Discovery Commons Raincross

Type of visit: Case Management - Other

On August 7, 2026, Licensing Program Analyst (LPA), Jarred Torres, arrived at the facility unannounced to obtain additional information pertaining to an incident that occurred on July 31, 2026, interview witnesses, and obtain photographs. LPA met with Administrator, Juan Espino, explained the purpose of the visit, requested and received additional documents, conducted on-site interviews with witnesses, and telephone interviews with additional pertinent parties. Photographs were not received because the facility does not take photographs of their residents' injuries, and LPA was unable to obtain consent to take photographs. During this visit, LPA did not observe any health, safety, or personal rights risks to residents in care. No deficiencies were issued during this visit. An exit interview was conducted, and this report was discussed and provided to Administrator, Juan Espino, whose signature on this form confirms receipt.the state’s words, verbatim · CDSS document, Aug 7, 2026

Type of visit: Case Management - Deficiencies

On August 4, 2026, Licensing Program Analyst (LPA), Jarred Torres, arrived at the facility unannounced in response to a serious incident that occurred at the facility. LPA met with Administrator, Juan Espino, explained the purpose of the visit, toured the facility, and performed a health & safety check. Due to the nature of the incident, and the Administrator admitting that the physical abuse occurred resulting in the arrest of a caregiver, a deficiency was cited, and a plan of correction was developed. California Code of Regulations, Title 22, Chapter 1, Division 6, section 87468.2(a)(8) states residents in privately operated residential care facilities for the elderly shall have all of the following personal rights [...] to be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. An immediate civil penalty was issued with this deficiency. LPA did not observe any immediate health, safety, or personal rights risks to clients in care. This report, cited deficiencies, civil penalty, and appeal rights were discussed with Administrator, Juan Espino, whose signature on this form confirms receipt.the state’s words, verbatim · CDSS document, Aug 4, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Aug 5, 2026

87468.2(a)(8) Additional Personal Rights of Residents in Privately Operated Facilities: [...] residents in privately operated residential care facilities for the elderly shall [...] be free from [...] physical abuse. This requirement is not met as evidenced by: Licensee did not ensure that a resident was free from physical abuse due to a caregiver inflicting physical abuse on a resident in care which resulted in that caregiver's arrest.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: Licensee immediately suspended the abuser and has already decided to terminate them. Also, licensee will retrain staff on residents' personal rights and best practices to avoid elder abuse. Proof of trainings shall be e-mailed to CCLD by August 31, 2026.

Allegation investigated: Facility staff do not safeguard resident's personal belongings, Facility does not provide meal service to resident. Facility staff do not assist resident with toileting.

On May 6, 2026, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegation and to deliver findings. The Department was met by Carlos Espino and reason for visit explained Investigation consisted of the following: On January 19, 2024, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegation mentioned above. During the visit, it was determined that the complaint required further investigation. On May 5, 2026, the department conducted an unannounced visit to continue investigation of above allegations. The department obtained the following documentation--a copy of theft and loss policy. The department needs to obtain additional information to render a finding, therefore the complaint requires further investigation. On May 6, 2026, the department obtained R1’s Physician’s report (dated: 6/13/23), R1’s Physician’s orders (dated: 6/22/23), R1’s Admission Agreement (dated 6/11/23), personal rights (dated 6/14/23), R1’s care plan (dated 5/6/26) and Task Administration Record (dated April 2026). The department conducted interviews with Executive Director (A1), Caregiving staff (S1) and Resident (R1). Page 1 of 4 Unsubstantiated The investigation revealed the following Allegation: Facility staff do not safeguard resident's personal belongings, The detail of complaint alleges when R1 the wakes up in the morning, her diapers, wipes, and other items have been stolen. On May 6, 2026, at 11:00am, the department interviewed Executive Director (A1). A1 informed the department that he has only served that role for 1 month, so he was unable to provide any information regarding the complaint, however he provided the department with pertinent documents related to the complaint. On 5/6/26, the department interviewed care giving staff (S1) who provides care for R1. S1 denied the allegation stating that R1 often fabricates, however R1 has never mentioned anything about missing items from her room to S1. All items are accounted for in R1’s room. On January 19, 2024, the department interviewed R1 who didn’t mention anything about her personal belongings allegedly being stolen. On January 19, 2024, the Department interviewed staff and the Executive Director at the time. Both denied the allegation, explaining that R1 has a history of reporting missing items from her room, but staff have not found anything to be missing. Staff also stated that the residents do not have roommates who receive visits from family members. On May 6, 2026, the department interviewed R1 who did not mention anything about missing items. On May 6, 2026, the department reviewed and evaluated the facility’s lost and theft policy. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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, therefore the allegation is UNSUBSTANTIATED. Page 2 of 4 Allegation: Facility does not provide meal service to resident. The detail of complaint alleges R1 must pay for all her meals out of pocket. R1 cannot afford to eat the meals there, so R1’s friends take her meals to help her On May 6, 2026 at 11:00am, the department interviewed Executive Director (A1). A1 informed the department that he has only served that role for 1 month, so he was unable to provide any information regarding the complaint, however he provided the department with pertinent documents related to the complaint. On January 19, 2024, interview conducted with Executive Director revealed that there is a tray service fee associated with having meals brought to the room and R1 allegedly didn’t want to pay that cost but wanted the service. This service is outlined in the admission agreement. On May 6,2026, the department reviewed and evaluated the admission agreement signed by R1 and responsible party. The department observed the section of Admission Agreement called Schedule of Additional fees which indicated the Room/Tray Service fee is $10.00 per meal per apartment. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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, therefore the allegation is UNSUBSTANTIATED. Page 3 of 4 Allegation: Facility staff do not assist resident with toileting. The detail of complaint alleges “staff makes R1 clean her own bottom when she is changed” On May 6, 2026 at 11:00am, the department interviewed Executive Director (A1). A1 informed the department that he has only served that role for 1 month, so he was unable to provide any information regarding the complaint, however he provided the department with pertinent documents related to the complaint. On May 6, 2026, the department interviewed care staff (S1) who denied allegation stating she and other staff assist R1 with all of her bathing/hygiene needs per her service plan and it is documented in Task Administration Record. On January 19, 2024, the Department interviewed staff and the Executive Director at that time. They denied the allegation, explaining that R1 often requests an additional wipe after caregivers have finished cleaning her because she feels she is not fully clean and prefers to complete the task herself. Staff further reported that they would never require any residents to wipe themselves. On May 6, 2026, the department reviewed and evaluated the R1’s service plan, and the Task Administration Record which includes R1’s scheduled showers, changing schedule and other tasks. Staff who performed the task are also listed. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Carlos Espino. No deficiencies cited during today’s visit. Copy of report provided. Page 4 of 4the state’s words, verbatim · CDSS document, May 6, 2026 · control 18-AS-20240112095238

Allegation investigated: Facility staff are not properly addressing pest infestation in facility

On May 5 , 2026, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegation and to deliver findings. The Department was met by Carlos Espino and reason for visit explained Investigation consisted of the following: On April 30 2024, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegation mentioned above. During the visit, it was determined that the complaint required further investigation. On May 5, 2026 The department obtained a copy of the following documents: Staff Roster (dated 3/30/26), Resident Roster (5/1/26) Pest control invoices (3/28,24, 4/12/24, 4/5/24, 4/10/24, and 4/17/24), Consent release confidential information for hospice (7/31/23), Admission Agreement (7/18/23) and Resident rights (7/18/23) The department interviewed Administrator (A1) 5 staff (S1-S4), 4 Residents (R2-R5). Page 1 of 3 Unsubstantiated The investigation revealed the following: Allegation: Facility staff are not properly addressing pest infestation in facility The detail of the complaint alleges there are unknown bites on R1 that the hospice nurse suspected that they came from bed bugs. The facility eventually got R1’s room fumigated but the bed bugs continued to return. On May 5, 2026 at 12:00pm, the department interviewed Executive Director (A1). A1 informed the department that he has only served that role for 1 month, so he was unable to provide any information regarding the complaint, however he provided the department with pertinent documents related to the complaint. On May 5, 2026, the department interviewed 5 staff (S1-S5) regarding the allegation. Of those interviewed 5 out 5 denied the allegation stating that the facility address issues regarding pests right away. Additionally, 5 out of 5 stated that there has been only 1 instance of bed bugs at the facility and that was the time related to this complaint. Lastly, 5 out of 5 state that the facility handled the issue with the bedbugs right away and follow any recommendations from the pest control professional. On May 5, 2026, the department interviewed 4 residents (R2-R5). R1 no longer lives at the facility as she has since passed away. Of those interviewed, 4 out of 4 state that they are well taken care of and if they need assistance, staff is available to them. 4 out of 4 residents state that they have never had issues with bedbugs. Page 2 of 3 On May 5 2026, the department reviewed and evaluated the following documents: Staff Roster (dated 3/30/26), Resident Roster (5/1/26) Pest control invoices (3/28,24, 4/12/24, 4/5/24, 4/10/24, and 4/17/24), Consent release confidential information for hospice (7/31/23), Admission Agreement (7/18/23) and Resident rights (7/18/23). The Pest control invoices showed that the facility was actively addressing the bed bug issue. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; 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, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Carlos Espino. No deficiencies cited during today’s visit. Copy of report provided. Page 3 of 3the state’s words, verbatim · CDSS document, May 5, 2026 · control 18-AS-20240423144139

Allegation investigated: Licensee is restraining resident. Licensee is forcing resident to remain at the facility against their will. Staff are inappropriately medicating resident.

Licensing Program Analyst (LPA), Armando Perez and Ahliah Sharp, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Resident Care Director WIlliam Lewallen, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and witnesses and file reviews. On February 11, 2026, Community Care Licensing Division (CCLD), received a complaint alleging that Licensee is restraining resident, licensee is forcing resident to remain at the facility against their will and staff are inappropriately medicating resident. Interview with Executive Director, Mary McClure, revealed that the name provided did not match any current residents. Information obtained through Interview with Responsible Party confirmed Resident 1 (R1) did not reside at the facility. Additionally, RP elected not to provide the current location of R1. LPA interviewed Witness 2 (W2), and corroborated statements made by ED and RP confirming the facility was not the R1’s residence. A review of facility records, including resident rosters, revealed no documented names matching the name reported. Continued on LIC 9099-C. Unfounded Based on interviews, research, and record review, the allegation that Licensee is restraining resident, licensee is forcing resident to remain at the facility against their will and staff are inappropriately medicating resident is unfounded due to the listed resident not residing at the facility. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, this complaint is dismissed. An exit interview was conducted. A copy of this report was provided to Resident Care Director WIlliam Lewallen.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 18-AS-20260211100003

Allegation investigated: Staff are not ensuring resident receives phone calls

Licensing Program Analyst (LPA), Armando Perez and Ahliah Sharp, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Resident Care Director WIlliam Lewallen, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and witnesses and file reviews. On February 05, 2026, Community Care Licensing Division (CCLD), received a complaint alleging that facility staff are not ensuring resident receives phone calls. Interview with Executive Director Mary MCClure, revealed that the name provided did not match any current residents. A request to interview Additional Witness 1 (AW1) was attempted and AW1 did not respond to request to obtain further information. Information obtained through Interview with Responsible Party confirmed Resident 1 (R1) did not reside at the facility. LPA interviewed Witness 2 (W2), and corroborated statements made by ED and RP confirming the facility was not the R1’s residence. A review of facility records, including resident rosters, revealed no documented names matching the name reported. Continued on LIC 9099-C. Unfounded Based on interviews, research, and record review, the allegation that facility staff are not ensuring resident receives phone calls is unfounded due to the listed resident not residing at the facility. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, this complaint is dismissed. An exit interview was conducted. A copy of this report was provided to Resident Care Director WIlliam Lewallen.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 18-AS-20260205122032

Type of visit: Required - 1 Year

Licensing Program Analysts Tremayne Barra and Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Executive Director, Mary McClure. The LPA informed Mary of the purpose for the visit. The inspection included the following: The facility is a one building structure with two stories and services both memory care and assisted living residents. LPA observed the facility to be clean and in good repair. LPA toured the facility inside and outside. LPA inspected 10 resident rooms for the required furnishing. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid material present. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals on the second floor. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility and no bodies of water observed. LPA began review of client records. Seven (7) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be available and complete. LPA began review of employee records, Seven records were reviewed. LPA observed personnel records to be available and complete. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 10/26/2026. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen. Medications are centrally stored. Medications are stored in a locked room. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were found to be operational. Fire extinguishers are in compliance and can be found throughout the facility. This LIC 809 report was reviewed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Feb 9, 2026

Allegation investigated: Resident has a suspicious head injury.

Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to the facility to deliver findings on a complaint alleging Resident #1 (R1) sustained a head injury due to neglect. LPA Singh met with Facility Staff and was granted entry into the facility. Facility Executive Director Mary Mcclure, facility representative arrived during this visit. LPA singh introduced herself and stated the purpose of this visit to the facility representative- Executive director-Mary Mcclure The investigation conducted by LPA Singh consisted of interviews and records review. Based on the information gathered, LPA Singh was not able to find sufficient evidence to corroborate the allegation listed above. Resident had an unwitnessed fall, Med-tech was called, bodycheck done, noted laceration to left forehead and first aid rendered. Interviews with facility staff and R1’s family did not disclose any concerns regarding R1’s head injury. In addition, R1’s family indicated the facility provided R1 adequate care while living at the facility. Statements, records, and interviews obtained did not provide sufficient information to corroborate the allegation. Unsubstantiated Based on the evidence found during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.the state’s words, verbatim · CDSS document, May 12, 2025 · control 18-AS-20210319160235

Allegation investigated: Resident was not provided a copy of the Admissions Agreement. Resident's charges were increased without proper notice.

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Executive Director, Mary McClure who was informed of the purpose of the visit. LPA conducted interviews and conducted records review. It was alleged “Resident was not provided a copy of the Admissions Agreement.” It was alleged Resident #1 (R1) and their legal representative did not receive a copy of the facility’s new admission agreement. Interview with R1 was unable to be conducted as they have passed away. Interview with R1’s legal representative was attempted but unable to be conducted. Substantiated Interview with (1) administrative staff revealed March of 2022 the facility was using a new fee structure where points were being allocated based on resident’s needs. R1’s Resident Ledger report revealed R1 was billed and rated at 13,692 care points March of 2022. Records review revealed R1 did not have a care points assessment for services rendered. Therefore, the allegation that R1 was being overcharged for services is unsubstantiated at this time. It was alleged “Resident is being charged for services not provided.” It was alleged R1 was being charged for services such as bathing, grooming, and transferring and were not being provided to R1. It was alleged R1’s hospice agency was providing bathes and facility staff would not transfer R1 out of bed. It was also alleged that R1 was being charged $35.00 for Cable television when R1 did not have a television. Interview with R1 was unable to be conducted as they have passed away. Interview with R1’s legal representative was attempted but unable to be conducted. R1’s Resident Ledger report and move in billing ledger revealed R1 was being charged for Cable television since admission in 2017. R1’s care plan dated 03/03/2022 revealed R1 required a (2) person assist for transfers, required assistance with dressing and grooming, and bathing services were being provided by an outside hospice provider. LPA conducted interviews with (4) staff who provided care to R1. (2) of (4) staff interviewed did not recall services provided to R1. (1) of (4) staff revealed R1 was transferred out of bed, while (1) of (4) staff revealed R1 was contracted and staff was unable to move R1 out of bed and would have been reflected in their care points assessment. No documentation for R1's care points assessment was found in R1's file. (2) of (4) staff revealed R1 was assisted with grooming, hygiene, and bathing as needed with R1's hospice agency providing most of the bathing. (4) of (4) Staff did not recall if R1 had a television in their room or was billed for cable television. Therefore, based on interviews and records review the allegation that R1 was being charged for services not rendered is unsubstantiated at this time. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided. On 03/22/2022 Department staff interviewed (1) administrative staff which revealed R1 and their representative did not sign the new revised admission agreement. Records review revealed the admission agreement for the facility had changed March of 2021 and the last admission agreement for R1 was signed in 2017. Therefore, the allegation that the R1 and their legal representative did not receive a copy of the new admission agreement is substantiated. This deficiency was cited for R1 on case management visit on 03/22/2022. Therefore, the facility was not recited on this report. It was alleged “Resident's charges were increased without proper notice.” It was alleged the facility changed their fee structure for services rendered from $6,085.00 to $11,141.97 for R1 March of 2022. It was alleged R1 and their legal representative were not informed of the fee changes. Interview with R1 was unable to be conducted as they have passed away. Interview with R1’s legal representative was attempted but unable to be conducted. Interview with (1) administrative staff revealed all residents including R1 were informed of the fee structure changes in a letter. Letter dated 03/01/2021 revealed residents were informed that the new fee structure would go into effect on the same day and could be referenced in the new residency agreement. Based on the substantiated allegation above, R1 did not sign a revised admission agreement with the new fee structure. Additionally, Health and Safety Code section 1569.655 states residents shall receive written notice no less than 60 days’ prior to increase of fees and must include the reason for the increase and the amount of the increase. No documentation of proper written notice was found in R1’s file. Therefore, based on interview and record review the preponderance of evidence standard has been met and .the allegation is substantiated. California Code of Regulations Title 22, is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 8, 2025 · control 18-AS-20220317170451

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655(a) · Plan of correction due date: May 8, 2025

(a) If a licensee…increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs… This requirement was not met as evidenced by: Based on interview and record review the facility did not issue proper notice to R1 and their representative of increase in fees. This poses a potential health saftey or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: The administrator provided proof of written communication sent to residents informing them of fee increases consistent with the section cited here. Deficency was cleared at the time of the visit.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Executive Director, Mary McClure. The LPA informed Mary of the purpose for the visit. The inspection included the following: The facility is a one building structure with two stories and services both memory care and assisted living residents. LPA observed the facility to be clean and in good repair. LPA toured the facility inside and outside. LPA inspected 10 resident rooms for the required furnishing. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid material present. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals on the second floor. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility and no bodies of water observed. LPA began review of client records. nine (9) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be available and complete. LPA began review of employee records, ten (10) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 10/26/2026. LPA observed personnel records to be available and complete. Administrator notified that a change was submitted, however, records still indicated the previous administrator information. LPA received required documents and will update facility file records with CCLD to reflect the new Administrators information.. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a location for knives and sharps in the kitchen. Medications are centrally stored. There is two locked rooms allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA received documentation of the previous inspection that determined the smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers were last serviced on, 10/04/2024. Fire drills are conducted quarterly at the facility with the last drill on 02/06/2025. Administrator could not find the record initially and attempted to search for the record in the Building Service Director's office and was not able to locate. Administrator then checked a binder in her office and was able to locate the record for fire drills. A technical advisory will be recorded and Administrator will have the record available in a timely manner. Based on the information received during this visit today in the areas reviewed, there are no deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809 report was reviewed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Feb 12, 2025

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff not providing adequate laundry services. Facility not providing residents with adequate housekeeping services.

On 11/21/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegations listed above. LPA met with Executive Director Mary McClure where LPA explained the purpose of the visit, and the elements of the allegations. The allegations were investigated and the investigation consisted of observations, interviews and records review. On 07/07/21 Community Care Licensing received a complaint alleging the staff are not providing adequate laundry services and that the facility is not providing the residents with adequate housekeeping services. Regarding the allegation of staff are not providing adequate laundry services it was alleged that Resident #1 (R1) clothes were smelly and dirty, and this was due to the washing machine being broken where the mechanism that dispenses the soap was not operable. LPA conducted interviews with Building Service Director Raul Hernandez whom explained that in or around 2021 the facility had soap dispenser installed by an outside company and if there are any issues the company will come out and make the repair. In addition that the only time there would be a delay in getting the appliance repaired is if a part is needed and it is not in Unsubstantiated in stock. Per interviews with staff there was (1) washer that was inoperable. During today's visit there was one (1) report of one of the dryers that were not working properly, which was reported to be looked into, however all washers were reported to be functional. Per an interview with ED Mary McClure, the assisted living residents are charged a laundry service fee. (1) load of laundry included in rent fees, any additional loads are $20 a load. For the memory care residents the facility does not charge a laundry fee. LPA conducted a tour of the facility and observed for there to be a total of three (3) laundry rooms (1 downstairs in memory care, 1 downstairs in assisted living, and a third one upstairs on the second floor). LPA observed for each laundry room to have (2) washers and (2) dryers. Per an interview with Raul if one of the washers were broken, the other two are available to use. Per resident interviews conducted revealed that there were not any issues with their laundry and that it smelled fresh. R1 was unable to be interviewed as they are no longer residing at the facility. LPA conducted a records review of resident shower and laundry list. The memory care residents have their bedding washed on their shower days, at a frequency of two (2) times per week. Per an interview with Executive Director Mary the Caregivers are responsible for laundry if there is additional cleaning needed then care staff are to take care of it. Based on observations, and interviews the allegation of staff are not providing adequate laundry services is unsubstantiated. Regarding the allegation of facility is not providing residents with adequate housekeeping services. It was alleged that the facility was short staffed and that there was no housekeeping staff. Per an interview with Raul there is currently 2 two (2) housekeeping staff, as there was three (3) but recently lost one. The housekeeping staff are responsible for cleaning resident rooms once a week, on their assigned day. In the resident rooms tasks consists of emptying the trash, cleaning the bathroom, dusting, mopping and any other identified issues or requests. Housekeeping staff are not responsible for laundry. It is estimated that there a total of 7-9 resident rooms being cleaned each day, in addition to the common areas, bathrooms, activity rooms, hallways being vacuumed and memory care dining. Per interviews with staff all items needed (broom, mop, mop buckets dust pan, towels, cleaners, paper goods) to complete the tasks assigned are available for use. Per an interview with Raul the facility is contracted with a company that provides all cleaners, disinfectants and soaps, that are delivered every Monday. Per interview with residents revealed that the rooms are cleaned once a week required, and there are times when the trash does need to be emptied they can ask and staff with take care of it. Based on observations and interviews the allegation of facility is not providing residents with adequate laundry services is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted and a copy of this report was provided to Mary McClure, Executive Director.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 18-AS-20210707115014

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Residential Care Director William Lewallen. The facility is a assisted living and memory care facility that serves elderly adults. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were in good repair and were present. The facility does not have any pools are bodies of water. The facility does not have firearms or ammunition on their property. LPA observed passageways to be free from obstruction. Facility contains a covered patio area with tables and chairs for residents to utilize when outdoors. Resident bedrooms and bathrooms contain a pull cord for the facility's signal system. LPA observed the signal system to be operable. LPA tested the water temperatures in resident restrooms that met Title 22 regulation requirements. LPA observed grab bars and nonskid mats and/or strips in the bathroom showers. LPA observed the kitchen and dining room area to be clean and free of odors. Facility kitchen has the ability to prepare food in clean environment and possessed equipment in good working condition. Food supplies were sufficient with an emergency food and water supply present. Facility receives two food deliveries per week. Cleaning supplies, disinfectants and toxins are kept in areas separate from food and are inaccessible to residents and are locked within the housekeeping carts and janitorial supply store rooms. Facility contains PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. Medication is centrally stored in the Assisted Living medication room and Memory Care medication room and are locked and inaccessible to residents in care and are administered according to their physician's instructions. Facility utilizes an electronic Medication Record Administration (eMAR) when distributing prescribed medication to the residents. LPA reviewed five (5) staff files and training. All staff have criminal record clearance and updated training along with CPR/First Aid Certification. Five (5) resident files were reviewed and possessed all required paperwork such as the resident's Admissions Agreement, Physicians Report, and Service Plan. LPA reviewed the facility's emergency and disaster plan. Riverside County Fire Marshal conducts fire drills monthly which meets department requirements. LPA observed required postings including the visitation polices, emergency/disaster plans, complaint procedures, and personal rights. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Lewallen.the state’s words, verbatim · CDSS document, Feb 26, 2024