Delta Shores Assisted Livimg

Type of visit: Case Management - Incident

On 09/09/26 at 2:24PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management visit and met with staff (ED, S1). LPA explained the purpose of the visit with staff. On 08/24/26, LPA received an unusual incident report which showed that resident (R1) was found unresponsive, pale and cold to the touch by staff while preparing to provide care on 08/23 at approximately 8:45PM.. 911 and local police were called. Police and fire department personnel arrived at approximately 9PM, initiated CPR and pronounced R1 deceased at 9:43PM. Family was notified by paramedics and R1's body was picked up by the funeral agency the same day. LPA interviewed the director of nursing (DN) who stated that on 08/20/26, staff observed R1 had altered mental state with confusion. Staff called 911 and R1 was admitted at the hospital with a diagnosis of neuropathic pain, given new medication and released the same day back to the facility. Review of R1's hospital discharge report dated 08/20/26 showed R1 was diagnosed with neuropathic pain. ED stated a copy of the coroner's report will be faxed to CCL once available.the state’s words, verbatim · CDSS document, Sep 9, 2026

Allegation investigated: Facility refused to accept resident back to facility after hospital visit

On 05/27/26 at 10:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (DN, MD), gathered information and delivered investigation findings to DN. LPA explained the purpose of the visit with staff. During investigation, the Department obtained the following documents from DN – Personnel record, Resident roster, R1's admission agreement, physicians reports, Needs & services plans, emails regarding R1's unsafe behavior and need for hospitalization, After discharge summary report, incident report. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Facility refused to accept resident back to facility after hospital visit Investigation Finding: Unsubstantiated On 05/27/26 at 10:30AM, LPA interviewed staff (DN, MD) who stated that dementia resident (R1) was sent to the hospital on 05/16/26 due to unsafe, aggressive behaviors towards staff and other residents as a result of her refusal to take her medications. R1 was admitted at the hospital with a diagnosis of altered mental state. Prior to R1's hospitalization, MD stated that she communicated with the hospital's Program Director (PD) and social worker (RP) via text messages on 05/15/26, alerting them that R1 may be sent to the hospital due to her unsafe behavioral expressions towards staff and other residents. MD stated she visited and assessed R1 on 05/19/26 and 05/26/26, discussed R1's unsafe behaviors with PD and RP and told them that R1 needs to take her medications so that staff can manage her behavioral expressions. R1 stayed at the hospital for 10 days and was safely released back to the facility on 05/26/26. DN stated R1 is currently taking her medications which allows staff to provide her with proper care and supervision. During visit, LPA observed R1 to be calm and comfortable in her surroundings while having lunch with other residents in the common dining area of the facility. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility refused to accept resident back to the facility after hospital visit was found to be unsubstantiated. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 27, 2026 · control 15-AS-20260521153649

Allegation investigated: Uncleared staff provided care to residents

On 04/30/26 at 4PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit, met with staff (ED, S1), gathered information and delivered investigation findings to ED. LPA explained the purpose of the visit with ED. On 04/30/26, LPA D Panlilio conducted interviews with reporting party (RP) and staff (ED, S) and obtained the following documents: Personnel record (LIC500), S1’s fingerprint clearance documents, job application, training certifications. Continued on next page, LIC9099-C Unfounded Allegation: Uncleared staff provided care to residents Investigation Finding: Unfounded During investigation, LPA D Panlilio conducted interviews with reporting party (RP) and facility staff (ED, S1) and reviewed staff (S1) documents. On 02/05/26, RP stated that HR staff (S1) informed her that she was fingerprint cleared in the Guardian Portal. RP stated she was hired on 02/05/26 and started working as a caregiver assisting residents with showers and activities of daily living from 02/17/26 to 04/15/26. On 02/17/26, the facility received a notice from the California Department of Social Services (CDSS), Care Provider Management Branch (CPMB) requesting the facility to complete and submit a criminal record exemption for S1 by 04/03/26. RP stated she submitted the completed exemption requirements to HR staff (S1) on 03/21/26. RP stated she was terminated on 04/15/26 because her criminal background clearance was rescinded. Review of S1’s background clearance documentation in the Guardian Portal showed S1 was fingerprint cleared and associated to the facility when she was hired on 02/05/26 and worked at the facility from 02/17/26 until 04/15/26 . Therefore, the allegation that uncleared staff provided care to residents is unfounded. No deficiency cited during visit. Exit interview conducted and a copy of this report providedthe state’s words, verbatim · CDSS document, Apr 30, 2026 · control 15-AS-20260429145308

Allegation investigated: Staff are not assisting resident with medications

On 03/18/26 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit, met with staff (ED, S1), gathered information and delivered investigation findings to ED. LPA explained the purpose of the visit with ED. On 03/03/26 and 03/13/26, LPAs P Manalo and D Panlilio conducted interviews with reporting party (RP), resident (R1), staff (ED, S1, S2) and obtained the following documents: Personnel record (LIC500), Residents roster, R1's admission agreement, appraisals /needs & services plan, physician's report, progress notes, centrally stored medication logs, medication administration records and incident reports. Continued on next page, LIC 9099-C Substantiated Allegation: Staff are not assisting resident with medications Investigation Finding: Substantiated During investigation, LPAs P Manalo and D Panlilio conducted interviews with reporting party (RP), resident (R1) and facility staff (ED, S1, S2) and reviewed resident (R1) documents. On 03/03/26, LPA P Manalo interviewed RP who stated that staff were not assisting R1 with his Lovenox injections. RP stated that the injection requires two working hands, one to pinch subcutaneous fat and the other to inject the medication. RP stated R1 can only use one hand due to a weakness in his left hand. RP stated that he spoke with S1 who assured him that staff would assist R1 with the injection. However, when RP spoke with R1 again, R1 told him that he had to inject the medication himself and that staff just handed him the injection. S2 confirmed with LPA that staff only handed R1 the injection and let him administer the injection himself. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff are not assisting resident with medications was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided. Allegation: Staff are not ensuring resident’s medical needs are met Investigation Finding: Unsubstantiated During investigation, LPAs P Manalo and D Panlilio conducted interviews with reporting party (RP), resident (R1) and facility staff (ED, S1, S2) and reviewed resident (R1) documents. RP stated R1 did not have a hospital bed upon admission at the facility on 02/06/26. On 03/03/26, LPA P Manalo confirmed with staff (Marketing, S2) that R1 did not have a doctor’s order for a hospital bed with rails on admission because they were waiting for Medi-Cal to complete R1’s paperwork for the transfer. RP told LPA that the facility provided R1 with the hospital bed with rails on 02/07/26. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff are not ensuring resident’s medical needs are met is unsubstantiated. Allegation: Due to lack of supervision, resident was hit by another resident Investigation Finding: Unsubstantiated During investigation, LPAs P Manalo and D Panlilio conducted interviews with reporting party (RP), resident (R1) and facility staff (ED, S1, S2) and reviewed resident (R1) documents. Review of incident reports dated 02/25/26 and 03/01/26 showed R1 had an argument with another resident (R2) while eating breakfast in the dining room. R2 punched him in his right eye when R1 tried to stop R2 from grabbing his wheelchair. Both incidents showed staff redirected R1 and R2, called 911 for R1 to be evaluated and treated at the hospital. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff failed to supervise resident is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 15-AS-20260226101220

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 18, 2026

To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by staff failing to assist resident with medications which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: Deficiency corrected on 02/28/26. Director of Nursing (DN) conducted in-service retraining with all Med Techs on proper procedure in assisting residents with injections.

Type of visit: Case Management - Other

On 03/03/2026 at 3:55 PM, Licensing Program Analyst (LPA) P. Manalo conducted an unannounced case management visit. LPA met with Administrator (ADM) Jared Pickard, and explained the purpose of the visit. While LPA was at the facility for another visit, LPA observed multiple laundry tower machines in the front desk area. Interview with ADM revealed that the machines are placed there temporarily and will be installed by the corporate maintenance team by the end of the week. LPA is requesting for facility to submit proof of the machines removed from the front desk area by 03/09/2026. No deficiencies cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 3, 2026

Type of visit: Required - 1 Year

On 01/30/25 at 02:30PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. ADM has current administrator certificate# 6077625740 which expires on 06/05/2027. At 02:55PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 74 deg F. Hot water temperature was measured at 117 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 5 staff and 5 resident files. Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 25, 2026

Allegation investigated: Staff do not ensure that resident has clean laundry

On 02/18/2026 at 10:20am, Licensing Program Analyst (LPA), Carol Fowler arrived unannounced to deliver complaint findings for the allegations above. LPA met with Jared Pickard, Administrator and explained the reason for the visit. During the investigation LPA interviewed W1, S1, S2, S3, S4 and S5. LPA reviewed facility and Staff Roster, Physician Reports, Care Notes, and Laundry Schedule. CONTINUE ON LIC 9099C Substantiated CONTINUE FORM LIC 9099A Allegation: Resident sustained an unexplained injury Investigation Finding: unsubstantiated. During the investigation, the LPA interviewed W1, S2, and S3. Interview with W1 revealed that W1 was concerned about an injury on R1s leg and was upset no one knew where the injury came from. Interview with S2 revealed that R1 had a couple of injuries that came from repositioning R1, S2 stated that R1 had a couple skin tears on R1s arm and leg. Interview with S3 revealed that R1 has an area on R1s leg that S3 felt like it came from the Hoyer lift, S3 stated that S3 was the one that reported the injury, and the family was aware. THEREFORE THIS ALLEGATION IS UNSUBSTANTIATED. Allegation: Staff are not adequately trained Investigation Finding: unsubstantiated. During the investigation LPA interviewed W1, S2 , S3, S4 and S5. W1 expresses concerns that the facility staff are not trained to take came of the residents. LPA conducted a record review which revealed that all staff has been trained and also continues attending in-service training's. Interview with S2 revealed that S2 had yearly annual training's and in-service training's as well. Interview with S3 revealed that the facility has training's annual training and in-service, S3 also stated that the facility had a lot on non-english speaking staff but the training's were being translated for them as well. Interview with S4 revealed that S4 is a CNA (certified Nursing Assistant) and S4 has training's to keep S4 certificate current. S4 also stated that the facility also has in-service training. S5 stated that the facility has training, video training and in-service training. THEREFORE THIS ALLEGATION IS UNSUBSTANTIATED. CONTINUE FROM LIC 9099C Allegation: Facility is in disrepair Investigation Finding: unsubstantiated. During the investigation LPA interviewed W1, S2, S3 and S4. W1 reported Concerns with a hole in the wall located in R1s room, W1 reported that W1 didn’t know how the hole got there and it needed to be repaired. LPA conducted a tour and the hole in the wall had been repaired. Interview with S2 revealed that the family brought a lot of furniture and R1s room was a small room, S2 stated that S2 is not sure if it was the furniture or R1s bed that made the hole in the wall but it was repaired within a week. Interview with S3 revealed that the family reported the hole to S3 and S3 reported the hole to the Administrator. S3 stated that S3 feels that the hole in the was might have been caused by R1s bed hitting against the wall when R1 was being transferred on the Hoyer lift. S3 stated that the facility fixed the hole after maybe a month. Interview with S4 revealed that S4 stated that the walls are so thin that the hole in the wall could have come from the door, and the facility repaired it fast. THEREFORE THIS ALLEGATION IS UNSUBSTANTIATED. Allegation: Staff do not ensure that resident is appropriately dressed Investigation Finding: unsubstantiated. During the investigation LPA interviewed W1, S2, S3 and S4. W1 reported Concerns regarding the way R1 was dressed and felt R1 should have been dressed better. Interview with S2 revealed that S2 had never seen R1 not dressed appropriately, however the family would complain but the family would bring R1s clothes to wear. Interview with S3 revealed that R1s family brought clothes for R1 to wear and that family would complain in R1s socks didn’t match. S3 stated that R1 would always be wearing sweats with a t-shirt and the matching jacket and sometime a hat because R1 would be cold. S3 also stated that the family would come in and would wash R1 up and change R1s clothes. S3 also stated that R1 was always clean and dress appropriately. Interview with S4 revealed that R1 was always dressed well and the family would bring good clothes for R1. S4 stated that R1 was always taken real good care of. THEREFORE THIS ALLEGATION IS UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided. CONTINUE FROM LIC 9099 Allegation: Staff do not ensure that resident has clean laundry Investigation Finding: unsubstantiated. During the investigation LPA interviewed W1, S1, S2, S3, S4 and S5. W1 reported Concerns regarding laundry services. W1 reported that R1s laundry would pile up and the family would have to take the laundry home to wash. Inter with S1 revealed that when S1 arrived at the facility there was no laundry department and knows that there was an issue with the laundry services S1 also stated that the company has purchased 6 new washers and dryers, 3 for the 1st floor laundry room and 3 for the second-floor laundry room. S2 Interview revealed R1s family would complain about the laundry. S2 also stated that the facility has only 2 washers and 2 dryers and they were not working well and there was only staff that washed laundry in the mornings. S2 stated that the facility was short staffed during that period of time. Interview with S3 revealed that laundry was always a problem, the facility was short staffed, and the laundry was overflowing and if you needed something washed you would have to go to the laundry room to ask the staff to wash the item for you. Interview with S4 revealed that the facility had a problem with the washer and dryer and at one time the facility rented washers and dryers, S4 stated that staff was always complaining about the laundry. Interview with S5 revealed that there is 2 washers and 2 dryers and they have problems, S5 also stated the facility has bought new washers and dryers and they should be delivered today 2/18/2026. THIS ALLEGATION IS SUBSTANTIATED.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 15-AS-20241104113626

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(F) · Plan of correction due date: Mar 6, 2026

87307 Personal Accommodations ... (a) Living accommodations and grounds shall be ...function. The facility shall... provide comfortable ... residents, staff, and ... The following provisions shall apply: (F) Basic laundry service (washing, drying, and ...). Based on interviews and observation, licensee did not comply with the section cited above by not having timely basic laundry services, not replacing washers and dryers and hiring additional laundry staff.the state’s words, verbatim · CDSS document, Feb 18, 2026

Plan of correction: Administrator agreed that the facility will purchase new washer and dryers and provide the department with a copy of purchase order and photos of the new machines once installed.

Allegation investigated: Facility staff do not ensure that residents are provided with activities

On 02/18/26 at 5PM, Licensing Program Analyst (LPA) D Panlilio conducted a complaint visit, met with staff (ED, S1, S2), gathered information and delivered investigation finding to ED. LPA explained the purpose of the visit with ED. On 02/18/26 at 5:15PM, LPA conducted interviews with staff (ED, S1, S2) and residents (R1, R2, R3, R4) and obtained the following documents: Personnel record (LIC500), Residents roster, monthly activities schedules. Continued on next page, LIC9099-C Unsubstantiated Allegation: Facility staff do not ensure that residents are provided with activities Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with residents (R1, R2, R3, R4) and facility staff (ED, AD, RA1, RA2, RA3) and reviewed recreational activities' February and March 2026 daily schedules. ED stated they have an Activities Director (AD) and Recreational Assistants (AD, RA1, RA2, RA3) who engage residents in daily recreational activities such as current event, sit & fit, bingo, music, Karaoke, trivia games, balloon toss, corn hole, movie nights, puzzles, exercise, arts & crafts. AD stated there are three recreational assistants (RA1, RA2, RA3) who help residents participate in the facility’s daily recreational activities. At 5:10PM, recreational staff (AD, RA1, RA2, RA3) confirmed with LPA that they inform residents of the monthly recreational schedules by posting them inside their bedrooms as well as in the activities area to allow them the opportunity to participate in the daily recreational activities. Residents (R1, R2, R3, R4) stated they participate in the facility’s daily recreational activities while other residents prefer to smoke outside or rest inside their rooms. Review of facility’s monthly recreational activities’ schedule showed a variety of activities such as bingo, exercise, arts & crafts, movie nights, balloon toss, Karaoke, trivia games, puzzles, nail coloring, pool noodle toss, sip & paint offered for residents to participate in. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that facility staff do not ensure that residents are provided with activities is unsubstantiated. No deficiencies cited during visit. Exit interview conducted and a copy of this report providedthe state’s words, verbatim · CDSS document, Feb 18, 2026 · control 15-AS-20260217164311

Allegation investigated: Staff do not treat resident with respect Staff do not intervene when residents bully other residents

On 02/18/26 at 4PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit, met with staff (ED, S1), gathered information and delivered investigation findings to ED. LPA explained the purpose of the visit with ED. On 02/12/26 at 2:15PM, LPA conducted interviews with staff (ED, S1, S2, S3, S4, S5, S6) and residents (R1, R2, R3, R4) and obtained the following documents: Personnel record (LIC500), Residents roster, R1's admission agreement, appraisals /needs & services plan, physician's report, progress notes, centrally stored medication logs, medication administration records and incident reports. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Staff do not treat resident with respect Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP), residents (R1, R2, R3, R4) and facility staff (ED, S1, S2, S3, S4, S5, S6) and reviewed resident (R1) documents. Staff (ED, S1, S2, S3, S4, S5, S6) denied calling R1 derogatory remarks and did not witness other residents bully him. R3 stated she has been living at the facility since July 2025 and is constantly with R1 eating their daily meals at the common dining hall and participating in recreational activities together with other residents and staff. R3 stated she did not witness any resident or staff call R1 names or bully him. R3 stated that R1 is experiencing paranoia and would not listen to her. ED and S6 also stated they did not observe any resident or staff calling R1 derogatory remarks or bully him while in care. Other staff (S1, S2, S3, S4, S5) and residents (R2, R3, R4) denied making derogatory remarks towards R1 or harass him. RP also stated that she did not observe R1 being called derogatory names or being bullied by staff during visits. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff do not treat resident with respect is unsubstantiated. Continued on next page, LIC 9099-C pg1 Allegation: Staff do not intervene when residents bully other residents Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP), residents (R1, R2, R3, R4) and facility staff (ED, S1, S2, S3, S4, S5, S6) and reviewed resident (R1) documents. Staff (S1, S2) stated they would greet R1 at the start of their recreational activities with “Good Morning, how are you” and he would get agitated and reply back to them that they were calling him derogatory remarks and bullying him. Staff denied calling him names or bullying him. Staff (S1, S2, S3, S4, S5, S6) stated they always intervene and redirect residents whenever there is an argument or agitation among residents. R3 stated she is with R1 at the facility during meals and recreational activities daily. She stated she did not observe any resident or staff call R1 names or bully him. Other residents (R2, R3, R4) also stated that they did not witness any resident or staff bully R1 or call him names. Review of incident reports dated 01/20/26 and 02/11/26 showed staff intervened and redirected aggressive residents from other residents and staff notified responsible parties, primary care physicians and called 911 for evaluation and treatment. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff do not intervene when residents bully other residents is unsubstantiated. No deficiencies cited during visit. Exit interview conducted and a copy of this report providedthe state’s words, verbatim · CDSS document, Feb 18, 2026 · control 15-AS-20260205121421

Type of visit: Case Management - Other

On 12/02/25 at 12PM, LPA D Panlilio conducted an unannounced case management visit to deliver an immediate exclusion to staff (S1) from facility for conduct inimical. LPA met with administrator (ADM) and explained the purpose of the visit. At 12:11PM, ADM stated that S1 only works on call and has not been called in the past two months to work at the facility. ADM stated he will deliver immediate exclusion letter to S1 and terminate her employment effective 12/02/25. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 2, 2025

Allegation investigated: Staff neglect resulted in resident hospitalization

On 11/19/25 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the finding of above allegation. LPA explained the purpose of the visit with ADM. During investigation, the Department obtained the following documents from administrator – personnel record, residents’ roster, admission agreement, physicians report, Needs & services plans, centrally stored medication logs, hospital discharge summary reports, incident reports Continued on next page, LIC 9099-C Substantiated Allegation: Staff neglect resulted in resident hospitalization Investigation Finding: Substantiated During investigation, the Department reviewed resident’s (R1) medical records which showed R1 was admitted to the hospital twice (08/02/24 and 08/06/24) in one week due to heat exposure. On 08/02/24 at approximately 1800 hours, R1 was found outside the facility lying on concrete for an unknown period of time. It was noted that it was nearly 100 degrees Fahrenheit that day. 911 was called and emergency Medical Services (EMS) recorded R1’s body temperature at 107degrees Fahrenheit. R1 was transported to the hospital where he was admitted and diagnosed with heat exposure. On 08/06/24 at approximately 1630 hours, R1 was found by staff outside the facility on his wheelchair unresponsive. 911 was called and staff administered Cardiopulmonary resuscitation (CPR) until EMS personnel arrived. R1 had a weak pulse with his body hot to the touch. It was noted that it was also very hot outside that day with temperatures close to 100 degrees Fahrenheit. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff neglect resulted in resident hospitalization was found to be substantiated. On 7/30/25 S1 was interviewed and reported that on 8/2/24 S1 noticed from the medication room monitor that R1 was lying down outside of the patio area and believed that he had been on the ground for 45 minutes. S1 further stated that R1 was hot to the touch and that S1 had called for assistance but none responded to the calls and that other staff remained “sitting around.” S1 also reported that on 8/6/25 that R1 was found by non-caregiver staff outside in R1’s wheelchair. S1 came out to check R1 and found R1 to be unresponsive and not breathing. S1 stated that care staff neglected R1 because he had previously been hospitalized for being left outside. Immediate civil penalty of $500 assessed during visit. Additional civil penalty determination is pending relating to this complaint. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 15-AS-20240807122234

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 19, 2025

Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs… This requirement was not met as evidenced by R1 being left outside unattended during hot weather for extended amounts of time, resulting in R1 twice requiring hospitalization, which poses an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: Immediate civil penalty of $500 assessed during visit. Non compliance meeting (NCC) will be scheduled. By POC due date, Administrator agreed to complete and submit in-service staff training on proper care and supervision of residents in compliance with Title 22 Section 87468.2 (a)(4)

Allegation investigated: Staff mismanaged resident’s medications Staff did not attend to resident’s call for help

On 11/07/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with staff (Director of Nursing (DN); Care Director (CD)) to deliver findings of above allegations. LPA explained the purpose of the visit with staff. During investigation,LPA conducted interviews with staff, toured the facility and obtained the following documents: Personnel record (LIC500), Residents roster, admission agreements, appraisals /needs & services plan, physician's reports, incontinence records, centrally stored medication logs, medication administration records, incident reports. Continued on next page, LIC 9099-C Substantiated Allegation: Staff mismanaged resident’s medications Finding: Substantiated During investigation, LPA interviewed reporting party (RP), facility staff (ADM, S1) and reviewed resident’s (R4) documents. Review of R4’s admission agreement, centrally stored medication logs and medication administration records showed he was first admitted at the facility on 09/11/25 coming from a skilled nursing facility (SNF). On 09/16/25, staff informed R4 that his prescribed medication had run out. Staff (ADM, S1) confirmed with LPA that they failed to follow up with R4’s primary care physician on his prescription refill requirements. Based on interviews and observations which were conducted, the preponderance of evidence standard has been met and the above allegation(s) that staff mismanaged resident’s medications is substantiated. Allegation: Staff did not attend to resident’s call for help Finding: Substantiated During investigation, LPA interviewed reporting party (RP/ Ombudsman (OMB)), facility staff (ADM, S1) and residents (R1, R2). On 09/17/25, RP/Ombudsman witnessed a resident (R1) in Room #207 shouting for help at 3:10PM. RP/OMB informed housekeeping who was cleaning a room on the 2nd floor who called the front desk for help with no staff response. At 3:53PM, RP/OMB informed staff on the 1st floor that R1 needed assistance. RP/OMB stated staff finally arrived around 3:55PM and helped R1. On 09/24/25, ADM confirmed with LPA that residents do not have a call button device available to alert staff for assistance when needed. Based on interviews and observations which were conducted, the preponderance of evidence standard has been met and the above allegation(s) that staff did not attend to resident’s call for help is substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal rights and a copy of this report provided. Allegation: Staff left residents in soaked bedding Finding: Unsubstantiated During investigation, LPA interviewed reporting party (RP), staff (ED, S1, S2), random residents (R1, R2, R3, R4) and reviewed residents’ documents. Staff (ADM, S1, S2) denied leaving residents in soaked or soiled bedding. S1 stated staff conducts daily care rounds per shift to assist residents with toileting, showering, changing diapers/linens/clothing as needed. Review of residents’ weekly incontinence records dated 08/01/25 until 10/31/25 showed staff provided assistance with residents’ ADLs which included assisting with incontinence care (3X to 4 X per day or as needed), changing wet linens/beddings, toileting, transferring, showering, dressing, grooming, medications, meals and doctors’ appointments. During unannounced visits on 07/03/25 and 08/11/25, LPA observed residents to be clean, well-groomed, odor free and comfortable in their surroundings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation that staff do not ensure that resident’s incontinence needs are met is unsubstantiated Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 7, 2025 · control 15-AS-20250919120610

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(1) · Plan of correction due date: Dec 5, 2025

There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation. This requirement was not met as evidenced by staff mismanaging resident’s medication which posed a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Nov 7, 2025

Plan of correction: By POC due date, ADM agreed to complete and submit to CCL in-service staff retraining certifications on residents’ medication management in compliance with Title 22 Section 87465 (c) (1).

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(4) · Plan of correction due date: Dec 5, 2025

To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by staff did not attend to resident’s call for help which posed a potential health & safety risk to resident in carethe state’s words, verbatim · CDSS document, Nov 7, 2025

Plan of correction: By POC due date, ADM agreed to complete and submit to CCL in-service staff retraining certifications on residents’ personal rights in compliance with Title 22 Section 87468 (a) (4).

Type of visit: Case Management - Incident

On 08/08/25 while at the facility for another reason, LPA D Panlilio conducted an unannounced case management visit and met with staff (ED, DN). LPA explained the purpose of the visit with staff. At 3:30PM, LPA discussed the self reported incident report dated 08/04/25 with staff (ED, DN) where resident (R1) was found by staff on the floor face down with brownish fluid all over the floor around 3:23PM on 08/01/25. R1 was unresponsive and 911 was called. Staff was instructed to start CPR and when paramedics arrived, they took over. R1 was pronounced deceased by paramedics at 3:43PM. Director of Nursing (DN) stated that she talked to R1 around 1PM that day and he looked OK. DN will submit copy of death report to CCLD when available. LPA also discussed another incident regarding resident (R2) who managed to exit the facility without staff knowledge on 08/02/25 around 9:47PM. Antioch police called the facility and reported that R2 was found wandering the neighborhood and was sent to Sutter Delta hospital for evaluation. R2 safely returned back to the facility from the hospital with no injuries the same day. During visit, LPA observed R2 walking around the main hallway in good spirits and comfortable in his surroundings. He was observed well groomed and odor free. ED stated a new security code has been implemented for the exit door and increased monitoring of all residents. No deficiencies cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 11, 2025

Allegation investigated: Staff inappropriately pushed a resident while in care Staff inappropriately restrained a resident while in care

On 07/03/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit, met with staff (ED, S1), gathered information and delivered investigation findings to ED. LPA explained the purpose of the visit with staff. During investigation, LPA obtained the following documents from executive director – Personnel record (LIC500), Residents roster, admission agreement, reappraisals, needs & services plan, physician's report, centrally stored medication logs, medication administration records, incident reports. Continued on next page, LIC 9099-C Substantiated Allegation: Staff inappropriately pushed a resident while in care Investigation Finding: Substantiated During investigation, LPA conducted interviews with, reporting party (RP), third party witness (W1) and facility staff (ED, S1, S2) and reviewed resident (R1) documents. Review of R1’s records showed he was first admitted at the facility on 02/28/24. R1 was assessed as having dementia, non-ambulatory and needs total assistance with bathing, dressing and behavioral expressions. LPA interviewed ED and W1 who confirmed that the incident occurred on 05/20 at 2PM wherein staff (S2) inappropriately pushed R1 against a wall while in care and that S2 was written up by ED. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated. Allegation: Staff inappropriately restrained a resident while in care Investigation Finding: Substantiated During investigation, LPA conducted interviews with, reporting party (RP), third party witness (W1) and facility staff (ED, S1, S2) and reviewed resident (R1) documents. RP and W1 stated that on 05/20/25 at 2PM, staff (S2) inappropriately restrained R1 by holding him against a wall. ED confirmed with LPA that staff (S2) was internally investigated and was written up for inappropriately restraining R1. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 3, 2025 · control 15-AS-20250528222146

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jul 25, 2025

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 requirement was not met as evidenced by staff inappropriately pushing resident which posed a potential health & safety risk to resident in carethe state’s words, verbatim · CDSS document, Jul 3, 2025

Plan of correction: By POC due date, ED agrees to complete and submit to CCLD in-service staff retraining by a certified vendor on proper redirecting of resident in compliance with Section 87468.1(a)(3).

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jul 25, 2025

To be accorded dignity in their personal relationships with staff, residents, and other persons This requirement was not met as evidenced by staff inappropriately restraining a resident which posed a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 3, 2025

Plan of correction: By POC due date, ED agrees to complete and submit to CCLD in-service staff retraining by a certified vendor on personal rights of resident in compliance with Section 87468.1(a)(1).

Type of visit: Case Management - Incident

On 07/03/25 while at the facility for another reason, LPA D Panlilio conducted an unannounced case management visit and met with executive director (ED). LPA explained the purpose of the visit with ED. At 3:50PM, LPA discussed the self reported SOC341 with ED dated 06/30/25 where resident (R2) refused to take her routine medications because her PRN pain medication was not given at the same time by Med Tech (S4). Staff denied punching R2 in the face with a closed fist. Police was called twice and observed no visible injuries on R2's face. ED suspended S4 for 2 days and she returned back to work on 07/01/25 since internal investigation showed S4 did not punch R2 in the face with a closed fist. Other staff witnessed R2 throwing water and yelling at S4 during the incident. During visit, LPA checked on R2 and observed no visible injuries on her face. LPA observed R2 to be in good spirits and comfortable in her surroundings. No deficiencies cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 3, 2025

Allegation investigated: Facility is malodorous Facility is unsanitary

On 05/28/25 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (ED, S1, S2), gathered information and delivered investigation findings to ED. LPA explained the purpose of the visit with staff. During investigation, the department obtained the following documents from ED – Personnel record, Residents admission agreements, physicians reports, Residents’ roster, Needs & services plans, housekeeping schedules, staff training records, pest control records, incident reports. Continued on next page, LIC 9099-C Substantiated Allegation: Facility is malodorous Investigation Finding: Substantiated On 05/28/25 at 1PM, LPA toured the facility with ED and inspected common areas, kitchen, dining room, living room and 5 random bedrooms on the first and second floors (Rms#114A,117A, 119A, 205A, 208A/B). LPA smelled strong bad (feces) odors upon entry into Rms#117A and 119A. The smell of urine was also observed on the first floor common hallway. LPA observed poor ventilation inside the facility with musky odors in common areas, bedrooms and bathrooms. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated. Allegation: Facility is unsanitary Investigation Finding: Substantiated On 05/28/25 at 1PM, LPA toured the facility with ED and inspected common areas, kitchen, dining room, living room and 5 random bedrooms on the first and second floors (Rms#114A,117A, 119A, 205A, 208A/B). LPA observed dirty floors, walls and baseboards in common areas, dining room and living room. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided via email Allegation: Staff did not ensure the facility was kept free of pests Investigation Finding: Unsubstantiated On 05/28/25 at 2PM, LPA interviewed staff (S1, S2, S3) who stated that dementia resident (R1) called the police on 05/21/25 complaining about ants and roaches in his room. Staff (S1, S2, S3) stated that police arrived at the facility around 5PM on 05/21/25 and conducted a health check with R1 and inspected his bedroom. Staff stated police did not see any ants or roaches inside R1's bedroom or on his person. S2 confirmed with LPA that she was on duty that day and did not observe any ants or roaches on R1 or inside his bedroom. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure the facility was kept free of pests is unsubstantiated. Allegation: Staff are not properly trained Investigation Finding: Unsubstantiated During investigation, LPA reviewed staff’s training records from 01/01/25 until 05/01/25 which showed staff completed 20 hours of annual training which included reporting requirements, observation of residents and how to address residents’ changes in condition. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the staff are not properly trained and found it to be unsubstantiated. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not properly trained is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 28, 2025 · control 15-AS-20250521134034

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Jun 30, 2025

Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met as evidenced by bad odor in bedrooms & bathrooms which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: By POC due date, ED agreed to have common areas, bedrooms, bathrooms, kitchen, living & dining rooms deep cleaned by a professional company and submit a copy of completed cleaning receipt to CCLD. In addition, ED agreed to complete and submit to CCLD in-service house staff retraining on proper cleaning procedures implemented daily at the facility for cleanliness maintenance.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(a)(2)(A) · Plan of correction due date: Jun 30, 2025

Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. This requirement was not met as evidenced by dirty facility which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: By POC due date, ED agreed to complete and submit to CCLD in-service house staff retraining on proper sanitation practices on a regular basis to ensure facility is safe and sanitary.

Type of visit: Case Management - Other

On 03/07/25 at 2PM, LPA D Panlilio arrived unannounced to conduct a case management visit regarding change in ownership and met with new executive director/administrator (ED). LPA explained the purpose of the visit with ED. Facility's administrator has a current certificate # 6075477740 which expires 02/05/2027. At 2:10 PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. LPA observed several benches available for use by residents in the backyard. Facility has sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 73 deg F. Hot water temperature was measured at 110.5 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator (ED). Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 7, 2025

Allegation investigated: Residents sustained injuries due to lack of supervision Resident fell out of wheelchair due to lack of supervision Facility staff did not seek medical attention for resident Facility staff hit resident on the hand Facility staff ignored request for help from resident Facility staff did not meet incontinence needs of residents Facility staff did not receive the required on the job training Facility staff did not provide activities for residents

On 01/30/25 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM. During investigation, the department obtained the following documents from ADM – Personnel record, Residents roster, admission agreements, physician's reports, reappraisals/assessments, Needs/Services plans, ID/Emergency information, hospital discharge summary reports, Staff training records, resident activities schedules, incident reports. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Residents sustained injuries due to lack of supervision Investigation Finding: Unsubstantiated During investigation, the department interviewed staff and reviewed resident’s (R1) documents. R1 was first admitted at the facility on 05/02/23 with chronic left facial weakness due to a stroke in 1997 as well as chronic leg swelling. She has dysphagia, dementia and is totally assisted by staff with bathing, dressing, grooming, dental care, toileting, transfers, meals and dementia care. Review of R1’s progress care notes from 06/12/23 to 02/23/24 showed staff monitored R1’s changes in condition and sent her to the hospital for treatment and evaluation on 08/13/23, 08/27/23, 12/25/23 and 02/04/24. On 01/22/24, R1 was placed under hospice care. Staff stated that they followed R1’s hospice care plan and communicated frequently with R1’ hospice care team and responsible party about R1’s condition. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that residents sustained injuries due to lack of supervision is unsubstantiated. Allegation: Resident fell out of wheelchair due to lack of supervision Investigation Finding: Unsubstantiated During investigation, the department interviewed staff and reviewed resident’s (R1) documents. LPA interviewed (S1) who stated that on 01/21/24 at around 1:37AM, R1 had an unwitnessed fall. R1 was found on the floor by caregivers during their 4X per shift status checks. R1 complained of head hurting with a large lump on her right temple. Staff contacted hospice nurse and ice was placed on the bump every 5 minutes until the swelling subsided. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that resident fell out of the wheelchair due to lack of supervision is unsubstantiated. Continued on next page, LIC 9099-C1 Allegation: Facility did not seek medical attention for resident Investigation Finding: Unsubstantiated During investigation, the department interviewed staff and reviewed resident’s (R2) documents. LPA interviewed staff (S1) who stated that R2 was first admitted at the facility on 05/01/23 with dementia. Review of R2’s care notes dated 02/11/24 showed staff noticed R2 had a right “blood shot eye”. Staff stated R2 denied feeling any discomfort with her right eye. Staff continued to monitor R2’s right red eye, notified her primary care physician and responsible party. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that the facility did not seek medical attention for resident is unsubstantiated. Allegation: Facility staff hit resident on the hand Investigation Finding: Unsubstantiated During investigation, the department interviewed staff and reviewed resident’s (R3) documents. LPA interviewed staff (ED, S1) who stated that R3 was first admitted at the facility on 07/02/2018 with a diagnosis of dementia. Review of R3’ s physician’s report dated 06/13/23 showed R3 as ambulatory and having disruptive, combative behaviors. Staff denied hitting any resident’s hand when displaying agitated behaviors. On 02/23/24 at around 03:22AM, staff was able to redirect and calm R3 when she became very agitated during shift rounds. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility staff hit resident on the hand is unsubstantiated. Continued on next page, LIC 9099-C2 Allegation: Facility staff ignored request for help from resident Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (ED, S1) who denied that staff ignore any resident’s’ request for help. Staff are trained to assist each resident with their activities of daily living such as toileting, grooming, dressing, incontinence care, meals and medication management. During unannounced visits on 02/23/24, 02/27/24 and 08/09/24 LPA observed staff assisting residents with medications, meals, snacks, recreational activities, pharmacy refills, doctors’ appointments. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff ignored request for help from resident is unsubstantiated. Allegation: Facility staff did not meet incontinence needs of residents Investigation Finding: Unsubstantiated During investigation, staff (ED, S1) confirmed with LPA that they followed residents’ weekly shower schedules in the AM/PM shifts and assisted residents with their daily hygiene needs such as changing diapers, toileting, grooming and dressing activities. LPA also reviewed random residents’ care plans which showed staff provided daily assistance with bathing (2X or more per week), daily toileting (AM, PM), dressing (AM, bedtime), changing diapers (2X to 3X per shift or as needed), dental care & grooming (AM, PM). Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility staff did not meet incontinence needs of residents is unsubstantiated. Continued on next page, LIC 9099-C3 Allegation: Facility staff did not receive the required on the job training Investigation Finding: Unsubstantiated During investigation, LPA reviewed staff’s training records dated 03/2024 which showed staff completed 20 hours of annual training which included reporting requirements, observation of residents and how to address residents’ changes in condition. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the staff did not receive the required on the job training and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not receive the required on the job training is unsubstantiated. Allegation: Facility staff did not provide activities for residents Investigation Finding: Unsubstantiated During investigation, LPA observed residents have daily recreational activities managed by their activities director which includes music hours, exercise, games, crafts, arts, morning strolls, board games, bingo and ball toss. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that facility is not providing activities to residents and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility is not providing activities to residents is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 30, 2025 · control 15-AS-20240222113909

Type of visit: Required - 1 Year

On 01/30/25 at 02:30PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. ADM has current administrator certificate# 7013576740 which expires on 05/12/2025. At 02:55PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 75 deg F. Hot water temperature was measured at 119 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 5 staff and 5 resident files. LPA was unable to interview 5 residents due to dementia and unwillingness to answer questions. Continued on next page, LIC 809-C LPA observed the following deficiencies during visit: Expired fire extinguishers last inspected 11/27/23 Chipped common hallway wall edges with small dents and holes in various places Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance Deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 30, 2025

Type of visit: Case Management - Deficiencies

While at the facility for another reason, during the tour of the facility Licensing Program Analyst (LPA) Carol Fowler observed strong smell of urine in the hallway next to the stairs and along the hallway on the second floor. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided..the state’s words, verbatim · CDSS document, Nov 5, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Nov 14, 2024

Managed Incontinence(b)(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by: Based on LPA observation, the hallways on the first and second floors had a strong urine odor which posed a potential Health & Safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 5, 2024

Plan of correction: ED will have all hallways deep cleaned and will train all staff on cleaning criteria, sanitary disposal, and ensure the facility does not have urine odor. ED will submit self certification of training with date, time, and attendees. ED will submit training material regarding the listed topics on Line 1 by POC date.

Allegation investigated: Staff handled resident in a rough manner Staff are provoking resident Staff did not allow resident to have his cigarettes

On 08/09/24 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM. During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, admission agreements, physicians reports, needs & services plans, physicians’ orders, medication administration records, narrative charting notes, incident reports, staff training certifications. Continued on next page, LIC 9099-C Substantiated Allegation: Staff handled resident in a rough manner Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (ED) who confirmed that staff (S2) had an inappropriate physical interaction with resident (R1) during an incident that occurred on 02/25/24 between 7PM and 9PM. Review of video footage recorded during the incident on 02/25/24 showed S2 had inappropriate physical interaction with R1. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff handled resident in a rough manner was found to be substantiated. Allegation: Staff are provoking resident Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (S1) who confirmed that staff (S2) provoked resident (R1) during an incident that occurred on 02/25/24 when S2 refused to give R1 his request for extra juice and to have his cigarettes. Review of video footage recorded incident dated 02/25/24 showed R1 and S2 engaged in a physical/verbal altercation in the activities area. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff are provoking resident was found to be substantiated. Continued on next page, LIC 9099-C1 Allegation: Staff did not allow resident to have his cigarettes Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (ED, S1) who confirmed that staff (S2) provoked resident (R1) during an incident that occurred on 02/25/24 by not allowing him to have his cigarettes. Review of video footage recorded during the incident on 02/25/24 showed S2 engaged in a physical/verbal altercation with R1 and did not allow R1 to have his cigarettes. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not allow resident to have his cigarettes was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Staff are mismanaging residents’ medication Investigation Finding: Unsubstantiated During investigation, LPA interviewed residents (R1, R2, R3, R4) who stated that staff assisted them with their medications daily. Review of centrally stored medication logs and medication administration records showed staff assisted residents with their daily medications as prescribed by their primary care physicians (PCP). Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff are mismanaging residents’ medication and found it to be unsubstantiated. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are mismanaging residents’ medication was found to be unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 9, 2024 · control 15-AS-20240226115617

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 30, 2024

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 was not met as evidenced by staff handling resident in a rough manner which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 9, 2024

Plan of correction: By POC due date, Administrator agreed to submit completed in-service retraining of all staff on residents’ personal rights in compliance with Title 22 Section 87468.1 regulations.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 30, 2024

To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by staff provoking resident which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 9, 2024

Plan of correction: By POC due date, Administrator agreed to submit completed in-service retraining of all staff on personal rights in compliance with Title 22 Section 87468.2 regulations.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(3) · Plan of correction due date: Aug 30, 2024

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 requirement was not met as evidenced by staff did not allow resident to have his cigarettes which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 9, 2024

Plan of correction: By POC due date, Administrator agreed to submit completed in-service retraining of all staff on personal rights in compliance with Title 22 Section 87468.1 regulations.

Type of visit: Case Management - Health Checks

On 08/09/24 at 1:10PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Health and Safety check due to the department receiving a priority 2 complaint. During the health and safety check, LPA observed a total of 12 staff members and 52 residents at the facility. LPA toured facility with executive director, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 9, 2024

Type of visit: Required - 1 Year

On 02/23/24 at 11AM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. At 11:20AM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 72 deg F. Hot water temperature was measured at 110 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 5 staff and 5 resident files. LPA also conducted 3 staff interviews. LPA was unable to interview 5 residents due to dementia and unwillingness to answer questions. Continued on next page, LIC 809-C LPA observed the following deficiency during visit: Missing stairwell lift chair for emergency evacuation Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 23, 2024

Type of visit: Case Management - Health Checks

On 02/23/24 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Health and Safety check as a result of the department receiving a priority 2 complaint. During the health and safety check, LPA observed a total of 5 staff members and 41 residents at the facility. LPA toured facility with administrator, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 23, 2024