Delta at the Portside

Type of visit: Case Management - Legal/Non-compliance

On 9-2-2026 at 9:45am, Licensing Program Analyst (LPA) Michael Bilger and Licensing Program Manager (LPM) Liza King arrived unannounced to conduct a quarterly inspection visit. LPA and LPM met with Administrator Tammy Isam and explained the purpose of the visit. During todays unannounced quarterly inspection the following were reviewed: A. Respondents shall operate the facilities in substantial compliance with the regulations and statutes governing the operations of adult residential facilities and residential care facilities for the elderly. B. During the period of probation, the Department, in its sole discretion, may conduct unannounced site visits for the purpose of determining whether there is compliance with the regulations and statutes governing the operation of adult residential facilities and residential care facilities for the elderly. C. Respondents, and each of them, shall ensure that all individuals working, residing or volunteering in the facility shall, to the extent required by law, obtain criminal record clearances or exemptions prior to their initial presence in the facility and shall maintain proof of such criminal record clearances or exemptions at the facility. VERIFIED by review of staff present today and guardian roster. Staffing schedules reviewed were dated 8/30-2026 to 9/1/2026 D. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period VERIFIED by observation E. Respondents are required to maintain accurate, complete and current client rosters which must be made available to the Department upon request. VERIFIED by record review F. Within thirty (30) days of the effective date of this Stipulation, Respondents shall submit to their respective licensing offices written summaries of their hiring and training practices, including job descriptions for each position at the facility. COMPLETED {Cont. on 809C} G. Respondents shall report to their respective Licensing offices the following: any unusual incident including, but not limited to, client death or injury which requires medical treatment, any allegations of or suspected physical or psychological abuse of any client, any physical plant changes and all unexplained absences, pursuant to applicable statutes and regulations. VERIFIED by record review. H. Respondents shall maintain current personnel records of each employee pursuant to California Code of Regulations, Title 22 Regulation sections 80066, 85066, and 87412 VERIFIED through review of ten staff files and interview with vice president and chief operations officer Madison Fetyko. Personnel training records were provided by Madison Fetyko. I. Respondents shall ensure that medications and any other toxic products are properly stored and kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication pursuant to California Code of Regulations, Title 22 Regulation section 80075, 85075, and 87465, as applicable. Respondents will ensure that medications are properly and timely disposed of according to the applicable regulations VERIFIED by means of facility tour J. Respondents shall ensure that each facility is clean, safe, sanitary and in good repair at all times. An observation of resident rooms revealed 6 of 6 rooms observed did not contain soap, toilet paper, and paper towels. Additionally, various resident rooms contained dresser drawers not functioning properly. LPM observed overgrown shrubbery outside near the back hallway area. Additionally, various windowsills contained dead insects and required cleaning. K. Respondents shall provide quarterly training to all facility staff on applicable Title 22 regulations including mental health assessments, client behaviors, observation of the clients/residents, medication protocols, the Department's inspection authority, personal rights, notice requirements, reporting requirements, transfer trauma and care and supervision, generally. Respondents shall keep a record of staff who attend such training and make such records available to Licensing staff upon request. VERIFIED by review of staff training from May 2026 to July 2026 which including training topics of care and supervision. During the past quarter, staff were provided training on care and supervision. {Cont. on 809C} L. Food Service items noted: LPM observed expired yogurt and garlic spread from June and August 2026 respectively. Additionally, LPM observed spinach with mold. As a result of today's visit, citation is issued and noted on LIC 809D. An exit interview was conducted with administrator and a copy of this report was provided. A copy of this report was further read and verified by vice president and chief operations officer. LIC 811 provided for reference. Appeal rights provided.the state’s words, verbatim · CDSS document, Sep 2, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(3) · Plan of correction due date: Sep 11, 2026

87307 Personal Accommodations and Services. Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident...This requirement was not met as evidenced by: Based on observation, Licensee did not ensure the availability of soap, toilet paper, and papertowles in 6 of 6 resident rooms observed. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: Licensee or designee will submit a plan to ensure the availability of personal items for residents in care. Plan to be submitted to LPA by POC due date.

Type of visit: Case Management - Health Checks

On 5-15-2026 at 11:30am, Licensing Program Analyst (LPA) Noel WolfPetersen and Licensing Program Manager (LPM) Liza King arrived at this facility unannounced to conduct a case management visit regarding a new client placed at facility on 5-13-2026. LPAs met with the Admin Tammy Isam and explained the purpose of the visit. During todays visit LPA and LPM conduct visits with resident1 (R1). Based on visits conducted, it was determined that all residents noted above moved into facility on 5-13-2026 and has in possession all necessary personal belongings and medications in place. LPA and LPM observed resident in room near lunchtime. LPA inspected the physical plant including but not limited to the common areas, resident bedrooms; resident bathrooms to ensure compliance with Title 22 regulations. Facility is a Residential Care Facility for the Elderly (RCFE) with a current census of 30 Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. No presence of odor. Several residents were met in the hallways during the tour, were friendly and please with their current living situation, Fire extinguisher was checked last serviced in Oct 2025. LPA did not observe any cleaning supplies or other dangerous items assessable to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. On the Laguna side of the building, 2 of 3 resident bedroom doors could not be locked, 2 bathrooms were locked and were reported as being staff and visitor bathrooms although one was at the end of the hall closest to a residents room and should be unlocked as there were no other bathrooms in the proximity. 3 additional bedooms and 2 bathroom locks were checked and functional on the Marina side of the building. Admin agreed to fix before eod. LPA observed current stipulation posted within facility for viewing. LPA observed personal rights and complaint information posted. No citations were issued during todays visit, an exit interview was conducted with Tammy. And a copy of the report and technical assistance was provided.the state’s words, verbatim · CDSS document, May 15, 2026

Type of visit: Case Management - Legal/Non-compliance

On 5-6-2026 at 10:00am, Licensing Program Analyst s(LPAs Michael Bilger and Albert Johnson arrived at this facility unannounced to conduct a quarterly inspection visit. LPA met with the Administrator Tammy Isam and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen area, common areas, resident bedrooms; resident bathrooms, laundry area and outside of the facility to ensure compliance with Title 22 regulations. Facility is a residential care facility for the elderly (RCFE) with a current census of 32. The facility has an approved infection control plan in place. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Fire extinguisher was checked 10-29-25. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. During this inspection 10 staffing files were reviewed for training verification per stipulation order. LPA reviewed current client rosters, and observed current stipulation posted within facility for viewing. All staff files reviewed contained criminal background clearances. LPA observed personal rights and complaint information posted. Facility has appropriate internet access available for resident use. LPA reviewed facility’s disaster plan to ensure regulatory compliance. LPA requested an updated copy of LIC 308 and LIC 500. During today's visit, LPA reviewed various incident reports involving medication refusals. LPA offered consultation on care plan updates regarding medication refusals. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to interim Administrator. LIC 811 provided for reference.the state’s words, verbatim · CDSS document, May 6, 2026

Allegation investigated: Questionable death

LPA Johnson conducted a complaint visit to this facility to deliver findings for the above allegation. Allegation: Neglect/Lack of Supervision: Due to staff neglect/lack of supervision, R1 was AWOL and found deceased. Finding: Substantiated Conclusion: R1's death certificate listed R1’s cause of death as Acute Methamphetamine with Cirrhosis of the liver listed as another significant condition contributing to death. R1’s date of death is listed as 06/02/2025. Continued Substantiated Former facility Staff (S1) reported that they saw R1 go to dinner on 05/31/2025 between approximately 1700 hours to 1800 hours. S1 took her hour long break, and returned to conduct room checks. Between approximately 1900 hours and 2000 hours, S1 looked for R1 but could not find him, so she notified former Administrator Aria Alaghemand. S2 marked that R1 did not receive his evening medication that occurs at 2000 hours on 05/31/2025. S2 failed to report the incident and was terminated. Administrator did not notify law enforcement that R1 was AWOL until 1543 hours on 06/01/2025, although he learned about his AWOL on 05/31/2005 at approximately 2237 hours. R1 should have been reported missing “immediately.” R1’s physician report noted that R1 is to not leave the facility unassisted. Chief Operating Officer Madison Fetyko reported that the facility staff did not follow proper policy and procedures. Therefore, the allegation is substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency was cited on a 809-D page, on 6/03/2025 during a case management visit regarding the same incident. The facility Administrator was informed that an additional civil penalty was pending review during the 6/3/2025 case management visit and may be assessed according to Health and Safety Code § 1569.49(e). Once a civil penalty has been determined, the Department will return at a future date to assess civil penalty. Exit interview conducted and report provided. Appeals rights printedthe state’s words, verbatim · CDSS document, Mar 17, 2026 · control 27-AS-20250605103303

Type of visit: Office

An in-person office meeting was held on 02/06/2026 at 11:00 AM at the Sacramento Regional Office for the purpose of reviewing the Stipulation and Waiver, and Order. The Stipulation and Waiver; and Order was adopted on 01/09/2026. Licensing Staff Present: · Regional Managers: Brenda White, Stephenie Doub, Acting Regional Manager Troy Ordonez · Licensing Program Manager: Liza King · Licensing Program Analysts: Albert Johnson, Melinda Melina, Michael Bilger and Kevin Mcknelly Facility/Licensee Representatives Present: · Chief Executive Officer, Managing Member, LLC, Dr. Christopher Zubiate and David Fetyko · H & K LLP, Attorney for LLC, Bruce Zabarauskas · COO, Madison Fetyko, Personal Assistant, Heidi Badasci The Regional Manager discussed the purpose of the meeting and explained the conditions and terms of the Stipulation and Waiver with Order, including probationary licensing, compliance expectations, monitoring authority, and enforcement provisions. The Stipulation was reviewed in detail with the Administrator and Licensee, who acknowledged understanding of the terms and conditions. EVER WELL HEALTH SYSTEMS, LLC, EVER WELL CARE SYSTEMS, LLC, Ever Well Health Systems, LLC dba Enclave at the Foothills 10650 Road 256 Terra Bella, California 93270 Ever Well Health Systems, LLC; Ever Well Care Systems, LLC dba Delta at Holly Oaks 1880 Live Oak.Blvd. Yuba City, California 95991 Ever Well Health Systems, LLC dba Delta at the Portside 1950 E. Sonora Street Stockton, California 95250 Ever Well Health Systems, LLC dba Enclave at the Delta 4951 Eight Mile Road Stockton, California 95212 Ever Well Health Systems, LLC dba Delta Manor 1201 W. Swain Rd. Stockton, California 95207 Ever Well Health Systems, LLC dba Delta at the Sherwoods 1215 W. Swain Road Stockton California 95207 Ever Well Health Systems, LLC dba Foothills at the Alta 550 N. Lillie Ave. Dinuba, California 93618 Items Discussed During the Meeting: · The Stipulation and Waiver; and Order was served on 01/09/2026 and is effective immediately. Ever Well Health Systems, LLC dba Foothills at the Alta license was forfeited as a matter of law and revoked upon the Departments adoption of this Stipulation and Waiver. · Revocations: Stayed with Probation from January 9, 2026, through January 9, 2028. · Upon adoption of the Stipulation as an Order, EVER WELL HEALTH SYSTEMS, LLC, EVER WELL CARE SYSTEMS, LLC LLC’s licenses at Licensee facilities are revoked; however, the revocation is stayed for a period of two (2) years, during which probationary licenses are granted. · During the probationary period, Respondents shall operate the facility in substantial compliance with all applicable statutes and regulations governing Adult Residential Facilities and Residential Care Facilities for the Elderly. · The Department may conduct unannounced site visits at its sole discretion throughout the probationary period to assess compliance. · Respondents shall ensure that all individuals working, residing, or volunteering at the facility obtain required criminal record clearances or exemptions prior to presence in the facility and that proof is maintained on-site. · The Stipulation shall be posted in a conspicuous location at the facility for the full duration of probation. · Respondents shall maintain accurate, complete, and current client rosters, which must be made available to the Department upon request. · Within thirty (30) days of the effective date of the Stipulation, Respondents shall submit written summaries of hiring and training practices, including job descriptions for each position, to the appropriate licensing offices. Completion of Probation: · If Respondents LLC successfully comply with all terms of the Stipulation, at the conclusion of the two (2) year probationary period, all imposed conditions shall expire and the licenses shall be granted or restored in full. The Licensees/Respondents/Representatives stated they would abide by the following: Abide by the contents/terms of the Stipulation Provide Licensing an updated Plan of Operation for the type of client serve Submit written summaries of hiring and training practices, including job descriptions for each Position to the Department on or before February 8, 2026 CHRISTOPHER ZUBIATE and DAVID FETYKO shall complete required training's on or before March 10, 2026 and provide proof of completed training to the Department by on or before April 9, 2026. Ensure quarterly training of Staff according to the terms of the stipulation (The first is to be completed by end of February of 2026 and quarterly thereafter for a total of two hours for each session.) CCLD will do the following: Increase monitoring Referral to TSP was offered Per the California Code of Regulations, Title 22, no violations cited during this visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 6, 2026

Allegation investigated: Staff sexually abused resident in care

LPA Johnson arrived unannounced to deliver findings for the above allegation. These are the findings from the department. Based on interviews and records reviewed, R1 stated S1 is coming into her room every night and raping her. R1 has never woke up when this has happened but knows it is happening because she wakes up in “pain.” R1 knows it is S1 because S1 is the only facility staff who lives at the facility. According to R1, she and S1 have never talked to one another before and that S1 is “very quiet” so that’s why she knows it is him. Unsubstantiated Administrator Tammy Isam stated that according to R1’s conservator, R1 has a history of making these allegations. After the facility was first made aware of the allegation, S1 was moved out of the facility. R1 has still been making the allegation. The facility took R1 to the hospital to get checked out as well. Stockton PD was made aware of the allegations. Tammy has never had concerns with S1 before. No one has ever made an allegation about S1 before. Tammy informed me that R1 first said resident R2 was the one who raped her. R2 denied knowing who R1 was. R2 stated he has never had any interactions with R1. R2 stated he couldn’t even point out who R1 is. Other residents interviewed did not disclose any issues or serious complaints regarding the facility, the facility staff, or S1. Planned Work: Interview suspect, interview R1’s conservator Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 29, 2026 · control 27-AS-20251201090128

Allegation investigated: Facility staff are not giving medication as ordered by Physician

LPA Johnson arrived unannounced to deliver findings for the above allegations. Allegation: Facility staff are not giving medication as ordered by Physician. Based on records reviewed the facility is assisting R1 with the administration of medication. There was medication refusal eight times in November of 2025. After reviewing the needs and service plan for R1 and other residents the department has determined that the facility has identified service needs and uses checkmarks to determine if the need will be addressed by the facility, Physician or other a consultants. The language is not tailored to individual needs but generically written to cover the targeted need. This is also identified in the interventions for non-compliance for R1, based on this information the department is unable to determine if R1's refusal of medication / non-compliant with medications was addressed by the primary care physician the records on the medication records do not reflect alternatives or replacement guidance. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 29, 2026 · control 27-AS-20251021103537

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Albert Johnson and Jason Lund arrived unannounced to conduct an annual inspection. LPAs met with Administrator and explained the purpose of the visit. LPAs and Administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. Observed during the tour were sufficient furniture and lighting throughout the facility. Observed during the tour was sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 106 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. During the inspection of the kitchen it was observed that the facility is not keeping a cleaning schedule, not keeping a log of temperatures for food serviced and there was expired food in the dry storage/emergency food storage (emergency food has been used.) There is not a qualified person as identified in the regulation for kitchen supervision. If this person is not a nutritionist, a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided at appropriate times, during at least one meal. A written record of the frequency, nature and duration of the consultant's visits shall be secured from the consultant and kept on file in the facility. Continued Fire extinguishers and smoke detectors/carbon monoxide detectors are operational. LPAs, and Administrator observed centrally stored medications are kept locked and inaccessible to residents. LPAs, and Administrator reviewed and compared resident medication vs. resident medication logs. During the medication review it was observed that R1's PRN medication was not listed on the PRN letter as required for instruction from the doctor to the facility. LPAs and Administrator reviewed 15 resident and 10 staff files, including criminal record clearances. First aid kit was checked and is complete. Citation given pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted. Appeal rights and report given at conclusion of the inspection.the state’s words, verbatim · CDSS document, Dec 10, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(b) · Plan of correction due date: Dec 17, 2025

(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. This requirement is not met as evidenced by records reviewed the facility does not have prescribed PRN medications listed on their PRN letter for R1. This poses a risk to residents in carethe state’s words, verbatim · CDSS document, Dec 10, 2025

Plan of correction: The facility will submit an updated the PRN letter to included all prescribed medications to be used by the facility for R1 and any other resident in care. By POC date 12/17/2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(17,28,29) · Plan of correction due date: Dec 17, 2025

The following food service requirements shall apply:(17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service. If this person is not a nutritionist, a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided at appropriate times, during at least one meal. A written record of the frequency, nature and duration of the consultant's visits shall be secured from the consultant and kept on file in the facility. (28)All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by observation the facility is not keeping a cleaning schedule, not keeping a log of temperatures for food serviced and there was expired food in the dry storage/emergency food storage (emergency food has been used.) There is not a qualified person as identified in the regulation for kitchen supervision. This is a potential health and safety risk.the state’s words, verbatim · CDSS document, Dec 10, 2025

Plan of correction: The facility will throw out expired food, develop a cleaning schedule and check food temperatures daily for all meals served. The facility will also hire a kitchen staff as required by the regulation cited. By POC date 12/17/2025

Allegation investigated: Staff did not maintain accurate records for residents Staff did not provide records to resident's mental health clinician Staff do not have the required credentials to provide skilled care to residents

LPA Johnson and Lund arrived unannounced to deliver findings for the above allegations. Allegation: Staff did not maintain accurate records for residents, based on records reviewed the facility has records maintained for C-1, however, the records are not accurate as it relates to the required follow-up to notification of the primary care physician. C-1 continues to refuse medication. The facility has attempted to address the refusal, however C-1 refuses to see the doctor. The records are somewhat accurate but lack the required information from the PCP to assist C-1 with alternatives to medication refusal. Continued Unsubstantiated Allegation: Staff did not provide records to resident's mental health clinician. Based on interviews with mental health the facility does provide the case workers with information, however the information is not immediately given. The information is faxed to the case worker and the time frame is different according to the level of information requested. Allegation: Staff do not have the required credentials to provide skilled care to residents. Based on records reviewed the facility is using a licensed from the California Department of Consumer affairs and NPI registered individual to provide care required by a licensed professional. The department was unable to confirm that this is happening with all required client health needs. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 27-AS-20250808091011

Allegation investigated: Staff member is harassing resident in care. Staff member is not according privacy to residents in care.

LPAs Johnson and Lund conducted a complaint visit to this facility to deliver findings. Allegation: Staff member is harassing resident in care. Based on interviews conducted and records reviewed, the department has determined that the allegation is unsubstantiated. Staff interviewed denied harassing or not affording privacy to any resident. Residents interviewed stated that the staff members are doing better with knocking on the door before entering. Continued Unsubstantiated Allegation: Staff member is not according privacy to residents in care. Based on interviews conducted the facility is attempting to respect the wishes of the residents. Some residents voiced their concerns about staff coming into their rooms without knocking on the door and talking loud to their roommates. The staff interviewed confirmed that they receive training on personal rights and they are required to check with residents by knocking and announcing before entering their roomsthe state’s words, verbatim · CDSS document, Oct 2, 2025 · control 27-AS-20250709165309

Type of visit: Case Management - Incident

LPAs Johnson and Lund conducted a case management visit to follow-up on information discovered during the complaint visit. The facility received a narrative on 6/3/2025 for C-1 refusing a medication or all medication 22 of 30 days in April of 2025 and 11 of 19 days for May of 2025. This is recorded on the medication administration record and notes on the facilities' recording system for medication management. The facility has addressed this need in the service plan for C-1. The facility continues not to report the refusals of medication for C-1 to the department and C-1's primary care physician. The facility is to continue to report refusals of medication to the physician if the refusal of medications is ongoing. Based on the records the refusal is ongoing and has not been reported for multiple days in June of 2025, July of 2025, August of 2025 as per intervention plan created 7/22/2025. Per California Code of Regulations, Title 22 Division 6, Chapter 8, this deficiency is being cited on the attached 809-D page. Exit interview.the state’s words, verbatim · CDSS document, Oct 2, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f) · Plan of correction due date: Oct 16, 2025

87464 Basic Services: (f) Basic services shall at a minimum include:(1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by the facility not following the plan of service designed by the facility on 7/22/2025the state’s words, verbatim · CDSS document, Oct 2, 2025

Plan of correction: The facility will conduct an in service to address service plans as outlined in the citation and provide training log sign-in sheets to LPA via email by poc date 10/16/2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Oct 16, 2025

(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. This requirement was not met as evidenced by interview conducted the facility failed to notify primary care physician and the department of multiple incidents of medication refusalsthe state’s words, verbatim · CDSS document, Oct 2, 2025

Plan of correction: The facility will conduct an in service to address reporting requirement as outlined in the citation and provide a training log and sign -in sheets to LPA via email No later than 10/16/2025

Type of visit: POC

LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued on 5/20/2025 and 6/03/2025. LPA toured the facility, reviewed document submitted for plans of correction observed that the deficiencies cited have been cleared. Deficiencies cited under Title 22 Regulations have been cleared. Licensee complied with the terms of the POC by POC due date. Facility was provided POC cleared letter. Exit interview conducted.the state’s words, verbatim · CDSS document, Jul 2, 2025

Allegation investigated: Staff do not keep accurate medication logs.

LPA Johnson arrived to deliver findings. Based on records reviewed and inspections conducted the facility did not keep accurate records for medication. Records reviewed during medication survey confirmed missing medication, documentation inaccurate and centrally stored medication log with missing medication documentation and PRN medication not stored as required. The facility received a citation on 12/3/2024 during the annual survey. On 5/20/2025, the facility received a finding of unsubstantiated on a complaint for not meeting the residents needs. The information confirmed that C-1 has refused a medication or all medication 22 of 30 days in April of 2025 and 11 of 19 days for May of 2025. This is recorded on the medication administration record and notes on the facilities' recording system for medication management. The facility has addressed this need in the service plan for C-1. Substantiated The facility did report the refusals in March of 2025 and the doctor made an adjustment, however, C-1 continues to refuse medications and the facility has not consistently followed the intervention plan for C-1. The facility is to continue to report refusals of medication to the physician if the refusal of medications is ongoing. Based on the records the refusal is ongoing and has not been reported for April as per intervention plan created 3/21/2025. The facility stated that they could get the information to show that the doctor was notified and had plans to address the situation, however, the records given show that the facility made the doctor aware of refills on 4/1/2025, 4/02/2025, 4/21/2025 and 4/25/2025 and not that C-1 was refusing medication, Additionally, documentation dated 5/22/2025 and 5/28/2025 addressed the refusal of medication to the doctor after the visit by the department on 5/20/2025. During the medication review today LPA observed PRN medication is not listed on the authorization letter for C-2 and the medication administration record for C-2 is missing documentation for this PRN medication that was given/popped from the bubbles pack on eleven medication passes. This allegation is substantiated.the state’s words, verbatim · CDSS document, Jun 3, 2025 · control 27-AS-20250218151202

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(6) · Plan of correction due date: Jun 4, 2025

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. Based on record review, the licensee did not comply with the section cited above for C-2 which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: The Licensee will conduct an in-service on medication administration, documentation and understanding the service needs of residents by POC date 6/4/2025.

Type of visit: Case Management - Incident

LPA Johnson arrived at the care facility and met with Aria Alaghenmand to conduct a case management visit into an incident reported to the department on 6/2/2025 C-1 AWOL'd from the facility on 5/31/2025 time unknown, Staff members noticed while doing rounds. Contact was made to the Administrator by staff on duty after noticing C-1 was missing. The Administrator contacted the police department and filed a missing persons report. According to C-1's Physicians report, C-1 is not allowed to leave the facility unassisted. C-1 was found in the community deceased. No other information is available at this time. LPA spoke to with the Administrator about the facilities care plan for C-1. LPA obtained copies of resident's service plan and other pertinent information. Deficiencies were cited on today's date. The incident is under review and a future civil penalty may apply based on H & S code 1569.49 (e). Exit interview and appeal rights provided.the state’s words, verbatim · CDSS document, Jun 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jun 4, 2025

87411(a)- Personnel Requirements - General-Facility personnel shall be sufficient in numbers, and competent to provide the services necessary to meet resident needs. -This requirement is not met by observation and records review C-1 AWOL'd from the facility. The LIC 602 states the resident was not allowed to leave the facility unassisted. This presents an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: The facility shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. Administrator shall send the in-service training materials, plan on how staff will ensure residents do not AWOL and a signature sheet of all staff who attended. Administrator shall email the date of the in-service training to LPA by 06/04/25 to meet the 24 hour POC requirement.

Allegation investigated: Staff did not provide resident with their weekly allowance.

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to deliver findings for the above allegations. Based on interviews conducted and records reviewed the facility failed to provide C-1 with his money pass on 5/19/2025. C-1 received personal and incidentals(P&I) funds on 5/15/2025 this was the last time C-1 received P&I funds. The facility informed C-1 on 5/19/2025 that he was not able to get his P&I funds because C-1 was late coming to the area where the money was being passed out. The facility does not have a signed policy that addresses consequences of missing money passes or reasons for residents not to get their P&I funds. This is a personal rights violation. The above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, this deficiency is being cited on the attached 9099-D. Substantiated After additional information reviewed and received from the facility. The above allegation is found to be SUBSTANTIATED. The facility received a citation on 6/3/2025 addressing the medication and service need deficiencies therefore an additional citation is not warranted. The facility will address the deficiencies as part of the in-service for the plan of correction.the state’s words, verbatim · CDSS document, May 20, 2025 · control 27-AS-20250212152319

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: May 27, 2025

(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirements was not met as evidenced by interviews conducted and records reviewed the facility failed to provide C-1 with his money pass on 5/19/2025.the state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: Please submit a letter of understanding and a copy of the completed in-service training to include date and signatures of trainer and attendees by POC due date. Licensee is to ensure that all in-service training are documented and residents' personal rights are upheld at all times.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Johnson and Program Manager Lisa Rios arrived at facility unannounced to conduct a visit to ensure compliance with Health and Safety Code (HSC) 1569.38 - Posting of Licensing Reports. LPA Johnson and LPM Rios met with Acting Administrator and explained the purpose of today's visit. The facility received accusation notifying the department has commences proceedings to suspend or revoke the license of the facility pursuant to Section HSC 1569.50. and will be required to post these in a location easily viewable by residents and visitors. A written notice was handed to Acting Administrator of these accusations The facility will comply with HSC 1569.38(a-h). A licensee who fails to comply with the requirements of subdivision (b) or (c) of the HSC 1569.38 shall be liable for civil penalties in the amount of one hundred dollars ($100) for each day of the failure to provide notification as required in this section. The total civil penalty for each day shall not exceed one hundred dollars ($100) regardless of the number of notices that the licensee fails to send that day. The total civil penalty for a continuous violation of subdivision (b) or (c) shall not exceed five thousand dollars ($5,000). An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2025

Allegation investigated: Staff did not prevent resident from severely harming another resident in care Staff did not provide incident report to resident's authorized representative

LPA Johnson conducted a complaint visit to this facility to deliver findings regarding above allegations. On 11/28/2024, R1 suffered a hip fracture after being pushed to the ground by another R2. R1 and R2 had a verbal altercation that R1 took responsibility for. After R1 followed R2 to his bedroom, R2 stated he pushed R1 with his hand. R1 reported that staff immediately ran to his aid and called paramedics and law enforcement. Residents were interviewed and reported no concerns with verbal/physical altercations at the facility. Residents also had no concerns regarding R2, who has a history of delusion and paranoia. Both R1 and R2 were said to be very vocal residents. Unsubstantiated Staff who were on duty at the time of the incident did not witness the altercation. Staff reported light concerns regarding staffing; however, no staff believed a lack of staffing, or care, were factors in the incident. Staff did not witness any physically aggressive behaviors from R1 or R2; however, some staff shared observations of R2 being verbally aggressive to residents and staff. Medical Service Assistant (MSA) Aamenah Ravaid referred to R2 as a “bully, with a short temper” Administrator, Momo Duoa was interviewed and reported that R2 had previous instances of verbal aggression. To mitigate R2’s aggression, Momo stated he has worked closely with R2’s San Joaquin County Behavioral Health team to provide R2 with the necessary support. Allegation: Staff did not provide incident report to resident's authorized representative IB inquired about the facility’s alleged refusal to provide the associated incident report to R1’s LPS conservator, Sharon McLaughlin. Sharon was interviewed and stated she reached out to the facility and Administrator, Momo Duoa, multiple times from 12/6/2024 to about 1/8/2025. According to the Unusual Incident Report (UIR), the facility contacted Sharon on 12/3/2024. Administrator Momo Duoa was asked about Sharon’s efforts to obtain the UIR and Momo had no recollection of Sharon’s requests. Sharon also spoke with an EverWell Health Systems staff named Martha (unknown) who was unable to assist her with her request. 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 violation occurred.the state’s words, verbatim · CDSS document, Apr 18, 2025 · control 27-AS-20250110155806

Allegation investigated: Staff did not seek medical attention for a resident in care. Staff called a resident an inappropriate name.

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to deliver findings for the above allegations. During the investigation the department reviewed documents, interviewed staff and residents. Based on this information the department was able to confirm that the facility schedules appointment for residents and provides transportation as well. R1 reported that he has been having chest pains and wants to see a physician. R1 reported that the staff told him that they cannot make an appointment on his behalf. R1 further reported that when he asked the staff if they can take him to the hospital, the staff member said "no I don't want to." Continued Unsubstantiated The department was unable to determine the date of the event that the alleged refusal for medical services did occur and R1 was not able to provide a date when this event was alleged to have taken place. The alleged events were to have taken place on the same day which includes staff calling R1 an inappropriate name. The Department reviewed dates and times for scheduled appointments for 2024 including medical, dental and podiatry appointments. 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 violation occurred.the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 27-AS-20241002120745

Type of visit: Case Management - Other

LPA Johnson and Lund arrived unannounced and met with the Administrator who assisted LPA with the visit. The purpose of this visit was to follow up on a request by the department to review the new admits to the facility and plan correction. LPA's toured the facility to follow-up on the verbal advisories given during the annual inspection and continued inspection on 12/3/2024 and 12/6/2024. The facility presented a work order for a resident bathroom across from room #2 and #3 that was dated 11/22/2024 for a clogged toilet. Today the door was unlocked and accessible to residents. Also observed were buildings and grounds violations including kitchen cleanliness with food behind the stove, food with out expiration dated, and broken blinds in multiple rooms. LPA conducted records review of resident roster and staff roster and obtained copies. Citation given as a result of this visit. Exit interview conducted and appeal rights given.the state’s words, verbatim · CDSS document, Dec 18, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Dec 18, 2024

(a) 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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by observation and photos taken. The facility presented a work order for a resident bathroom across from room #2 and #3 that was dated 11/22/2024 for a clogged toilet. Today the door was unlocked and accessible to residents. Also observed were buildings and grounds violations including kitchen cleanliness with food behind the stove, food with out expiration dated, and broken blinds in multiple rooms.the state’s words, verbatim · CDSS document, Dec 18, 2024

Plan of correction: The facility will complete the work orders for the items presented to the department 12/6/2024. The facility will provide the department with a cleaning schedule for daily, weekly and monthly task.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced Case Management annual continuation visit today to assess civil penalties for citation cited during the annual visit on 12/03/2024. LPA Johnson was met by Momo to explain the purpose of today's visit. The LPA continued with the facility visit to ensure there are no health and safety hazards and review of fire drills and kitchen cleaning schedule and (Advisories given). Fire drill was conducted on 9/17/24. Per California Code of Regulations, Title 22 Division 6, Chapter 8, Type A deficiencies were observed on 12/3/2024 and cited during that visit. Civil penalties for those violations were assessed on today's annual continuation visit. Exit interview held with the acting Administrator Momo and a copy of the report was given at the conclusion of the visit.the state’s words, verbatim · CDSS document, Dec 6, 2024

Type of visit: Required - 1 Year

On this date 12/3/2024, Licensing Program Analyst (LPA) Albert Johnson and Licensing Program Manager (LPM) Lisa Rios arrived unannounced to conduct an annual inspection. LPA met with Administrator and explained the purpose of the visit. LPA, LPM and Administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. Observed during the tour were sufficient furniture and lighting throughout the facility. Observed during the tour was sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 106 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. During the tour of the kitchen LPA, LPM and Administrator observed an outdated Ansul system. The system required service on 11/14/24. Fire extinguishers and smoke detectors/carbon monoxide detectors are operational. LPA, LPM and Administrator observed centrally stored medications are kept locked and inaccessible to residents. LPA, LPM and Administrator reviewed and compared resident medication vs. resident medication logs. During the medication review it was observed that medication counts are off and PRN medications are not stored as required. LPA, LPM and Administrator reviewed 15 resident and 10 staff files, including criminal record clearances. S1 is not associated. During the file review for the residents LPA, LPM and Administrator observed outdated services plan for three of fifteen residents. First aid kit was checked and is complete. Citation given pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted. Appeal rights and report given at conclusion of the inspection.the state’s words, verbatim · CDSS document, Dec 3, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Albert Johnson arrived at the facility unannounced to conduct a case management visit. LPA met with Staff and explained the purpose of the visit. Later joined by Momo Duoa. The facility has submitted the required information to appoint a new Administrator. The department reviewed the record of pending applications and confirmed that the information has been submitted to renew the certification of the appointed Administrator. No further action required.the state’s words, verbatim · CDSS document, Nov 14, 2024

Type of visit: Case Management - Incident

LPA Johnson arrived unannounced to conduct a complaint investigation and case management visit. LPA met with Administrator Kelly Stern and explained the purpose of the visit. LPA requested a tour of the facility, during the tour of the facility LPA and Administrator observed and photographed unlocked toxin/ cleaning supplies on the cleaning cart. The cart does lock and has a key; however, the locker area was being used to store paper supplies and not the cleaning product. (Citation given) The facility's buildings and grounds needed attention in two areas: the first area included the vents in the hallways have no filters and are covered with build-up dust (photos taken). Also observed throughout the facility were broken or missing blinds in several rooms including the T.V. Room. (Advisories given) The facility will not provide the department with copies of the resident face sheets. The facility stated that these are internal documents and only to be viewed and not copied for the department.(Citation given). LPA took photos of the face sheet to assist the investigation of the complaint. LPA was confronted about the photos and was told that the facility will not sign the reports. Because the LPA was observed taking photos of the face sheets. LPA asked Momo Duoa for copies of the facesheet again was told that a copy of the LIC 9020A was be provided. The form provided was not a LIC form but a facility form with similar information for all residents not the two residents that information was requested for R1 and R2. The citations are included on the attached 809D Page. An exit interview was conducted and a copy of this report and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 7, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Oct 8, 2024

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Based on observation, the licensee did not comply with the section cited above. LPA observed a cleaner unlocked on the cleaning cart unattended observed to be accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2024

Plan of correction: Licensee will provide training to new employees regarding this regulation cited and will provided the department with the attendees of this in-service by the POC date 10/8/2024 The department can be notified by email or fax with the required information request in the plan of correction.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87755(c) · Plan of correction due date: Oct 8, 2024

(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b). The facility will not provide the department with copies of the resident face sheets. The facility stated that these are internal documents and only to be viewed and not copied for the department. The facility offered a Licensing form 9120 in lieu of the face sheet.the state’s words, verbatim · CDSS document, Oct 7, 2024

Plan of correction: The facility will amend there program design to include the use of electronic files for staff and residents if this is the method to be used by the facility for evaluations, inspection or other business related to the licensed facility. The facility will also provide the department with an in-service for all staff to review the regulation 87755 Inspection Authority of the Licensing Agency. The department can be notified by email or fax with the required information request in the plan of correction.

Type of visit: POC

On 3/28/24, LPA Johnson arrived unannounced to conduct a plan of correction and case management visit. LPA met with Administrator T. Monge and explained the purpose of the visit. The following deficiencies, initially cited during a visit on 03/13/2024, have been cleared: Section Cited: 87465(I) Date Due: 03/28/2024. Plan of Correction: The facility will provide training to all med-tech on medication records and destruction of medication with documentation by 3/28/2024. The training will be included in the med-techs file. Corrections: Cleared by Visit Clearance Date: 03/28/2024. The facility confirmed that the in-service have been conducted and the information will be in the med-tech's files for review by the department during visits. The department received two incident reports with information regarding two visits on two separate occasions to the emergency room for R1 and R2. R1 was discharged back to the facility with the standard recommendation to follow-up with primary care provider within 1 to 3 days. No medication changes. R2 was discharged back to the facility with a new medication. The new medication has been started and the standard recommendation to follow-up with primary care provider within 1 week has been recommended. An exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 28, 2024

Allegation investigated: Staff do not ensure unused medications are properly disposed of

Licensing Program Analyst (LPA) Albert Johnson arrived at facility on 3/13/2024 unannounced to deliver findings for the above listed allegation. LPA Johnson met with Gina and explained the purpose of today's visit. Later joined by Tina Perez. Based on records reviewed and interview with Med-tech, the facility is disposing of medications and using the medication destruction record form, However the facility is not following 87465 Incidental Medical and Dental Care. (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Substantiated Both shall sign a record, to be retained for at least three years. The facility records confirm that there is one signature but no witness signature on 7 of 7 forms reviewed. The above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D.the state’s words, verbatim · CDSS document, Mar 13, 2024 · control 27-AS-20231023100256

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(I) · Plan of correction due date: Mar 28, 2024

(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. This requirement is not met as evidence by the facility records confirm that there is one signature but no witness signature on 7 of 7 forms reviewed.the state’s words, verbatim · CDSS document, Mar 13, 2024

Plan of correction: The facility will provide training to all med-tech on medication records and destruction of medication with documentation by 3/28/2024. The training will be included in the med-techs file.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff does not treat resident with respect

On 03/06/2024 at 09:30 AM, Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced facility visit to open a complaint investigation. LPA Campbell met with Leah Zubiate, Director of Clinical Relations and explained the purpose of today's visit. It was alleged that staff did not treat residents with respect. Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated. LPA Campbell conducted an interview with the reporting party (RP) who requested that the complaint be retracted. The RP stated they were having a bad day and that they can no longer remember the details of the inciting incident. Also, of the 5 residents interviewed, LPA Campbell received no reports that staff had not treated them with respect. Therefore, the above listed allegation is found to be UNSUBSTANTIATED. UNSUBSTANTIATED complaint findings mean that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies issued per Title 22 regulations. Exit Interview. Copy of report provided to facility representative. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 6, 2024 · control 27-AS-20240227153938

Allegation investigated: Staff are verbally abusive to resident(s) in care.

Licensing Program Analyst (LPA) Albert Johnson arrived at facility on 2/07/2024 unannounced to deliver findings for the above listed allegation. LPA Johnson met with Tanya Monge and explained the purpose of today's visit. Later joined by Laura Li (CAO) Based on this site visit, overhearing staff engaging with a resident that was escalating and the lack of support that the resident was receiving, the department has determined that S2 in the lunchroom did not use a professional tone to de-escalate a resident. LPA had to address the staff and inform her to stop the back and forth with the resident. S2 stated that he the resident will keep going and going. LPA stated to S2 that is why you let him go on his way and not say anything. LPA reported this to the CAO. The above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D. Substantiatedthe state’s words, verbatim · CDSS document, Feb 7, 2024 · control 27-AS-20231011115928

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Feb 22, 2024

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by observation and intervention by LPA Johnson. This is a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 7, 2024

Plan of correction: Licensee is to ensure that all in-service training are documented and residents' personal rights are upheld at all times. Please submit a letter of understanding and a copy of the completed in-service training to include date and signatures of trainer and attendees by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Albert Johnson arrived at facility on 2/07/2024 unannounced to follow-up on information requested by the department on 10/16/2024 and information received by the department. LPA Johnson met with Tanya Monge and explained the purpose of today's visit. Later joined by Laura Li (CAO) Chief Administrative Officer. The department received information regarding internal instruction to "not attempt any patient lifting as to avoid any potential back injuries."Based on records reviewed and interviews with staff the facility is using protocols to minimize the potential for additional injuries to the residents after a fall. The facility provides staff with training through on-line services, this happens during their initial hiring and on-going training. These training include procedures for assessing residents after a fall witnessed or not witnessed. The facility is following the personnel requirements for training under the Title 22 regulations as it relates to 87411 personnel requirements for a Residential Care facility for the Elderly. No deficiencies cited. As for the follow-up on requested information for S1. The information was requested for on 10/16/2023, the information was never given. The facility sent an email to the department requesting clarification as to the reasoning for the request of information for a staff. The request is based on inspection authority and will assist in the findings for the allegations listed in the complaint report. Continued The department is requesting S1 and S2's file including any corrective actions or coaching. The facility did not have the records available for review as required by 87412 personnel records. During the request for information for S1, information was shared with the department that S1 resigned. After talking with the CAO at approximately 12:50pm, the facility attempted to provide the department with a electronic file for S1, However the electronic file was missing information including why the staff resigned or was terminated. Deficiencies cited. An exit interview was conducted and a copy of this report with appeal rights given.the state’s words, verbatim · CDSS document, Feb 7, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87755(c) · Plan of correction due date: Feb 8, 2024

87755 Inspection Authority of the Licensing Agency(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement was not met as evidenced by the lack of records available for inspection after email sent to support the requested information from the LPA's visit on 10/16/2023. LPM Richardson on 10/18/2023 sent an email response to CAO Li confirming that the requested information is relevant to the outcome of this investigation of the allegations.the state’s words, verbatim · CDSS document, Feb 7, 2024

Plan of correction: The facility will amend there program design to include the use of electronic files for staff and residents if this is the method to be used by the facility for evaluations, inspection or other business related to the licensed facility. Please provide a date when the information to be revised will be updated by 2/8/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: Feb 21, 2024

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. This requirement was not met as evidenced by lack of records available for inspection on 10/16/2023 and again on this date including the reason for termination or the letter of resignation.the state’s words, verbatim · CDSS document, Feb 7, 2024

Plan of correction: The facility will amend there program design to include the use of electronic files for staff and residents if this is the method to be used by the facility for evaluations, inspection or other business related to the licensed facility. Additional please provide the requested information for S1 by 2/8/2024

Type of visit: Case Management - Incident

LPA Albert Johnson made an unannounced case management visit and to follow-up on the annual inspection completed on 11/08/2023 and an incident report for an AWOL (resident has not returned). The facility submitted an incident report dated 11/13/2023 detailing that R1 had signed out and did not return after curfew. R1's physician's report confirmed that she is able to go into the community unassisted. The facility has placed a bed hold with San Mateo County for R1. LPA was unable to obtain copies of the updated City business license expired 8/31/2023. Additionally the facility was not able to provide a copy of the Surety Bond for this business location. LPA was told that the department should have a copy in the facility file located at CDSS. Deficiencies are being cited today as a result of this case management visit. Copy of this report and appeal rights given. Exit interview conducted.the state’s words, verbatim · CDSS document, Nov 17, 2023

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.60(a) · Plan of correction due date: Nov 24, 2023

§1569.60 Surety bond requirement of licensees handing residents funds (a) The director shall require as a condition precedent to the issuance of any license for a residential care facility for the elderly, if the licensee handles or will handle any money of a person within the facility, that the applicant for the license file or have on file with the department a bond issued by a surety company admitted to do business in this state in a sum to be fixed by the department based upon the magnitude of the operations of the applicant, but which sum shall not be less than one thousand dollars ($1,000), running to the State of California and conditioned upon his or her faithful and honest handling of the money of persons within the facility. This requirement was not met as evidenced by records reviewed the information provided did not have the facility identifed as the insured.the state’s words, verbatim · CDSS document, Nov 17, 2023

Plan of correction: Licensee/ Administrator will get a copy of the surety bond with this facility identifed as the insured and will provide proof of current surety bond along with LIC400 to CCL by 11/24/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(2) · Plan of correction due date: Nov 24, 2023

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. The facility is operating with an expired business license expired 8/31/2023. This is a potential safety risk for residents in care.the state’s words, verbatim · CDSS document, Nov 17, 2023

Plan of correction: The Licensee/ Adminstrator will get a current copy of the business license from the City of Stockton and provide that information to the department by 11/24/2023.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Administrator Tanya Monge and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 108 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors/carbon monoxide detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 15 resident and 5 staff files, including criminal record clearances. All staff are fingerprinted and cleared. During the file review for the residents LPA observed 3 of 15 outdated service plans, two of the three plans were sent over to the facility with updated information from the main office during the inspection. First aid kit was checked and is complete. Fire drill was conducted on 6/20/2023. Citation given pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted. Appeal rights and report given at conclusion of the inspection.the state’s words, verbatim · CDSS document, Nov 8, 2023