Crown Point Villa

Allegation investigated: Staff are not following universal precautions to prevent the spread of scabies

On 05/15/2026, Licensing Program Analyst (LPA) Graham Gunby arrived at the facility unannounced to deliver complaint findings into the allegation listed above and met with Licensee, Violet Mubeezi. *Report will continue on LIC9099-C* Unfounded Based on observation, record review, and interviews, the facility was following infection control requirements. Public Health was contacted and they stated since it was only one client, they were not going to get involved. The administrator provided documentation regarding doctors’ appointments for R1 on 01/23/2026 and 02/05/2026. The administrator did submit an incident report to the department and provided an updated Infectious Disease Control Plan. As a precaution, during the first sign of a rash, facility provided PPE for staff and residents in care, notified staff of the potential of scabies, and an in-service training for staff on proper hand washing and universal precautions. Facility encouraged residents to stay in their room during the episode. It was observed facility had required PPE available at the facility; therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, May 15, 2026 · control 59-AS-20260202100741

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Graham Gunby arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Licensee, Violet Mubeezi, and explained the purpose of the visit. LPA and Licensee conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to resident bedrooms, bathrooms, kitchen, common areas and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies are locked and inaccessible to residents in care. The hot water temperature was measured in the kitchen sink at 112.7 degrees Fahrenheit. LPA observed fire detectors and carbon monoxide alarms to be operable. LPA observed pool fence is locked. The fire extinguisher is located in the dinning and was last serviced on 02/12/25. LPA observed required Licensing posters posted in the entry of the facility. LPA observed medications to be locked and inaccessible to residents in care. LPA reviewed six (6) resident files. Resident files contained all required documentation. LPA reviewed three (3) staff records. Staff have all required documentation and first aid training. No deficiencies are being cited during today's inspection. Exit interview conducted and a copy of the report will be emailed to Licensee.the state’s words, verbatim · CDSS document, Jan 21, 2026

Type of visit: Case Management - Annual Continuation

On January 31, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an annual continuation case management visit. LPA met with Licensee and explained the purpose of the visit. During today's inspection, LPA conducted a file review for five residents and four personnel records. LPA observed required documents present. LPA and Licensee discussed that all resident medical assessment should be completely annually and/or with change of condition. LPA was informed Licensee has an appointment for the following Monday for fire extinguisher inspection. Licensee is to submit a photo of inspection tag once completed. Pool gate observed to be locked and inaccessible to residents in care. LPA observed a copy of active Administrator Certificate present. LPA observed facility liability insurance to be active. At this time, LPA is requesting a copy of LIC 500 and LIC 308 to be emailed to LPA by Friday February 7, 2025. No deficiencies cited. Exit interview conducted and a copy of report was provided.the state’s words, verbatim · CDSS document, Jan 31, 2025

Type of visit: Post Licensing

On January 24, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual inspection. LPA met with Administrator and explained the purpose of the visit LPA is conducting an annual inspection today but this report is being generated to clear the Post-Licensing inspection in the system. There are no citations issued on this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 24, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection. LPA met with Licensee and explained the purpose of the visit. Today's census is five residents in care, with two residents on hospice. LPA was informed at once point there was four residents on hospice services. Facility is licensed for hospice waiver of two, but upon file review, it revealed hospice waiver increase was approved in 2022 but license was never updated. LPA informed facility it will be updated and new license will be mailed. LPA and Licensee conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: residents bedroom, bathrooms, laundry, kitchen, backyard, garage and common areas. During today's visit, LPA was unable to complete visit. Visit will be continued at a later date. Exit interview conducted.the state’s words, verbatim · CDSS document, Jan 24, 2025

Allegation investigated: Staff force fed resident.

On 1/24/2024, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing (CCL) received on 08/07/2023. LPA met with administrator, Violet Mubeezi, and explained the purpose of the visit. During the course of the investigation, the Department conducted interviews with facility staff and obtained pertinent documents relevant to the complaint investigation such as resident’s (R1) physician’s report, admission agreement, preplacement appraisal information, consent for emergency medical treatment, and appraisal/needs and services plan. Continue on page LIC 9099-C. Unsubstantiated The Department received a statement from the complainant indicating that the facility did not follow hospice orders. Sutter Health Hospice ordered the facility to not feed R1 due to R1’s body shutting down. R1 was in hospice and had refused to eat when offered food or when asked if R1 was hungry. Food is to be provided when R1 requests it. On 07/18/2023 at 8 PM, R1’s responsible party (RP) called the facility to check on R1 and was notified that staff (S1) was able to get R1 to eat a bowl and a half of pureed food. Complainant and RP believed, R1 was forced fed by S1. R1 refused to eat when offered food or when asked if R1 was hungry for four (4) days. On 08/01/2023, R1 was relocated to another residential care facility for the elderly. On 08/05/2023, R1 passed away due to declining. The Department requested and reviewed R1’s physician’s report. The physician’s report indicated that R1 is on a special diet and R1 can feed self. R1’s preplacement appraisal information indicates that R1 has Diabetes Type 1 and 2. R1 is on a diabetic diet and requires finger stick sugar checks. R1 is diagnosed with Dementia. The Department received an interview statement from R1’s RP. RP stated that the facility did not follow hospice’s orders to stop feeding R1. There was no written order from R1’s physician or hospice. The direction was given verbally by hospice which the facility failed to follow. The Department interviewed a total of three (3) facility staff. Interview statement received from S1 indicated that R1 can communicate needs and often request for something to drink. S1 denies force feeding R1. S1 stated residents have the right to refuse and if they don’t want to eat the staff would not force them. Same goes for medications. Interview statement received from S2 indicated that R1 was on a special diet. The hospice nurse conducted visits to the facility to check on R1 and notified staff if R1 was hungry to provide food to R1. S2 stated hospice never notified the facility to stop feeding R1. S2 stated if staff do not feed R1 when R1’s hungry or when R1 request for food then that is considered neglect. Interview statement received from administrators indicated there were no doctor’s orders to stop feeding R1. On 11/14/2023, the Department called and spoke to R1’s Sutter Health Hospice Nurse. The Hospice Nurse refused to provide a statement and requested the Department to reach out to Sutter Health Hospice management to get approval. Hospice Nurse explained Nurse is not allowed to provide any information until management approves of it and this is due to company’s policy. The Department reached out to Sutter Health Hospice Manager and requested for an approval. Sutter Health Hospice Manager stated will reach out to CCL once there is direction on how to proceed with getting authorization. The Department did not hear back from Sutter Health Hospice. On 01/11/2023, the Department reached out to Sutter Health Hospice and spoke to another Sutter Hospice Manager. The Department requested an update on the authorization. Sutter Hospice Manager stated will get back to CCL and will have to ask management for approval. The Department was unable to gather statements from R1’s hospice nurse. Due to the information above, CCL finds the allegation to be UNSUBSTANTIATED, meaning 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 left at the facility.the state’s words, verbatim · CDSS document, Jan 24, 2024 · control 59-AS-20230807131437

Allegation investigated: Facility did not clearly specify fees charged to resident prior to admission.

On 12/14/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 7/31/2023. LPA met with administrator, Violet Mubeezi, and explained the purpose of the visit. During the course of investigation, the Department interviewed residents, facility staff, and obtained pertinent documents relevant to the complaint investigation such as, resident’s (R1) physician’s report, admission agreement, preplacement appraisal, and appraisal/needs and services plan. Continue on page LIC 9099-C. Substantiated According to interviews received, R1’s responsible party (RP) was told to pay a $500.00 refundable deposit to hold room for R1. RP asked administrator if the $500.00 deposit fee could be applied towards rent and was told no. The deposit will be refunded after R1 moves out of the facility. On 7/28/2023, R1 relocated to another facility and RP requested for the facility to refund the $500.00 but was told by the administrator the $300.00 of the $500.00 was used for transportation fees to doctor’s office. RP cannot recall what administrator used the remaining $200.00 for. RP indicated that per the admission agreement, doctor’s visit fees are included in the basic service rate. Deposit fees or preadmission fees cannot be found in the admission agreement. The Department reviewed R1’s admission agreement. R1’s date of admission is 6/29/2023. Admission agreement indicated the facility will provide R1 with basic services which include single room, food service, and helping gain access to supportive services as follows doctor visits. Plans arrange and/or provide for transportation to medical and dental appointments as follows is family responsible. The monthly private pay rate for basic services as specified is $6,000.00. According to refund policy the agreement must indicate whether or not all, or any portion(s), of a payment will be refunded. A refund will be granted as follows: not applicable. The Department requested and reviewed the facility’s program description for transportation outside of facility planned events. Crown Point Villa shall gladly arrange for resident transportation outside of facility events. Methods of transportation may vary and may include taxicabs, paratransit, local bus, and other non-medical transportation companies. All medical and dental appointments requiring facility transportation must be approved in advance by the facility administrator, to ensure adequate staffing levels for the residents at all times. According to the facility’s admission fee/policy, Crown Point Villa shall not charge a preadmission fee. For the purpose of this section, “preadmission fee” means application fee, processing fee, admission fee, entrance fee, community fee, or other fees, however designated that is requested or accepted by a licensee of a residential care facility for the elderly prior to admission. Crown Point Villa shall not require, request, or accept any funds from a resident or resident’s representative that constitute a deposit against any possible damages by a resident. The facility provided email conversations between the administrator and RP. On 7/29/2023, RP emailed the administrator and requested for deposit to be refunded. On 8/3/2023, the administrator responded to RP’s email by providing a list of what was being charged and receipts. The Department received interview statement from facility administrator. The administrator indicated that R1 was transported three times and had gone over receipts with RP to ensure there was an agreement with the expenses. 1.Transportation of R1 from previous facility to Crown Point Villa including all of R1’s belongings. 2. Transportation of R1’s to doctor’s appointment at Kaiser, two caregivers were waiting outside for 2 hours. RP gave the administrator the wrong appointment date and administrator told RP the facility does not transport residents. Administrator stated RP told administrator to charge from deposit. 3. Transportation of R1 to Kaiser Emergency Department for blood sugar levels. The administrator called wheelchair transport and called RP who requested the administrator to transport R1 to the hospital. The Administrator notified RP that the facility does not transport residents for free and the fee would be charged from the deposit which RP agreed upon. The administrator notified RP that basic services are provided at the facility in the admission agreement but does not include transportation. The administrator denied telling RP that deposit fee was refundable. The administrator stated it is not Crown Point Villa’s practice to ask for deposit fee and never asked for deposit from any other facility, however, in this case facility had charged R1’s RP $500.00 to secure a room for R1. The administrator indicated that the facility does not have a deposit policy in place. The administrator and RP had a verbal agreement that the deposit fee of $500.00 would be used for transportation and the facility had issued RP receipts on the last day R1 relocated to a different facility. The administrator indicated that has no issue refunded the $500.00 and had reached out to RP on multiple occasions but did not receive a response from RP to pick up check. According to the facility’s admission policy, Crown Point Villa shall not charge a preadmission fee. For the purpose of this section, “preadmission fee” means an application fee, processing fee, admission fee, entrance fee, or other fees, however, designated that is requested or accepted by a licensee of a residential care facility for the elderly prior to admission. Crown Point Villa shall not require, request, or accept any funds from a resident or resident’s representative that constitute a deposit against any possible damages by a resident. R1 was admitted to the facility on 6/29/2023 and relocated to another facility on 7/28/2023. It was discovered that there was no written general statement that clearly explained the conditions for refund. R1 left the facility during the first month of residency, the resident shall be entitled to a refund of at least 80 percent of the preadmission free amount. Based on the information provided, it does not appear that the administrator accepted this deposit under the requirements and conditions of the California Health and Safety Code. The following deficiency is cited as per California Health and Safety Code section 1569.651(h)(2). Based on interviews and records review, the Department finds the allegation to be SUBSTANTIATED. A finding that the allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted and report provided. Appeal rights provided. According to an interview statement received, R1 was charged $200.00 for transportation to Kaiser Roseville which was approximately one mile from the facility. R1 was transferred to the hospital twice. According to R1’s admission agreement, the facility agrees to ensure a safe and healthful living environment for all residents, the following basic services must be available. The services actually provided will be those the resident wants and those the residents need, based on the individual’s pre-admission appraisal, and the needs and services plan. Subsequently resident appraisals may result in the need for additional basic services: helping gain access to supportive services as follows, doctor visits. Plan, arrange, and/or provide for transportation to medical and dental appointment as follows: family responsible. According to the facility’s program description, Crown Point Villa shall gladly arrange for resident transportation outside of facility events. Method of transportation may vary and may include, taxicabs, paratransit, local bus, and other non-medical transportation companies. All medical and dental appointments requiring facility transportation must be approved by in advance by the facility administrator, to ensure adequate staffing levels for the residents at all times. The facility’s program description and R1’s admission agreement does not specify how much the facility will charge residents in care for medical transportation fees. The Department interviewed and received a statement from the administrator. According to the administrator, the facility does not assist residents in care with transportation to medical and dental appointments. The administrator indicated residents’ responsible parties are responsible for transporting residents to medical and dental appointments. If residents in care needs assistance with transportation the resident’s responsible party would notify administrator in advance for approval. The administrator stated had spoken to R1’s RP and had a verbal agreement that the $500.00 deposit fee will go towards R1’s medical transportation and relocation of R1 from previous facility to Crown Point Villa. There was no written agreement between the facility and R1’s RP. The facility did not specify or provide RP with an itemized list of charges. The Department is unable to determine if the facility overcharged resident. Due to the information above, CCL finds the allegation to be UNSUBSTANTIATED, meaning 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 left at the facility.the state’s words, verbatim · CDSS document, Dec 14, 2023 · control 59-AS-20230731123914

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.651(h)(2) · Plan of correction due date: Dec 21, 2023

1569.651 Preadmission fee or deposit for elderly at residential care facilities; written statement describing costs and stating whether fee is refundable; conditions for refund ... If the resident leaves the facility for any reason during the first month of residency, the resident shall be entitled to a refund of at least 80 percent of the preadmission fee amount in excess of five hundred dollars ($500). This requirement is not met as evidenced by: Based on interviews and records review, the facility did not refund R1’s RP after R1 relocated to a different facility during the first month of residency. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: Administrator agrees to refund R1's RP $400.00 A copy of the check is to be submitted to CCL for review by POC due date, 12/21/2023.

Allegation investigated: - Staff not allowing resident to have visitors at facility. - Staff not communicating with responsible party about resident's care.

On 11/30/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 7/20/2023. LPA met with administrator, Violet Mubeezi, and explained the purpose of the visit. During the course of investigation, the Department interviewed residents, facility staff, and obtained pertinent documents relevant to the complaint investigation such as, resident’s (R1) physician’s report, admission agreement, preplacement appraisal, and appraisal/needs and services plan. Continue on page LIC 9099-C. Unsubstantiated Allegation: Staff not allowing resident to have visitors at facility. – Unsubstantiated. According to an interview conducted, on 7/20/2023 at approximately 12:45 PM, R1’s responsible party (RP) was refused entry into the facility and was asked by the facility’s administrator to leave the facility. The Department received an interview statement from R1’s RP. RP stated arrived at the facility during lunch time and was refused visitation. RP requested to wait in R1’s bedroom until lunch was over. Administrator refused and asked RP to leave. RP stated R1’s family member was there to observe the incident. The Department reviewed R1’s admission agreement. According to the admission agreement, the agreement must include the facility policy concerning family visits and communication. The policy must be designed to encourage regular family involvement with the resident. The policy must also provide ample opportunity for family participation in facility activities. Facility visiting hours are 9 AM to 4 PM. The Department received interview statements from a total of three (3) facility staff (S). Interview statement received from S1 stated, visitation hours are from 8 AM to 4 PM. Visitors are welcome at the facility during visitation hours. Staff are not allowed to turn visitors away. Interview statement received from S2 indicated, there is a visitation policy that the residents’ family members agreed upon which is to visit residents before or after lunch. This is due to residents not wanting to eat when visitors are around. S2 stated R1’s RP comes to the facility everyday to visit R1. RP came during lunch time and administrator requested for RP to come visit before lunch time. RP was waiting in R1’s bedroom while residents were finishing their meals. Interview statements received from the facility’s administrator indicated that R1’s RP visited the facility every day. RP would stand at the table for most of the meals and make comments and give instructions to other residents on what they should eat first. According to the administrator, RP was being disruptive. A resident (R2) made complaints about RP’s presence at the facility during mealtimes. RP had showed up to the facility with different agents at mealtimes during lunchtime. The Department received an interview statement from R1’s family member (FM). Interview statement received from FM indicated that RP and FM arrived at the facility to visit R1 during lunch time and were refused entry into the facility. Administrator told RP and FM that the facility was audited, and they cannot have people here at the facility while residents are having their lunch. The administrator then proceeded to notify RP and FM that an email was sent indicating the facility is not allowing visitors. The Department is unable to determine if facility staff are not allowing residents to have visitors at the facility. Allegation: Staff not communicating with responsible party about resident's care. – Unsubstantiated. According to an interview conducted, R1’s RP asked administrator what R1 had for lunch and was told R1 had eaten a taco. R1 was unable to remember what R1 ate due to dementia. Due to RP asking questions about R1’s lunch administrator told RP, “I am restricting your hours.” RP indicated that RP should be allowed to ask questions related to R1’s care e.g., what R1 ate for lunch. The Department reviewed R1’s physician’s report. According to physician’s report, R1 has mild cognitive impairment and Type II Diabetes. According to R1’s appraisal, R1 can feed self but sometimes needs assistance. R1 is on a pre-diabetic diet. Interview statement received from administrator indicated, administrator denied restricting visitation hours and did provide RP when asked about the food being provided to R1. Due to the information above, CCL finds the allegations to be UNSUBSTANTIATED, meaning 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 left at the facility.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 59-AS-20230720132814

Type of visit: Required - 1 Year

On 11/30/2023 at 8:45 AM, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Administrator, Violet Mubeezi, and explained the purpose of the visit. At 9:20 AM, LPA and administrator toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, garage and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. Toxic and cleaning supplies locked and is inaccessible to residents in care. LPA observed pool in the backyard is locked and inaccessible to residents in care. The hot water temperature was measured in the kitchen at 118 degrees Fahrenheit. First aid kit was completed. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher was last serviced on 03/24/2023. Fire drill was last conducted on 09/31/2023. LPA observed medications to be locked and inaccessible to residents in care. LPA observed required Licensing posters posted throughout the facility. At 9:40 AM, LPA reviewed a total of five (5) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for five (5) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of two (2) staff record. Staff has training in first aid and CPR, and other various areas of care provision. No deficiencies being cited during today's inspection. Exit interview conducted and report providedthe state’s words, verbatim · CDSS document, Nov 30, 2023