Delicate Stems for the Elderly Inc.

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection and met with care staff, Novella "Marsha" Pascoe. Administrator, Laura Doxan, arrived shortly to the facility. LPA observed (2) residents present in the common area. This report is being generated to clear the Post Licensing inspection that was not conducted earlier. The annual inspection being conducted today is documented on another inspection report. There are no deficiencies issued in this report. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 9, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection and met with staff, Novella "Marsha" Pascoe. Administrator, Laura Doxan, arrived shortly. LPA observed (2) residents in the common area. The facility is licensed for (1) ambulatory resident and (4) non-ambulatory residents and has an approved hospice waiver for (4) residents- Currently (0) residents are under hospice care. LPA and the Administrator toured the interior/exterior of the facility including common areas, (2) shared resident bedrooms, (1) private resident bedroom, (2) bathrooms, kitchen, staff area, laundry area and outside patio. LPA observed the facility to be clean, in good repair and odor-free. Bathrooms have the necessary grab bars, skid-resistant flooring, hygiene supplies, and a trash can with a lid. There is sufficient 2+day perishable food, including fresh produce, and 7+day non-perishable supply of food. Sharps are locked in the kitchen, toxins in the laundry area and medications are secured in a separate cabinet. The fire extinguisher was last serviced 9/12/2025, and smoke/monoxide alarms are working. Disaster drills being conducted - last drill Feb 2026- will vary the time of day and type of drill. Inside temperature 76*F, and hot water measured 106*F in the kitchen. There are non-audio cameras in the common areas. Postings are visible in common area. Exit doors have alerts and there are no blockages present. There is (1) unlocked exit gate and no pools. Annual fees were recently paid. Discussed multiple topics. LPA reviewed (2) resident and (2) staff files. Files were organized and contained required documents. Medications were reviewed for (2) residents. Administrator to get updated signed medication lists that reflect medications no longer being taken. Staff training was documented within the last (12) months- will update to reflect more current training. There are no deficiencies issued. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 9, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a Plan of Correction (POC) inspection and met with care staff, Novella "Marsha" Pascoe who contacted the Administrator by phone. LPA spoke to Administrator, Laura Doxan, and stated the reason for the inspection was to follow up on a prior Plan of Correction due earlier in November 2025. The administrator stated she was out of the facility at the time of the inspection and confirmed she did not previously submit a statement of understanding, per the POC, and agreed to do so by tomorrow, Wednesday, November 26, 2025. LPA stated she would print a copy of the regulation so she can review it and submit the statement of understanding. LPA conducted a brief tour and observed (3) residents to be watching television, (1) resident eating and (1) resident resting in their room. LPA observed sufficient non-perishable and perishable food, including fresh produce and did not observe any health or safety risk to residents in care. There were no deficiencies observed during today's inspection and there are no citation issued in this report. Exit interview. Copy of report provided to care staff who is authorized to sign licensing reports.the state’s words, verbatim · CDSS document, Nov 25, 2025

Allegation investigated: Due to lack of supervision, resident eloped from the facility. Unlawful eviction.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete a complaint investigation and deliver findings to a complaint received July 21, 2025. LPA initially met with care staff, Novela "Marsha" Pascoe who contacted the Administrator by phone. LPA observed (1) resident watching television in the common area, (1) resident outside on the patio and (2) residents in their rooms. The administrator arrived at 11:20 am to meet with LPA. During the investigation, LPA interviewed facility staff, (1) resident, (1) placement agency staff, and a family member of resident (R1). Documentation was reviewed relating to (R1), including, but not limited to, monthly progress reports, the admission agreement, emails and text messages between the facility administrator and (R1's) family member, placement agencies and health care providers. The results are as follows: Resident (R1) moved in on January 15, 2025 and had a diagnosis of Dementia, and needed assistance with dressing, bathing and medications. (R1) was more independent with ambulating, toileting, and eating. *cont on 9099C-1.. Substantiated 9099C-1... Allegation: Due to lack of supervision, resident eloped from the facility. The allegation states resident (R1) eloped from the facility without staff knowledge on 7/12/25, and the "bell" was not on the door. The Administrator stated that there were (2) nurses and a care aid present at the facility when (R1) eloped to the neighbor’s house on 7/12/25, and explained the incident was caught on camera. The administrator acknowledged that this incident was reported to the Department and a completed incident report was provided to the Department on 7/23/25, when the complaint was opened. Staff (S1) stated (R1’s) family member was outside in the car when (R1) exited the facility on 7/12/25. (S1) explained she and the family member circled the block and other neighbors assisted with searching for (5) minutes before locating (R1) in the neighbor's backyard, two houses over. (S1) stated she was serving dinner when (R1) was able to exit through the front door. A resident who was present on 7/12/2025 stated they recalled (R1) trying to often leave the facility through the front door. This resident confirmed the front door always has a “beep” sound or alert when it’s opened, but it must have been turned off when (R1) was able to leave that day. The resident stated staff was talking to a nurse who was visiting, and the alarm must have been turned back on after (R1) exited the care home. Interviews also concluded that (R1) tried to leave the facility previously on 7/2/25 but was unable to leave the property before staff were made ware and redirected resident back inside the care home. Based on information obtained, LPA finds this allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. *cont on 9099C-2.. 9099C-3... Regarding a higher level of care: The family member stated the administrator believes (R1) needs memory care after they eloped on 7/12/25, but (R1’s) Delirium was temporary and was due to a new medication that (R1) is no longer taking and (R1) is "fine". Documentation was reviewed by the department, including (R1’s) Monthly Progress Report that reflect (R1) becoming increasingly more confused, agitated, aggressive, needing more redirection, staying awake all night, and more difficult to redirect from February 2025 through July 2025. Additionally, the reasons for each hospitalization, on the following dates: June 24-25; July 2- 7; July 12, 2025, are due to the same behaviors. The administrator emailed LPA on July 16, 2025 regarding the elopement incident on July 12, 2025 which stated: Her daughter sent her out. She was extremely delirious and confused. She was at the facility that day. She also was on the phone with (R1’s) health care plan and spoke with the nurse and physician. The administrator also provided a letter to the department that she was “reassured that (R1) would be relocated to a different facility that would be more appropriate for (R1’s) psychosis”…and the administrator “had open communication with the agency who is in charge of (R1’s) placement and corresponded with their daughter as well and was told that every effort will be made to make sure (R1) would be relocated to a SNF or a memory care facility”. The administrator stated also in writing that "(R1’s) primary care and psychiatrists have been notified and kept informed” and “requests for medical evaluation or adjustments have been requested” and provided multiple text messages showing conversations between the administrator and (R1’s) placement agencies, health care staff and (R1's) family member. Staff and resident interviews corroborated that (R1) became increasingly confused, agitated, had trouble sleeping at night and was hallucinating until (R1) left the facility and was found in the neighbor's backyard. On July 16, 2025, the Department was provided with a copy of the 30-day eviction notice issued on July 15, 2025, and it was determined to contain all of the required elements to be a lawful notice; however, due to the resident not being given a 30 day notice until after being told the facility would not allow resident to return on/around July 12, 2025, the Department finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. *cont on 9099C-2.. 9099C-2- Allegation: Unlawful eviction. The allegation states (R1’s) responsible person received a copy of a 30- day eviction letter on July 15, 2025, to be effective August 14, 2025, and the letter cited two reasons for the eviction 1- nonpayment of rent, and 2- (R1) needing a higher level of care due to delirium. Regarding the: rent: When moving into the facility, (R1) was participating in a funding program through a placement agency. As part of the contract, effective May 1, 2025, (R1) was to begin paying a monthly co-payment to the facility. Due to non-compliance with meeting monthly co-payments, an “End of Service” notice was issued by the placement agency on/around June 12, 2025 to terminate (R1’s) contract effective July 15, 2025. A representative from the placement agency stated to LPA in July that the decision to terminate the contract was appealed and an extension was granted for (R1) to be able to stay at the facility until August 15, 2025; however, generally when funding stops, it doesn’t matter if the contract has been extended. The administrator stated she referred (R1’s) family member to the specific program and on/around June 16-18, 2025, a sales representative from this program met with (R1’s) responsible person to sign paperwork so (R1) could be added to their program, once the placement agency ended their contract with (R1). Also at this time, on June 19, 2025, the facility had a change in ownership, and a new facility license was issued. Under the new license, the facility no longer had a contract with this new program. The representative at the placement agency stated to LPA on July 30, 2025, that (R1’s) responsible person needs to contact the new program for assistance in finding a facility that currently contracts with them. (R1’s) family member stated that the administrator referred (R1) to this specific new program as there are many facilities in the area that participate and claims she was not informed by the administrator that she was not planning on signing a contract with them under the new facility license. Text messages from Thursday, July 17, 2025 document the Administrator telling the family member that “after reading the terms and conditions of the contract with ( ), I’ve decided not to contract with them “ and provided (2) local facility contacts that do contract with the company. The Administrator stated on July 30, 2025 that she has not received (R1’s) co-pay for July and confirmed that she refused to take (R1) back from the hospital before issuing the 30- day notice on July 15, 2025, due to their behaviors such as eloping and showing physical aggression. The administrator stated she had a 3-way call with (R1's) psychiatrist and family member, and the psychiatrist recommended the facility not take (R1) back until they were evaluated, observed and medications changed were effective. Records show (R1) was taken to the hospital on July 12, 2025 due to being “very confused, disoriented, aggressive and violent the prior days and nights” and interviews confirm (R1) did not return to the facility. *cont on 9099C-3..the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 59-AS-20250721093511

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Oct 22, 2025

Regulation 87705 (d) Care of Persons with Dementia- The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not ensure that (R1) was not able to leave the facility unassisted on July 12, 2025 (around 5:00 pm) , when (R1) was located in a nearby neighbor's backyard, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Licensee/Administrator agree to not deactive the door/bell alarm at any time, even when there are multiple visitors. The correction was done immediately following the incident and all staff are aware.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(1and4) · Plan of correction due date: Nov 4, 2025

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5): (1) Nonpayment of the rate for basic services within ten days of the due date, and (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement was not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) was given (30) days notice in writing, while in the hospital, prior to being evicted, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Licensee/Administrator agree to submit a 3-day eviction notice to the Deparment for review and approval if a resident has psychosis or shows extreme behavior where it is no longer safe for that resident and/or other residents. Also agrees to issue a 30-day as soon as there is a significant change in a resident's behavior if warranted. Documentation that Reg 87224 was read and is understood by 11/4/25. The hospital did keep (R1) for a while following the admittance, on 7/12/25, for observation but then was discharged to a higher level of care. The psychiatrist and family member were very involved.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Sabrina Calzada arrived announced for a scheduled pre-licensing inspection for a change in ownership and met with Laura Doxan, Administrator. Also present was staff, Novella "Marsha" Drummond and Elena Giuchici. LPA observed (2) residents in the common area, (2) residents outside on the patio, and (1) resident returned later during the inspection. The facility is currently licensed for (5) residents- (1) resident must be ambulatory and (4) may be non-ambulatory, and has a hospice waiver for (4). Currently, there is (1) resident on hospice. LPA and Administrator toured the interior/exterior of the facility including the common areas, (3) resident bedrooms, (2) full bathrooms, kitchen, office, staff room, and locked laundry area/garage. LPA observed the facility to be clean, in good repair and odor free and the bathrooms to have the necessary grab bars, shower chair, paper towels, soap, trash can and (20) second hand-washing poster. There is sufficient 2+day perishable, including fresh produce, and 7+day non-perishable supply of food. Sharps are locked in the kitchen, toxins are secured in the laundry room, and medications are secured in a nearby cabinet. Fire extinguisher was last serviced 9/3/24 and the smoke monoxide alarms are functional as well as the fire door. There are (2) complete First Aid kits and sufficient linens/towels/blankets/PPE supplies. There is an auditory alert device on each exit door. The inside temperature measured 72*F, and the hot water measured 117*F in a resident bathroom. There is one unlocked exit gate, no pools, and covered patio seating with a garden. LPA reviewed (2) resident and (2) staff files. Files were organized and contained all required documents. Required postings are visible in the common area. Visiting hours are posted. Component III was completed and other topics discussed. Pre-Licensing is complete and this facility has no deficiencies. LPA to notify the Department's application bureau. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 10, 2025

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 5 Census: 5 COMP II Participant: Laura Doxan, CEO/Administrator Interview Method: Telephone interview On 5/22/25, applicant/administrator participated in COMP II. Identification of the applicant/administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, May 22, 2025