Davis Guest Home VI

Type of visit: Case Management - Other

Licensing Program Analyst, LPA Noel Wolf Petersen arrived unannounced to the facility to conduct a case management for the findings a recent report prepared by the department. The LPA met with administrator Heather McClosky to explain the purpose of the visit. The findings of the Investigation Case Report are summarized: December 22nd of 2025, client (R1) arrived to the hospital from a fall with head injury. Hospital records of that visit reviewed indicated that Resident 1 (R1) was severely malnourished. R1 lost more than 20% of their usual body weight from the time of July 6th of 2025 (169.9 lbs recorded by American Rescue Ambulance) to their hospitalization(due to a fall with head injury) on December 22nd of 2025 (119.9 lbs recorded by American Rescue Ambulance). Staff 2(S2) in interview described R1's fall on December 22nd as a result of attempting to quickly reach the restroom, as R1's loose, unbelted falling down pants, presented a tripping hazard which resulted in the injury. In interview, Administrator McClosky reported completing an appraisal of R1 upon admission and gave a statement that she did not belive R1's condition had changed since their admission and therefore did not complete or document a reassessment. Further, she did not believe anything could have been done differently in R1's case and there was no lack of care and supervision that contributed to R1's decline in health. Continued on c Page Record review of r1's 602 dated April 2025 lists physical health status as fair, no special diet, and is able to feed himself, and prescriptions included mood stabilizers, appetite stimulants, and oxygen. R1's weight was recorded as 136lbs at admission(may 2025). R1 is described by Staff 3(s3) as "good when [they] arrived at the facility, [they were] independent and able to perform ADLs on their own". R1 is described by Staff 2(s2) as "very active and left his room often to socialize with others". Record review of the primary care physician's notes described r1 as "thin, frail, and fragile" in June 2025. record review of a caseworker's vists for R1 noted [R1 was] "much thinner than their last visit" in June 2025 and "visibly thinner and clothes no longer fit" in October 2025. It was learned in record review, R1's meal refusing related behaviors were documented by the facility going back to October of 2025. Staff 2(s2) gave a statement that R1's behavioral decline (not wanting to get out of bed, increased irritability) was communicated to R1's responsible party in October via telephone. S4 recalls meeting R1 for the first time in November and gave the statement "[R1] was thin, frail, and appeared malnourished,". Record review of medical records from a hospital visit from November 2025 indicated R1 presented with a productive cough and congestions with recent onset, and lab results that showed a pattern that may be consistent with decreased blood flow to the kidneys, linked to dehydration or heart failure. S4 reported R1 refused to engage with their ADLs in December, and began refusing medications towards the end of their stay at DGH. Collectively, these records and interviews indicate r1 was deteriorating physically and mentally for several months significantly from the starting point of being independent and able to take care of ADLs, most notably the increase in r1's behaviors of agitation and isolation and refusals to bathe and eat. while S3 reportedly took action to inform the reporting party as early as October regarding behaviors, no documentation supports the claim the reporting party was informed by the facility of R1's weight loss( as required in CCR section 87466 Observation of the Resident). While Administrator McClosky gave a statement that she verbally told the conservator in October that r1 was ready to move on to a new facility, no reappraisal or supporting documentation was made at that time and the administrator gave a statement that she did not believe a change in condition had occurred. Around December 8th of 2025, DGH submitted to r1's conservator a referral for seeking a higher level of care for r1. Continued on c2 page A concensus statement was not reached about a claim asserting the facility did not monitor the residents for signs of lithium toxicity. S2 staff gave a statement they noticed a decline in r1's weight in December coinciding with r1 becoming sick and lethargic. S3 gave a statement they did not observe signs and indicated r1 was more typically agitated than lethargic. Record review of r1's Lab work from the hospital visit of December 22nd indicated r1 was 1.1 on an acceptable range of .6 to 1.2. Unclear if lithium was one of the medications r1 refused towards the end of December. The report concludes, As to the neglect/lack of supervision in the aspect that r1 sustained significant weight loss due to staff neglect, an substantiated finding. The interviews of staff, the administrator, the caseworker, and conservator collectively describe R1 going from social to asocial, fair to malnourished from summer 2025 to winter of 2025. facility didn't meet its documentation(reappraisals triggered by presenting a danger to others, deterioration of mental ability, and unusual weight loss, deterioration of a physical health condition or changes in ability to care for or maintain ADLS independently) or reporting requirements regarding r1's care(physician, responsible party, and CCL should be informed of unexplained absences from the facility e.g. hospitalizations). If staff had met those requirements, they may have had the evidence to support moving the client to a higher level of care in when the administrator expressed interest in October, ahead of the more severe decline in December. An exit interview was conducted where this report was reviewed with the Administrator, citations were reviewed and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 17, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Sep 24, 2026

87463(a) Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement was not met as evidenced by: r1 has a significant change in condition(refusing food, refusing bathing, refusing to leave his room, hitting his doc), new diagnosis 10/2025, Per administrator interview, there were no documented attempts by the facility to reappraise the client’s needs for this period. In other interviews, staff (s2, s3, s4), and caregiver(cg1) gave statements that collectively corroborate a physical/behavioral decline in ADL performance for r1: agitation expressed by throwing food/ refusing to come out of their room /refusing meals/ low oral intake for nonpreferred meals/clothing no longer fitting; for the period of July 2025 to December 2025 Not following this requirement poses a risk to the residents health, safety, and personal rightsthe state’s words, verbatim · CDSS document, Sep 17, 2026

Plan of correction: The LPA recommended as aplan of correction : administrator should make a policy for how/when the reappraisal needs to be updated for a resident, send the policy to the LPA eod 9/25/26

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Sep 24, 2026

87211(a)(1)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (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. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. Not following this requirement was evidenced by: record review of a client's 8 emt evaluations leading to 6 hospital visits, only 2 of 6 made it to being reported to licensing as required. Not following this requirement posed a potential risk to the health, safety, or personal rights of clients in care.the state’s words, verbatim · CDSS document, Sep 17, 2026

Plan of correction: The LPA recommended as a plan of correction : administrator should send back a signed copy of 87211 signifying understanding of the regulation to the lpa(9/25/26).

Type of visit: Required - 1 Year

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct a annual inspection. LPA met with Administrator Heather McClosky and explained the purpose of the visit. Davis guest home VI is a 5 bedroom 3 bath with 9 residents currently residing in the facility. Physical Plant was inspected including but not limited to bathrooms, bedrooms, kitchen, common areas, exteriors, and evacuation route gate. Facility is clean, traffic areas are well lit and free of obstruction Bathrooms have hardware in good repair, Bedrooms have required furniture and furnishings. Kitchen has adequate storage for 2 days perishable and 7 days non perishable food, LPA gave guidance to dust, check for dents and dates, and generally inventory the nonperishable foods every 6 months or so. Foods outside their original container should be stored with the label or given a date for the start of the storage. Common areas and exteriors are free of trip hazards and have space for activities. evacuation route gate swings freely and latches closed.LPA was told small building on the east side of the property was storage that had no key. Fire extinguishers are dated 8/7/25. first aid kit is has all required items, smoke/co alarm is functional. 5 client records were checked at random. tb screenings, signed admission agreements, 602 medical assessments are present and up to date. LPA gave guidance the needs and services plans are the place to outline the specific care being provided and unique challenges to the residents, usually addressing whats in the 602 or functional capabilities assessments. 5 Staff records were reviewed: health screenings, fingerprint clearance, initial training documents present and up to date. LPA gave guidance that continuing training schedule should be reviewed for the timing and topics. Administrator files were reviewed, infection control plan, evacuation plan, facility posters, insurances, and control of the property documents present and up to date. No citations issued with this visit, a copy of the report was read and given to the administrator. Exit interview conducted.the state’s words, verbatim · CDSS document, May 7, 2026

Type of visit: Case Management - Other

Licensing program analyst LPA Arrived unannounced to ammend a previous report where a signture was missing from the facility. LPA Met with adminstrator heather mcclosky and explained the purpose of the visit. LPA aquired the signature no citations were given as apart 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, Mar 18, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct an annual inspection. LPA Campbell met with Heather McClosky, Administrator and explained the purpose of the visit. The facility is a one story building licensed to serve residents 60 and over. Of the 9 residents, 2 may be non-ambulatory and they may reside in room #4. Dementia residents are not included in the plan of operations. There is currently no hospice waiver. As observed by LPA Campbell, there are nine clients residing in the facility. Of the nine clients, 4 files were reviewed and were found to be complete. Their client files indicate that the residents are able to ambulate without assistance and all residents are conserved. All facility staff found on the facility schedule were fingerprint cleared. There were 5 files reviewed and they were found to be complete. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 75 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. LPA Campbell observed first aid supplies, a fully-charged and up-to-date fire extinguisher that was last inspected on 08/01/2024, and working carbon monoxide/smoke detectors. LPA Campbell observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Campbell observed locked closets and cabinets for the storage of medication. LPA Campbell observed locked storage areas for the storage of cleaning solutions and knives as well. Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted with Heather McClosky, Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 8, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renee Campbell made an unannounced visit to this facility to conduct an annual inspection on 04/18/2023 at 9:30 AM. LPA Campbell met with Heather McClosky, Administrator and stated the purpose of today’s visit. LPA Campbell inspected the physical plant to ensure compliance with Title 22 regulations. The facility is a one floor building licensed to service adults age 60 and over. The facility may serve up to 9 residents. Two may be nonambulatory residents in room 4 only. The Plan of Operation does not allow for care of residents with dementia. No hospice waiver may be granted. No body of water was found. Upon entry, LPA Campbell observed a resident sitting on the couch in front of the TV and several residents were socializing with staff in the dining room. LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyard of the facility. The courtyard had several seating areas under shade. A combination wood and black iron gate surrounded the backyard and provided security for the residents with a fire exit that lead to the front yard. Several residents also have patio door access to the outside as well. The facility was observed to be free of odor and in good repair. LPA Campbell observed that two residents lived in a room with an en suite private bathroom. There was a hallway bathroom for the rest of the residents, and guests. There were no changes to the building layout since the most recent floor plan. A fire extinguisher was observed to have last been inspected on 08/08/2023. The thermostat was set at 73 degrees Fahrenheit. LPA Campbell observed a washer and dryer along with the staff bathroom in a secured room between the garage and the kitchen. There were enough perishable foods to sustain the facilty for 3 days and enough non-perishable foods to last 7 days. The temperatures for the freezer and the refrigerator were in compliance. The administrator conducted a test for the smoke alarm and the carbon monoxide alarm successfully. There were no deficiencies observed during visit. Exit interview and report left.the state’s words, verbatim · CDSS document, Apr 18, 2024

Type of visit: POC

Unannounced Plan of Correction visit was made out to this facility on 02/02/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Heather McClosky. A brief interview was conducted with the facility designated Administrator at this time. Current census was 8 residents. The purpose of this plan of correction visit was to follow up on deficiencies that were observed and cited on a prior visit, conducted on 12/15/2023, for the following: Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. This facility did not meet the requirements as evidenced by not submitting the required information on forms and documents by the required timeframes. The plan of correction was completed by this facility by the due date. The Proof of Correction letter was printed and a copy was given to the facility designated Administrator. There were no additional deficiencies observed or cited during today's plan of correction visit. Exit Interviewthe state’s words, verbatim · CDSS document, Feb 2, 2024

Allegation investigated: Resident sustained an unexplained fracture while in care Staff are not addressing change in resident’s condition Staff changed resident’s medication without authorization

Unannounced complaint visit made out to this facility on 12/15/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Ariel Thomas, who was briefly interviewed. This LPA requested that the facility caregiver go ahead and contact the facility designated Administrator, Heather McClosky, to inform her that CCL was present at this time. The other facility designated Administrator, Misty Speegle, arrived shortly thereafter to this facility. Current census was 9 residents. The purpose of this visit was to deliver the findings of this investigation to this facility and its designated representatives at this time. Based on a review of the forms and documents that was retrieved during the course of this investigation, it was learned that R1 sustained an unwitnessed fall on 06/03/2023 and complained of discomfort and head related pain possibly from hitting R1's head on any surrounding furniture in R1's room. The facility personnel contacted 911 and had R1 transported to the local medical establishment for further review and evaluation. R1 was discharged later that same day to this facility without mention of any rib fractures. Unsubstantiated On 06/04/2023 R1 was still complaining of pain and discomfort and specified that R1 was suffering from chest and rib pains. Facility personnel contacted 911 and had R1 transported back to the local medical establishment where she was then diagnosed with a rib fracture and discharged with corresponding medications. Based on interviews and information gathered, it was learned that facility personnel were unaware of the rib fracture from the initial fall sustained on 06/03/2023 since it was not diagnosed by the local medical establishment and only addressed the issue of the possible head injury. It was learned that once it was properly diagnosed and documented that R1 had sustained a rib fracture by the local medical establishment on 06/04/2023, facility personnel then addressed the change in care and supervision at that time. It was learned that Nurse Practitioner, Karlene Bert, was employed under the medical group for licensed medical professional Rex Adamson. It was observed that there were several changes and amendments made to the prescribed medications for R1 during R1's admission to this facility. It was observed that all changes and amendments that were conducted for R1 had corresponding documents from the Nurse Practitioner, Karlene Bert, in lieu of the licensed medical professional Rex Adamson. All changes were properly documented and observed at this time. Nurse Practitioner Karlene Bert and licensed medical professional Rex Adamson were not employees of this facility. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Dec 15, 2023 · control 27-AS-20230728152451

Type of visit: Case Management - Other

Unannounced case management conducted out at this facility on 12/15/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Heather McClosky. A brief interview was conducted with the facility designated Administrator at this time. Current census was 9 residents. The purpose of this case management visit was conducted with a complaint visit that was finalized and the findings were delivered to this facility at this time. During the course of the complaint investigation, it was observed that incidents which took place in July 2023 which warranted a report and submission into CCL were not properly followed up and completed at this time by this facility. The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal rights were printed and a copy was given to the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Dec 15, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80061(b) · Plan of correction due date: Dec 22, 2023

Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. This facility did not meet the requirements as evidenced by not submitting the required information on forms and documents by the required timeframes.the state’s words, verbatim · CDSS document, Dec 15, 2023

Plan of correction: The facility designated Administrator stated that a review of this cited section, 80061(b), will be conducted and an in-service will be performed for all facility personnel providing care and supervision to the residents. A statement of correction, along with proof of completed training, detailing topic(s) covered, trainer, and list of attendees will be completed and submitted into CCL by the due date.