the administrator. exit interview was conducted.the state’s words, verbatim · CDSS document, Apr 21, 2026

Type of visit: Case Management - Other

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct a case management related to the recent cluster of falls. LPA met with administrator Ryan Hust, to explain the purpose of the visit. Covenant Living of Turlock is a 377 bed facility where 167 of the beds have clients in a condition of being provided care. LPA toured several rooms and apartments of the facility, asked for SI reports related to falls for the past 2 weeks, asked for a copy of Plan of OP selections related to employee training including any specific related issue to falls including reporting requirements, and Shift schedules for a period of days. The toured locations of the falls for the past two weeks(aspen, sequoia, redwood), LPA identified no environmental risks for increased falls (torn rugs/trip hazards, unsecured bannisters/grab bars). LPA notes the Plan of Op was last updated in 2015, and is requesting any updates of the past 11 years be sent along in a revised plan of OP to the LPA's email by March 10th 2026. (noel.wolfpetersen@dss.ca.gov) . Per the facilities Policy training on Medical Emergencies, "the community summons 911 when the resident exhibits signs and symptoms of distress and/or emergency condition: ...to include fall with deformity, severe pain or head injury...". Does not designate seperate policy for witnessed or unwitnessed falls, nor situations where behavioral expression or pathology prevents an expression of pain. 3 of 5 falls in SI reports from the past 6 weeks included a phonecall to 911, responsible party, and a physician. the remaining 2 of 5 falls in SI reports from the past 6 weeks fell outside of the plan of op's stated reporting criteria, asserted to have been determined by the facilities reporting parties. One SI report of these two included bruising on the hands and knees. One client of these two was inclined to be interviewed, and denied feeling as though there was a shortfall in the care and supervision by the staff related to the fall. Continued on C-Page Per administrator melina Nunez, Employees are trained about the fall policy several times in a year. Per staff(sequoia), It occurs about once or twice a year, three Staff Interviewed(sequoia) were somewhat able to review the fall policy and indicated the training leaned heavier on reporting requirements rather than the approach to the client. LPA's review of the shift schedules for several affected areas (sequoia, aspen, redwood) in the given times indicate that the facility was fully staffed at the times of the falls. Per adminstrator Ryan Hust, the facility has multiple redundant systems that are operational to alert staff in the event of a fall: Emergency pull cords in the public bathrooms, and emergency pendants are equipped to the residents, a nurses phone number given to the residents, and staff that move through the buildings with regular frequency (3+ times a day) and are able to respond to cries for help. Fall reporting is attended to in a verbal pass down between shifts and a client file, after a fall 72 hour report checklists are given the staff to assess the client in more detail, updates are forwarded to managers if the reporting staff identify any kind of risk. The LPA's concerns regarding the facilities fall prevention policies are satisfied at this time. LPA gave guideance to conduct a updated policy training for Medical Emergencices, soon and at least once a year, to include how to identify risks to the onboarding clients including falls, to understand appropriate 911 intervention approaches for witnessed and unwitnessed falls, the unique supervision and care concerns of the clients with fall risk who also have a dementia or are otherwise unable to report pain verbally, as well as what situations where changes in a clients welfare would trigger a LIC 624 notification of a significant incident to licensing. LPA gave additional guidance to observe a general maxim if a fall is unwitnessed, call for emergency send out and allow any client refusal/deteriminations of medical necessity to play out with the ambulance, and document as much of the process as possible. No citations were issued. a copy of the report was read and given to the administrator. exit interview was conducted.the state’s words, verbatim · CDSS document, Feb 10, 2026

Type of visit: Required - 1 Year

On 10/29/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the community to conduct an annual inspection. LPA Campbell met with Ryan Hust, Executive Director and explained the purpose of the visit. The community is a 3 story facility licensed to serve 313 nonambulatory and 64 ambulatory residents over the age of 60. During this visit, Executive Direction Ryan Hust assisted with the tour of the facility and obtaining requested documents. LPA Campbell toured the facility and inspected the physical plant including but not limited to the common areas, kitchen, dining area, client bedrooms and bathrooms, outside courtyards of the facility to ensure compliance with Title 22 regulations. Upon entry, LPA Campbell observed residents socializing, relaxing in their rooms and walking outdoors. LPA Campbell observed sufficient seven-day non-perishable and two-day perishable food supplies. The temperature for walk in freezers was 0 degrees Fahrenheit (F) or lower. The temperature for the refrigerator was 35 degrees F. Throughout the facility, LPA Campbell observed fire extinguishers that were last inspected 01/04/2025 and were fully charged. The kitchen ANSUL system was last inspected 09/30/2025. When the fire drill log was reviewed, LPA Campbell observed that Fire and Internal Disaster Drills were conducted once a month. LPA Campbell observed an indoor pool accessible to Independent and assisted Living residents per staff. Residents use key fobs to access the pool and there are no staff supervising residents who use the pool. Upon entry, LPA Campbell observed one resident floating in the pool, and one resident in the whirlpool. No staff were present. There was also a sauna, steam room and bathrooms available for use. LPA Campbell reviewed several appraisals and no statements were found identifying residents who could use the pool with or without supervision. Per Executive Director Ryan Hust, the pool along with all buildings on campus are licensed. Ryan Hust understands that all residents will need a reappraisal to ensure they can use the pool unsupervised. LPA Campbell also strongly suggested that staff be scheduled to supervise residents in the pool area to ensure their safety. Per the Executive Director, the community currently does not have enough staff to oversee the residents in the pool area in addition to seeing to their normal duties. In the meantime Executive Direct Hust will begin reappraisals on Monday, November 3, 2025, if not sooner. Reappraisals will be performed by the Licensed Vocational Nurse (LVN) on staff. The evaluations will begin with higher risk assisted living residents until all those residing in the facility have been seen by the LVN. Based on today's inspection, per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were not cited and on LIC 809D. Note that failure to correct any deficiencies will result in additional civil penalties.the state’s words, verbatim · CDSS document, Oct 29, 2025

Type of visit: Required - 1 Year

On 12/04/2024, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to conduct an annual inspection. LPA Campbell met with Jianne Bassi, Associate Executive Director and explained the purpose of the visit. With the assistance of staff Kelsey Henderson, Employee Experience Leader and Carrie Rodriguez, Human Resources Assistant, LPA Campbell reviewed staff files. Of the 159 staff files, LPA Campbell reviewed 10 staff files that were found to be complete. Due to insufficient time, the annual will require a continuation visit. The Department will return at a later date to complete the annual inspection.the state’s words, verbatim · CDSS document, Dec 4, 2024

Type of visit: Case Management - Incident

On 05/24/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannouncied to conduct a Case Management regarding an incident that occurred on 05/15/2024. LPA Campbell met with Melina Nunez, Assisted Living Director and explained the purpose of the visit. On 05/15/24, the facility self-reported an incident regarding a resident (R1) who left the facility unassisted. Per R1's 602, they were not to leave the facility unassisted and were prone to wandering behavior. A neighbor saw R1 walking unassisted about 8 minutes away from the facility and notified facility staff. Staff 1 (S1) returned R1 to the facility and a medical evaluation was conducted by S2 for R1. The incident report was submitted to the Department the next day on 05/16/2024. Per the Assisted Living Director, R1 was able to leave the facility because staff did not conduct a head count for Wander guard residents after the alarm signaled. Wander guard will alert if a resident is wearing one near the entrance. R1 was wearing a Wander guard. At the time of R1's elopement, there were several residents wearing Wander guard near the entrance. The residents were at the same entrance that R1 used to leave the facility and there was an alert. No staff verified the presence of all the Wander guard residents in the facility. Instead, staff assumed no residents had actually left the facility and were just at the entrance. The facility was unable to recount when R1 left the facility or for how long. R1's family was notified of the incident. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 809D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. A copy of their rights was provided (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1548(c)(3) · Plan of correction due date: May 31, 2024

1548 Civil penalties; regulations setting forth appeal procedures for deficiencies. (c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation...for...(3) Absence of supervision, as required by statute or regulation. This requirement is not met as evidenced by: R1 was able to leave the facility unassissted and absenst of supervision, as required by statute or regulation and their 602. This poses an immediate Health, Safety and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 24, 2024

Plan of correction: The facility will conduct an in service training for staff as well as agency staff regarding Wanderguard residents. Whenever the alarm sounds, a head count will be conducted for all Wande rguard residents and this procedure will be added to the policy procedure manual. The facility will provide the sign in sheet for the in-service training with signatures from both Covenant Living staff and agency staff.and will provide the updated page for the policy procedure manual regarding Wander guard head counts. All documentation will then be emailed to renee.campbell@dss.ca.gov by POC date.

Type of visit: Case Management - Incident

This report is being amended to complete the visit for 04/05/24 to update the original date recorded, the POC and correct verbiage. On 04/05/24 Licensing Program Analyst, (LPA) Renee Campbell made an unannounced case management visit to this facility. This visit was prompted by a fax from the Assisted Living Director (ALD), Melina Nunez who notified Community Care Licensing (CCL) about an alleged case of verbal abuse. LPA Campbell identified herself upon arrival and asked to speak with the ALD. LPA Campbell met with Melina Nunez, who is the Assisted Living Director and the Designated Facility Administrator and a brief interview followed. Over the course of the investigation, LPA Campbell interviewed staff and reviewed the report from the reporting party. Staff reported that S1 used an elevated volume and inappropriate tone with R1. Staff interviewed did not report abusive language was used. Based on interviews with W4, S3, S1, S2, W2 and W3, LPA Campbell found that there was a preponderance of evidence to support a violation of personal rights. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, a Type B deficiency is being cited on the attached 9099D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. A copy of their rights was provided (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 5, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 19, 2024

87468.1 Personal Rights of Residents ...: (a) Residents in ... care facilities for the elderly shall have all of the following personal rights:(1)To be accorded dignity in their personal relationships with staff,..., and other persons. This requirement is not met as evidenced by: Based on interviews with W4, S3, S1, S2, W2 and W3, the licensee did not ensure residents were accorded dignity to residents in residential care facilities.the state’s words, verbatim · CDSS document, Apr 5, 2024

Plan of correction: Licensee will create an in-service training for all staff on dignity and respect. A copy of the in-service itinerary and sign in sheet will be provided to LPA Campbell by POC date that will be emailed to renee.campbell@dss.ca.gov

Type of visit: Case Management - Incident

On 01/24/24, Licensing Program Analyst (LPA) Renee Campbell made an unannounced visit to Covenant Village of Turlock at approximately 1000. LPA Campbell met with Ryan Hust, Executive Director and Brenda Pisacco, Campus Nurse. During the visit, LPA Campbell observed the incident reported that was submitted on 01/16/24 regarding an incident that occurred on 01/13/24. LPA Campbell requested a Physician’s Report, hospital records and interviewed R1’s son who was their Durable Power of Attorney (DPOA). The physician’s report indicated that R1 was ambulatory and there was no cognitive decline or disorientation. R1’s son was contacted, and he confirmed that he requested that R1 not be sent to the hospital. Instead, the DPOA wanted to take the resident to the hospital himself. The incident report did not include that the DPOA was contacted and made this request. No deficiencies were cited on today's inspection. Exit interview was conducted with Ryan Hust and copy of this report provided.the state’s words, verbatim · CDSS document, Jan 24, 2024

Allegation investigated: Staff member accessed resident credit card account without authorization

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegation. LPA Lund met with Executive Director Ryan Hust and explained the reason for the visit. Staff member accessed resident credit card account without authorization-Based on records review, and interview with Executive Director Ryan Hust. On 8/29/2023 Administrator Ryan Hust reported to Community Care Licensing that a staff member (S1) did fraudulent activity on resident’s (R1) credit card in the sum of $19250.16 at the time. The facility reported it to the Turlock PD with report #TP23005126. On 11/15/2023 the facility paid the sum of $57862.92 to R1for the apparent loss of money to R1. The facility provided a detailed list of money owed to R1. Substantiated 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 deficiency was cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights was provided.the state’s words, verbatim · CDSS document, Nov 21, 2023 · control 27-AS-20230824155849

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87217(a) · Plan of correction due date: Nov 22, 2023

A licensee shall not be required to handle residents' cash resources. However, if a resident incapable of handling his own cash resources....... This was not met as evidenced by: S1 did fraudulent use R1’s credit card in the sum of $19250.16. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 21, 2023

Plan of correction: Executive Director returned the sum of $19250.16 to R1. S1 didn't return to the facility.