El Cerrito Royale

Type of visit: Case Management - Other

On 09/29/2026 at 9:25 a.m., Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding a 60-day eviction notice that was reported to the Community Care Licensing Division (CCLD) on 09/04/2026. LPA met with Executive Director (ED) Sonja Givens-Thomas and explained the purpose of the visit. The 60-day notice of eviction provided to Resident (R1) cited California Code of Regulations, Title 22, Section 87224(a)(3), “failure of the resident to comply with general policies of the facility.” Section 4 of R1’s admission agreement identifies the following facility policies as grounds for eviction: (a) verbal or physical abuse directed toward other residents; (e) destruction of property of the community; and (h) health conditions that require staffing levels not available in the community. On 09/09/2026, LPA received documents requested from Assistant Executive Director (AED) Tracy Gibson. The documents provided included R1’s admission agreement dated 01/10/2023, Physician’s Report (LIC 602A) dated 2023, medication list, Appraisal Needs and Services dated 08/31/2026, Resident Appraisal dated 08/31/2026, Care and Needs Assessment/Overview dated 08/31/2026, and Identification and Emergency Information dated 01/09/2023. LIC809-C Continued... LIC809-C (Page 2) During the Case Management visit on 09/29/2026, LPA reviewed R1’s resident file and additional documents, including Physician’s Reports (LIC 602A) dated 12/30/2022 and 05/21/2024, Appraisal Needs and Services dated 01/13/2023 and 02/07/2026, and a SOC 341 dated 09/25/2026. During an interview, Staff (S1) stated that R1 has demonstrated cognitive decline and behaviors that resulted in a verbal confrontation with Resident (R2), which became physical. S1 stated that the facility did not submit an Unusual Incident Report to CCLD regarding the incident. S1 further stated that the facility has a memory care unit; however, the memory care unit is currently at capacity, and R1 would need to be placed on a waiting list for admission to that unit. LPA reviewed the 60-day eviction notice and observed that the notice did not identify an effective date of eviction. LPA also observed that the CCLD telephone number listed on the notice was incorrect. Although there was a address for Empowered Aging there was failure to include information for State Long Term Care Ombudsman for filing a complaint. The deficiencies identified during this Case Management visit are documented on the LIC 809D and are cited pursuant to the applicable provisions of the California Code of Regulations, 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, Sep 29, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.683 · Plan of correction due date: Oct 6, 2026

§1569.683 Eviction notices; reasons for eviction contents; service (a) In addition to complying with other applicable regulations... the notice to quit shall include all of the following: (1) The effective date of the eviction...(3) Information about the resident's right to file a complaint... with the State Ombudsman. Based on interview and record review the licensee did not comply with the section cited above in serving R1 with an appropriate eviction notice that did not contain all items required under regulation, which poses a potential health and safety and personal rights risk to persons in care. This requirement is not met as evidenced by:the state’s words, verbatim · CDSS document, Sep 29, 2026

Plan of correction: The Administrator will read the regulation and submit self-certification that it has been read, understood and they will comply going forward to CCLD by POC due date. In addition, the licensee shall rescind the eviction, notify resident, responsible party, and issue legal notice if that is still licensee’s plan.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Oct 6, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D) below. This requirement is not met as evidenced by: Based on interview and records review, the licensee did not comply with the section cited above in notifying Licensing incidents that occured with R1 including but not limited to a water flood in R1's room and water damage to other residents' rooms which poses a potential health, safety and or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2026

Plan of correction: The Administrator will read the regulation and submit self-certification that it has been read, understood and they will comply going forward to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Oct 6, 2026

87463 Reappraisals (a) ...Pre-Admission Appraisal, shall be updated in writing...once every 12 months, whichever occurs first, to note significant changes in condition This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above in R1's LIC625 Appraisal/Needs and Services Plan were not updated from 01/13/23 until 02/07/26, 08/31/26 that were not signed by R1 or responsible party which poses a potential health, safety and or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2026

Plan of correction: The Administrator will read the regulation and submit self-certification that it has been read, understood and they will comply going forward to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(h) · Plan of correction due date: Oct 6, 2026

87463 Reappraisals (h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above in R1's LIC602A (medical assessments) were dated 12/30/22, 05/21/24 and 12/02/25 which poses a potential health, safety and or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2026

Plan of correction: The Administrator will read the regulation and submit self-certification that it has been read, understood and they will comply going forward to CCLD by POC due date.

Type of visit: Required - 1 Year

On 06/26/2026 at 8:30AM, Licensing Program Analyst (LPA) Andrew Christy arrived unannounced to conduct the 1-Year Annual Required inspection. LPA met with Administrator, Sonja Givens-Thomas, and explained the purpose of the visit. The facility currently houses 93 residents with a max capacity of 145 residents. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area, and backyard. All outdoor and indoor passageways are kept free of obstruction. No bodies of water were observed. A comfortable indoor temperature is maintained at 70.0 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 112.9 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 02/13/2026. At 11:00AM, LPA reviewed five (5) resident files and five (5) staff files, all found to be complete. The emergency disaster plan was last reviewed 03/18/2026. Quarterly emergency drills were last conducted 04/22/2026. A review of resident medications and the Medication Administration Record (MAR) found no outstanding errors. No deficiencies cited during visit. Exit interview conducted and a copy of this report was provided to the administrator.the state’s words, verbatim · CDSS document, Jun 26, 2026

Type of visit: Case Management - Health Checks

On 5/19/2026, at 12:00pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced conduct a case management health and safety check. LPA met with Sonja Givens-Thomas, Administrator, and explained the reason for the visit. During the health and safety check, LPA toured the facility including but not limited to common areas, kitchen, bathrooms, bedrooms, memory care, medication room, and outdoor common area. LPA observed lunch being prepared, there were residents sitting in the common areas, walking around, and in their rooms. LPA observed caregivers, administration workers, kitchen workers and housekeeper. LPA observed the hot water in shared bathroom on the 3rd floor was 99.2 and on the 1st floor 100.6 degrees F. The facility is noted to be clean, in good repair, and clients in care appear to be safe. There is a minimum of 7-day non-perishables and 2-day perishables foods. There are no imminent health/safety concerns on today's date. Fire extinguisher last services 2/13/2026. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 19, 2026

Type of visit: Case Management - Other

On this day, April 1, 2026, at 10:30 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct case management inspection to follow-up on the complaint investigation (Complaint # 15-AS-20260226143854) LPA conducted on March 3, 2026 to ensure the health and safety of residents. LPA met with Associate Executive Director (AED) Tracy Gibson and informed the reason for visit. LPA toured the Memory Care Unit with AED. LPA randomly selected 7 residents' rooms. The rooms were observed not locked except for 1 due to resident was out of the facility. Some of the residents were inside their rooms. LPA also observed 6 residents in the dining/activity area doing activities. LPA obtained copy of resident roster. No deficiency observed during today's visit. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Apr 1, 2026

Allegation investigated: Unlawful eviction Staff did not adequately address a change in resident's condition

On 03/12/2026 at 10:00 AM, Licensing Program Analyst (LPA), Carol Fowler arrived unannounced to open and deliver complaint findings for the above allegations. LPA met with Administrator Sonia Givens-Thomas and explained the reason for the visit. During the course of the investigation LPA toured the dining room, conducted resident and staff interviews. The following documents were collected by LPA: Resident Roster, Staff Roster, R1 Admission Agreement, R1's Physician Report, Appraisal Needs and Service Plan, Emergency ID, Pre Appraisal, Police Officers contact information, Progress Notes, MAR and a copy of the Evicition Letter. Continued on LIC9099-C. Unsubstantiated CONTINUE FROM LIC9099C ALLEGATION: Unlawful eviction It was alleged that Witness 1 (W1) is contesting a 60-day eviction notice issued on February 4, 2026, for R1 a resident of El Cerrito Royale, on the basis that the behaviors cited are related to R1’s diagnosed medical condition rather than intentional misconduct. LPA conducted interviews with Staff 1 (S1), S2, S3, S4, S5, S6 and S7. All staff reported that R1 is verbally and physically abusive toward staff, uses profanity, and has threatened several staff members. S3 reported witnessing R1 strike a caregiver and then move toward S3 in an apparent attempt to hit them, at which time S3 moved out of the way. S1 stated that R1 struck S1 and directed racial slurs toward them. S2 reported witnessing R1 hit S1 and used offensive language toward S1 and S7. S5 and S6 reported observing R1 use of offensive language toward residents in the dining room. S6 further stated that R1 frequently accused S6 of removing R1’s name tag from the dining room table and that S6 has witnessed R1 removing the tag personally. Interviews with Resident 1 (R1), R2, R3, R4 revealed additional concerns. They reported that R1 is unpleasant to be around and regularly enters the lounge, closes the blinds, moves chairs, and attempts to direct other residents to follow R1’s commands. R4 shared a video of R1 standing near the office using offensive language toward office staff. R4 further stated that R1 then walked toward R4 to leave the area. R4 stated feeling almost threatened by R1. R2 reported that R1 comes into the lounge, closes the blinds while residents are working on puzzles, and breaks up the puzzles that residents have assembled. R3 stated that R1 engages in disruptive behavior, such as coming into the room during signing group, moving chairs around, and attempting to make residents sit where R1 wants them to sit. R3 also stated that they try to avoid R1 as much as possible. LPA reviewed the eviction letter, and all required components were included in the eviction documentation. Therefore, the allegation is UNSUBSTANTIATED. CONTINUE ON LIC9099C CONTINUE FROM LIC9099 ALLEGATION: Staff did not adequately address a change in residents’ condition It was alleged that the licensee initiated the eviction process due to R1’s behavioral issues. W1 reported that R1 had a medication change on February 27, 2026 and requested that the facility allow a 30-day period to assess whether there was a change in R1’s condition. S3 reported that R1 did not have a medication change, but rather a time change, rather a time change, involving the same medication. Specifically, the medication schedule changed from 50mg at night to 25mg after lunch and 25mg at night. S3 also stated that they had not observed any changes in R1’s behavior. LPA conducted a record review of the MAR, which confirmed that there was modification to the time the medication was administered, while the medication itself remained the same. Therefore, the allegation is UNSUBSTANTIATED. Although the above 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.the state’s words, verbatim · CDSS document, Mar 12, 2026 · control 15-AS-20260302171030

Allegation investigated: Staff lock residents in their rooms.

On this day, March 3, 2026, at 11:00 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Executive Director (ED) Sonja Givens and informed the reason for visit. The reporting party (RP) stated the residents bedroom doors are locked in a manner that prevents them from exiting freely. RP also stated there has been no documented medical order authorizing room confinement. LPA obtained copies of resident roster and staff schedule, reviewed residents' records and obtained copies of LIC601 Identification and Emergency Contact Information and LIC602A Physician's Reports. LPA interviewed the ED, staff (S1 and S2), residents' family members (FM1, FM2 and FM3). LPA toured the Memory Care Unit with the ED and randomnly selected rooms for inspection. .....continued on 9099C Substantiated The Executive Director (ED) was able to identify residents in Memory Care Unit who have wandering, pacing and/or sundowning behaviors which included R1, R2 and R3. Review of these residents records confirmed the ED's statement. Staff (S1 and S2) stated residents rooms in Memory Care Unit are locked to prevent other residents from coming inside the rooms. FM1 and FM2 stated observing the residents' room locked and witnessing the staff unlocked the door from outside with a key to let them in. Although FM3 stated not witnessing R4's room locked, R4 does not have wandering behavior as indicated in R4's LIC602A Physician's Report. During inspection, LPA observed two of residents rooms' locked with residents inside the rooms. LPA knocked at one of the rooms and the resident who was inside tried but unable to open the door. The staff has to open the rooms with key to allow LPA in. Based on interviews and observation, the preponderance of evidence has been met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 3, 2026 · control 15-AS-20260226143854

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Mar 17, 2026

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.......... -This requirement is not met as evidenced by: -Based on interviews and inspection, the licensee did not comply with the section above in locking the residents rooms with residents inside which posed a potential personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Mar 3, 2026

Plan of correction: Executive Director stated she'll in-service the staff. Copy of training topic with attendees signatures to be submitted by 3/17/26.

Allegation investigated: Staff does not provide adequate supervision resulting in resident wandering away from facility.

On 05/30/25 around 03:00 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unnanounced visit to deliver the above complaint finding. LPA met with Tracy Gibson, Assistant ED and explained the purpose of the visit. During the invetigation, LPA toured the facility and interviewed Staff (S2, S3, S4, S5, S6), Witnessess (W1, W2, W3), reviewed and requested Staff and Resident roster, and the following documents from Resident's (R1, R2, R3, R4, R5, R6, R7) file: Physician's Report(s), Identification and Emergency Information, Appraisal Needs and Services Plan, any elopements for April-May, and LIC 500. Allegation: SUBSTANTIATED Continued on LIC9099C... Substantiated ...Continued from LIC9099. Staff does not provide adequate supervision resulting in resident wandering away from facility. LPA reviewed a sample of Residents records (R1, R2, R3). The LIC602 dated 02/25/25 for R1 revealed the R1 has macular degeneration, essential tremors, Mild Cognitive Impairment (MCI), and is unable to leave the facility unassisted. R1’s LIC 624 dated 05/20/25 reports that on 05/13/25 R1 left the facility without supervision and was returned to the facility by El Cerrito Police department. S6 stated that the staffing was questionable, and both Assisted Living and Memory Care's staffing should be assessed, and S7 stated that there should be more focus on the actual care of the residents. Based on information obtained, the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted, appeal rights and a copy of this report provided Tracy Gibson, AED. ...continued from LIC9099A. Allegation: UNSUBSTANTIATED Staff leaves resident soiled for an extended period of time. Staff does not ensure to dispose expired medical care supplies. Staff leaves resident soiled for an extended period of time. The allegation is related to R1 being soiled with feces for over 2 hours. Interviews with Staff S4, S5, S6 and S7 reveal that they were not aware R1 or any other resident remaining soiled for over 2 hours. S5 and S7 confirmed that a response to the resident could take up to 30 minutes after a caregiver is requested over the radio. Staff does not ensure to dispose expired medical care supplies. S8 stated that an expired medical supply was left unattended S1 at the facility. LPA and S2 toured the LPA toured the medical station, kitchen, shower and laundry room; there weren’t’ any expired medical supplies and the medication that were no longer in use were properly destroyed and remained lock with a destruction that was monitored and control by S3 on the day of the visit. Based on information obtained, the allegation is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that the allegations are not valid because the preponderance of the evidence standard has not been met. Exit interview conducted, appeal rights and a copy of this report provided Tracy Gibson, AED.the state’s words, verbatim · CDSS document, May 30, 2025 · control 15-AS-20250506154801

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(j) · Plan of correction due date: Jun 2, 2025

The licensee shall evaluate staffing needs to ensure that there is a sufficient number of direct care staff, as specified in Section 87411, Personnel Requirements – General, to support each resident's physical, social, emotional, safety and health care needs, as identified in their current appraisal. -This requirement is not met as evidenced by: Supervision was not present to prevent R1 from leaving the facility unassisted per R1's physician's report.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: Licensee (LIC) to establish new admissions protocol to review resident records, LIC602, preappraisal needs and services to ensure sufficient trained staff are available for the care and services of all residents. LIC & staff to certify with signatures that the regulation has been reviewed by POC.

Type of visit: Required - 1 Year

On 05/30/25 around 10:00 AM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced annual inspection. LPA Tracy Gibson, Assistant ED and explained the purpose of the visit. ED currently holds standard certificate #7000394740 exp. 02/03/2027. The facility’s fire clearance was approved for sixty (60) non-ambulatory residents; twenty (20) may have hospice waivers. Upon arrival LPA observed several residents lounging, conversing, putting a puzzle together. Several staff and residents were in the dining area. Staff and residents were moving about throughout the facility's common areas. LPA toured the facility including, but not limited to the common areas, bathroom, dining area, and front courtyard. The facility consists of individual apartments and a memory care unit. All outdoor and indoor passageways were free of obstruction. There were no bodies of water present. A comfortable temperature was maintained at the facility. The facility has an emergency food supply on site and contract with the same vendors is the past; Sysco Foods, Rubino Produce and Weber Meats along with other vendors for weekly deliveries. LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. Hot water temperature in the shared bathroom was 108 degrees Fahrenheit (F) with hand washing soap, signs, and paper towels; the areas were safe, and sanitary. Linen and hygiene products are available for all residents. PPE, sanitizer, and paper goods remain sufficient. Continued on LIC809C... ...continued from LIC809. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguishers were observed full and inspected on 02/07/25. Emergency Disaster Plan is updated, disaster drill last conducted January 2025. Five (5) staff and seven (7) residents records were reviewed and are complete. The following forms are to be updated and submitted to CCLD: -Resident Roster (Reviewed) -LIC500 Personnel Report (Reviewed) -LIC308 Update Designation of Administrative Responsibility (Reviewed) -LIC610D Emergency Disaster Plan (Reviewed) Exit interview conducted and a copy of this report provided to Assistant ED.the state’s words, verbatim · CDSS document, May 30, 2025

Allegation investigated: Staff unlawfully evicted a resident

On 01/15/25 around 09:35 AM L. Holmes, Licensing Program Analyst (LPA), arrived unannounced to conduct and deliver the finding for the complaint investigation. LPA met with Sonja Givens, Executive Director (ED) and explained the purpose of the visit. During the investigation LPA interviewed ED, Witness #1 (W1), and Resident #1 (R1) file. LPA requested a resident roster and staff roster. LPA requested the following for Resident #1 (R1): an updated reappraisal, written communications to R1 and the Responsible Parties regarding the (60) Sixty-Day Notice of Eviction from El Cerrito Royale. ...continued from LIC9099C. Substantiated ...continued from LIC9099. Staff unlawfully evicted a resident Interviews conducted with ED, W1, and records reviewed confirmed that S2 provided R1 with a sixty (60) days written notice to quit dated 11/15/2025 on 11/21/2024. On 11/21/24, S2 emailed LPA an updated notice dated 11/21/2024 that entailed the reasons for the eviction; however, the notice provided to R1 did not set forth a date, place, witnesses, and circumstances concerning the reason(s) for the notice to quit. Based on interviews and records reviewed, the preponderance of evidence for the violation has been met; therefore, the allegation is SUBSTANTIATED. Deficiency cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided to ED.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 15-AS-20250107110519

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Jan 17, 2025

87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.-This requirement is not met as evidenced by: The licensee provided R1 with a sixty (60) days written notice to quit dated 11/15/2025. The notice provided did not set forth a date, place, witnesses, and circumstances concerning the reasons for the notice to quit.the state’s words, verbatim · CDSS document, Jan 15, 2025

Plan of correction: Licensee to rescind R1's Notice of Eviction. In-service staff on the required regulations and provide proof of attendees with signatures by POC.

Allegation investigated: Lack of supervision by staff.

On 07/10/24 around 12:50 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced visit to amend the report to 'Public'. On 05/31/24 around 03:45 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced 10-day complaint visit to investigate and deliver the finding. LPA met with Tracy Gibson, Assistant ED and explained the purpose of the visit. Allegation: Lack of supervision by staff. For the allegation lack of supervision by staff, on 05/30/2024 Licensing Program Analyst (LPA) L. Holmes received a report of suspected elder abuse from Witness #1 (W1) and completed a case management. It was reported that on 05/27/2024 Resident (R1) slapped (R2) across the face. After record reviews of LIC500, Physician Reports and interview with ED, along with the same incident that was self-reported via an SOC 341 on 05/30/24 by Staff (S1), S1 observed R1 and R2 sitting next to each other in the Memory Care Unit (MC). Continued on LIC9099C... Unsubstantiated ...continued from LIC9099. R2 has a history of false perceptions and screaming; R2 was engaging in impromptu screaming on that day, R1 perhaps became annoyed and then made contact with R2's left side of the face with R1's palm. R1’s Physician Report dated 11/17/23 revealed that R1 has a history of neuro-cognitive disorder along with confusion, disorientation, and does not remember the chain of events. R2’s Physician Report dated 04/22/24 revealed that R2 is diagnosed with Dementia. R1 and R2 are spouses and are regularly supervised; therefore, the facility initiated to supervise R1 and R2 when they are together so that they can enjoy their meals throughout the day and redirect when necessary. Staffing was sufficient at that time, S1 and S2 were both present, and both have certified training in “Understanding Dementia”. 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 is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided to Assistant ED.the state’s words, verbatim · CDSS document, May 31, 2024 · control 15-AS-20240530153125

Type of visit: Required - 1 Year

On 05/30/24 around 01:00 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced annual inspection. LPA met with Sonja Givens, Executive Director (ED) and Tracy Gibson, Assistant ED and explained the purpose of the visit. ED currently holds standard certificate (#6002048740) exp. 02/03/2025. The facility’s fire clearance was approved for sixty (60) non-ambulatory residents; twenty (20) may have hospice waivers. Upon arrival, LPA observed five (5) residents lounging, conversing and putting a puzzle together. Several staff and residents were in the dining area. Staff and residents were moving about throughout the facility's common areas. LPA toured the facility including, but not limited to the common areas, bathroom, dining area, and front courtyard. The facility consists of individual apartments and a memory care unit. All outdoor and indoor passageways were free of obstruction. There were no bodies of water present. A comfortable temperature was maintained at the facility. The facility has an emergency food supply on site and contract with Sysco Foods, Rubino Produce and Weber Meats along with other vendors for weekly deliveries. LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. Hot water temperature in the shared bathroom was 107 degrees Fahrenheit (F) with hand washing soap, signs, and paper towels; the areas were safe, and sanitary. Linen and hygiene products are available for all residents. PPE, sanitizer, and paper goods remain sufficient. Continued on LIC809C... ...continued from LIC809. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was observed full and new tag to be replaced on 02/11/24. Emergency Disaster Plan is updated, disaster drill last conducted March 2024 and an elopement drill on 05/23/24. Five (5) staff and Nine (9) residents records were reviewed and are complete. The following forms are to be updated and submitted to CCLD: -Resident Roster (Reviewed) -LIC500 Personnel Report (Reviewed) -LIC308 Update Designation of Administrative Responsibility -LIC610D Emergency Disaster Plan (Reviewed) Exit interview conducted and a copy of this report provided to ED.the state’s words, verbatim · CDSS document, May 30, 2024

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.

Type of visit: Case Management - Incident

On 05/30/24 around 05:00 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced annual inspection. LPA met with Sonja Givens, Executive Director (ED) and Tracy Gibson, Assistant ED and explained the purpose of the visit. ED currently holds standard certificate (#6002048740) exp. 02/03/2025. The facility’s fire clearance was approved for sixty (60) non-ambulatory residents; twenty (20) may have hospice waivers. On 05/30/2024 Licensing Program Analyst (LPA) L. Holmes received a report of suspected elder abuse from Witness #1 (W1). It was reported that on 05/27/2024 that Resident (R1) slapped (R2) across the face. After record reviews and interview with ED, the same incident was reported via an SOC 341 on 05/30/24. Staff (S1) observed R1 and R2 sitting next to each other. R2 has a history of false perceptions, and screaming. R2 perhaps became annoyed and then made contact with R2's left side of the face from R1's palm. R2 has a history of neuro-cognitive disorder and does not remember the chain of events. R1 and R2 are spouses; therefore, the facility has initiated to supervise R1 and R2 so that they can enjoy their meals throughout the day and redirect when necessary. Exit interview conducted and a copy of this report provided to ED.the state’s words, verbatim · CDSS document, May 30, 2024