Elegance Berkeley

Type of visit: Case Management - Other

On 4/8/2026 at 12:30pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Maureen Lee, Administrator, and explained the purpose of the visit. While LPA L. Hall was conducting a pre-licensing (CHOW) LPA observed one staff (S3) was not associated to the facility. LPA observed during record review that the ten (10) personnel files were incomplete. *An immediate civil penalty of $500.00 will be assessed on today's date for 87355 association to facility* Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (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. A copy of the LIC421BG, appeal rights, and this report provided.the state’s words, verbatim · CDSS document, Apr 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Apr 9, 2026

(e) All individuals subject to a criminal record review... shall prior to working... licensed facility: (3) Request a transfer of a criminal record clearance... This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having S3 associated to the facility which poses a potential health, safety, and personal risk to persons in care.the state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: Administrator agreed to associated S3 to the facility and submit proof to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Apr 22, 2026

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement was not met as evidence by: Based on record review LPA observed ten personnel files were incomplete, which poses a potential health, safety, and person rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: Administrator agreed to complete all files and notify LPA to review by POC date.

Type of visit: Case Management - Incident

On 04/01/2026 at 10:30 AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced Case Management visit regarding information provided pertaining to a resident committing suicide at the facility. The facility sent in a death report on 03/11/2026 and spoke with CCL office support on 03/10/2026 to advise of incident. LPA met with Executive Director (ED), Quaid Holder, and Director of memory care, Maureen Lee, and explained the purpose of the visit. Death Report (LIC624A) indicated that Resident 1 (R1) was in shower with shower hose around neck. Staff performed CPR until Paramedics arrived. Paramedics pronounced R1 as deceased at 11:58am. During the visit, LPA reviewed, facility roster, death report, R1's service plan, physician report, face cover sheet, identification and emergency notification, and service plan. LPA may return at a later time. No deficiencies cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 1, 2026

Allegation investigated: Staff does not prevent resident from being verbally abusive to other residents Staff charging resident for services not received

On 12/10/25 at 1:18PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (Regional Operations Leader (ROL), Associate ED (AED), gathered information and delivered investigation findings of above allegations. LPA explained the purpose of the visit with ROL and AED. During investigation, LPA interviewed staff (ROL, AED), random residents (R1, R2, R3) and obtained the following documents from AED - staff roster, residents’ roster, admission agreement, physicians report, ID/Emergency information, Appraisal/Needs & Services plan, monthly invoices and incident reports. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Staff does not prevent resident from being verbally abusive to other residents Investigation Finding: Unsubstantiated On 12/10/25 at 1:20PM, LPA interviewed staff (ROL, AED), staff incident statements and reviewed R1’s documents. ROL stated that they have had two in person meetings with R1 and R2 to address and mitigate their verbal altercations. AED stated that on 11/20/25 after residents had their lunch, staff (S1,S2) safely redirected R2 back to his room when he started yelling at R1 when she purposely provoked R2 to make him more angry. Prior LPA L Holmes' interviews with residents (R1,,R3, R4) on 09/04/25 confirmed that staff safely redirected and separated R1 and R2 whenever they had a heated argument. 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 does not prevent resident from being verbally abusive to other residents is unsubstantiated. Allegation: Staff charging resident for services not received Investigation Finding: Unsubstantiated On 12/10/25 at 1:20PM, LPA interviewed staff (ROL, AED) and reviewed R1’s documents. Review of R1’s signed service plan agreement dated 04/22/25 showed R1 agreed to pay the Level I Assisted Living Care monthly charge of $960.48 effective 05/13/25. AED stated the change of monthly charge was due to the switch from Elegence at Berkeley Service Plan point system to the new Arbor at Berkeley Level of Care Plan system. Staff (ROL,AED) stated they explained the monthly service rate change to R1 and did not bill her the Level 1 Care package until 07/01/25 with a monthly discount of $200. 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 is charging resident for services not received is unsubstantiated. No deficiencies cited. Exit Interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 10, 2025 · control 15-AS-20251201102255

Type of visit: Case Management - Health Checks

On this day, December 8, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 1 complaint (Complaint # 15-AS-20251203154452). LPA met with Associate Executive Director Justin Zackzewski and informed the reason for visit. LPA also met with Regional Operations Leader Sarian Lichtenberger. LPA selected total of 5 residents apartments on second, third and fourth floors for inspection. LPA also inspected the common areas including but not limited to the dining area, activity room and hallways. No deficiency observed during today's inspection. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 8, 2025

Allegation investigated: Staff leave residents in soiled diaper for an extended period of time Staff does not ensure adequate food options are available for residents with dietary restrictions

On11/20/2025 at 10:30 AM, LPA's Ardalan Gharachorloo and David Doidge arrived unannounced to deliver finding for the above allegations. LPA met with Sarian Lichtenberger, Regional Operation Leader and explained the purpose of the visit. Allegation: Staff leave residents in soiled diaper for an extended period of time - Unsubstantiated On 9/18/2025, LPA initiated 10-day investigation, obtained records and interviewed staff and residents. During the visit, LPA interviewed Resident 3 (R3). R3 was identified by RP as the resident who is left in soiled diapers and whose room smells so bad when opened. During the interview, R3 states staff are nice and helpful. And that staff come to assist R4, if needed. While interviewing R3, LPA did not notice any urine smell. R4 appeared to be well groomed. R3 appeared excited about the performer coming for the day’s activity. ***CONTINUE ON 9099C*** Unsubstantiated ***CONTINUE FROM 9099*** During the visit, LPA with Justin Zackweski, Regional Director and LPA Lisha Holmes checked R3’s room. LPAs observed the room to be clean, organized and odor free. Staff interviewed state incontinent residents get changed 2-3 times during each shift. The first check/change is done at the start of shift, then after lunch and before end of shift. Allegation: Staff does not ensure adequate food options are available for residents with dietary restrictions - Unsubstantiated During the course of investigation, LPA reviewed facility menus for the last three months. There are two types of menu: regular and alternate. Interim ED states the regular menu has always two options for the residents to choose from. And then the alternate menu which can be served to the residents anytime they prefer to eat food apart from the regular. The information provided by the ED was confirmed by R3 who states that R3 has chosen the alternate menu a few times since living at the facility and everything is fine. An interview was conducted with R4 who states that R4 has dietary restrictions – Kosher diet, which the facility does not accommodate. R4 states the facility does not provide Kosher foods. When asked if the facility was made aware of R4’s restrictions during the admission process, R4 stated the facility should know but did not provide any further information. A review of R4’s medical assessment did not indicate any dietary restrictions or allergies. The report indicates R4 “has no special diet but has dietary preference.” The facility’s dietary board did not indicate R4’s name as one of the residents with dietary restrictions. Based on interviews and record reviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. A copy of this report was provided to Sarian Lichtenberger, Regional Operation Leader.the state’s words, verbatim · CDSS document, Nov 20, 2025 · control 15-AS-20250917090638

Allegation investigated: Staff did not prevent resident from harassing another resident. Staff did not provide resident with adequate food service. Licensee did not provide adequate notice of fee increase to resident.

On 09/18/2025 around 12:50 PM, Licensing Program Analyst (LPA) L. Holmes conducted a an unannounced initial 10-day complaint. LPA met with and explained the purpose of the visit to Maureen Lee, Memory Care Director. During the complaint LPA Interviewed Staff (S1, S2, S3, S4, S5), Residents (R1, R2, R3, R4, R5, R6), and Witnesses (W1, W2, W3) and requested the following documents: LIC501, Resident Roster, ID/Emergency Contact information, LIC 602, Preappraisal, House Rules, current Appraisal Needs and Services, and Admission Agreement, Monthly Menu and Always Available Menus. Allegations UNSUBSTANTIATED: Continued on LIC9099C... Unsubstantiated ...continued from LIC9099. Staff did not prevent resident from harassing another resident. R1 stated that R2 was verbally harassing him/her multiple times. In a prior to the complaint is when R2 used a curse word towards R1. R1 did not identify any witnesses. S2 and S5 stated that R2 does have occasional outbursts which may be due to a medical condition, but there’s never anything physical towards R1. S2 stated that he/she spoke to R1 and R2 regarding the interactions suggesting sitting away from each other and/or repositioning R1's chair for avoidance, and S2 will redirect when necessary; stating that both residents have personal rights. R1 requested LPA to allow him/her to remain anonymous with R2; therefore, LPA did not interview R2. S5 stated that the allegation is not surprising because R1 will go behind the bistro bar even though R1 is not supposed to enter the area, and R1 does not want R2 to say anything about it him/her, becomes rude, screams, complains and then acts as if nothing has happened. Staff did not provide resident with adequate food service. LPA toured the dining area and observed breakfast and lunch being served to residents on 08/26/25 and 09/04/25. The purchase orders and invoices from Vesta and Sysco food services for the month of August 2025, were consistent with the menus provided and the meals observed. Interviews revealed that S1, S2, S3, S4, W1, W2, W3, R1, R3 and R5 did not initiate any complaints about the meals, menu of food provided; R1 was not forth coming with names, dates or times of the allegation or when the incident was reported. Licensee did not provide adequate notice of fee increase to resident. Interviews with (S1, S2, S3 S4), Admission records and services fees reviewed for R1, R2, R3, and R4 did not reveal any rate increases, improper notices or advance notice (60 days) notices. S1 stated there has not been any new rent rate increases since the introduction of the new management company on 07/01/2025. Hospitality. Based on information obtained, the allegations are 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, and a copy of this report provided to Justin Zackzewski, Director of Hospitality.the state’s words, verbatim · CDSS document, Sep 18, 2025 · control 15-AS-20250827092248

Type of visit: Required - 1 Year

On 08/26/2025 around 09:45 AM, Licensing Program Analysts (LPAs) L. Holmes and L. Alexander arrived unannounced for a required annual inspection. LPAs met with Annemarie Domizio, Executive Director (ED) and Maureen Lee, Memory Care Director (S2), and explained the purpose of the visit. ED was not available due to the activities taking place a the facility. The facility’s fire clearance was approved for one hundred twenty (120) non-ambulatory residents; ten (10) may be bedridden, and ten (10) hospice. Upon arrival, LPAs observed multiple staff organizing a residential Hawaiian Luau, the receptionist was attending to several residents and guest visiting in the facility. LPA L. Alexander toured the facility S2. The areas included but were not limited to the common areas, dining room, bathroom, kitchen, med tech room, fitness center and courtyards. The facility consists of individual apartments housed by the residents and has a monitored floor for memory care. All outdoor and indoor passageways were free of obstruction. There were no bodies of water present. A comfortable temperature was maintained at 74 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. The hot water temperature in four different rooms measured at 108 to 120 degrees (F). The shared restroom had paper towels, soap and garbage cans; all areas were safe and sanitary. PPE, sanitizer, and paper goods remain sufficient. There was a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. ...continued on LIC9099C. ...continued from LIC9099. Smoke detectors and carbon monoxide units were in operating condition during visit. Fire extinguisher was observed full and serviced 07/24/25. Emergency Disaster Plan is updated. Safety drills are rotational and last inspected 07/23/2025. LPA reviewed seven (7) staff files, and ten (10) resident files. -At 11:35 AM, LPA confirmed through Guardian, and CCLD staff support that S2 was not associated to the facility; corrected during the visit. -At 12:15 PM, LPA confirmed through observation and reviewed seven (7) out of seven (7) personnel records were incomplete; no health screenings, no first aid, insufficient training. Deficiencies are being cited on the attached LIC 809D. Civil penalties were assessed for $100.00/day x five (5) days. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties. LPA L. Holmes advised ED that the use of the name, "The Arbor at Berkeley" must cease until licensed which includes but is not limited to signs, documents, flyers and announcements. Exit interview conducted. A copy of this report and appeal rights provided to S2.the state’s words, verbatim · CDSS document, Aug 26, 2025

The state marks this report as 8 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff working while under the influence of alcohol. Staff disrespectful to residents and residents' families.

On 07/02/2025 around 02:15 PM Licensing Program Analysts (LPA) L. Holmes and Y. Brown conducted an unannounced complaint visit to deliver the findings for the above allegations. Annemarie Domizio, Executive Director was in a meeting during the visit. LPA presented the allegations Justin Zackzewski, Director of Hospitality. LPAs conducted interviews with Residents (R1, R2, R3), Staff (S1, S2, S3, S4, S5, S7), and Witnesses (W1, W2).. LPAs requested the following documents for February 2025 - May 2025: Staff Schedule, Resident Roster, ID/Emergency Contact information, and personnel files for disciplinary action. Continued on LIC9099C... Unsubstantiated ...continued from LIC9099. Allegations: UNSUBSTANTIATED Staff working while under the influence of alcohol. The reporting party remained anonymous; however, S1 and S2 thinks they know who initiated the complaint. LPA reviewed personnel records for disciplinary actions against staff from February 2025 - May 2025, no records revealed any misuse of alcohol while staff were on duty. On 02/25/25, S2 stated that S3 was being mean towards S1; it wasn't right. S3 was looking for S1 with a disgusting look (teasing). S1 stated that the complaint has no merit and S1 is not comfortable being with S3. S3 stated that he/she did not want to mention who told him/her that S1 smells like alcohol because S3 doesn’t want to get them in trouble. S1 stated that S3 said he/she smelled tequila. S2, S3, S6, R1, R2, and R3’s interviews did not reveal any witnessing or knowledge of any staff working while under the influence of alcohol. Staff disrespectful to residents and residents' families. R1 stated that everything is okay at the facility. R1 said he/she had not met or talked to S1 yet, but R1 has seen S1. R2 thinks he/she is getting what R2 needs, but has not met S1, and has lived at the facility for over 2 years. R3 said he/she has only talked or interacted with S7, and “S7 is realistic about what’s going on.” R3 has not met S2 or S1. Based on information obtained, the allegations are 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, and a copy of this report provided to Justin Zackzewski, Director of Hospitality.the state’s words, verbatim · CDSS document, Jul 8, 2025 · control 15-AS-20250225105631

Allegation investigated: Staff are not ensuring that resident(s) receive their medications as necessary. Staff are not adequately supervising resident(s) in care. Licensee does not ensure that medical staff are able to communicate with staff regarding residents in care. Facility fax is in disrepair.

On 06/11/2025 around 12:00 PM Licensing Program Analysts (LPA) L. Holmes and Y. Brown conducted an unannounced complaint visit to deliver the findings for the above allegations. Annemarie Domizio, Executive Director was in a meeting during the visit. LPA presented the allegations Justin Zackzewski, Director of Hospitality. Amended reported to make public. LPAs conducted interviews with Residents (R1, R2, R3), Staff (S1, S2, S3, S4, S5, S7), and Witnesses (W1, W2).. LPAs requested the following documents for February 2025 - May 2025: R1's records, MAR, Staff Schedule, Resident Roster, ID/Emergency Contact information, and personnel files for disciplinary action. Continued on LIC9099C... Substantiated ...continued from LIC9099. Allegations: SUBSTANTIATED Staff are not ensuring that resident(s) receive their medication's as necessary. S6 reported on R1’s progress notes dated 03/15/2025 that R1 last received Sertraline on 03/12/25; The Electronic Medication Administration Records (EMAR) further reports that Omnicare and Elegance Berkeley had two different attending physicians. As a result, W1 wrote a prescription on 03/17/25 and W2 provided the medication to the facility for R1. S6 stated that the R4’s medication was discontinued on 02/28/25, but R4 missed the medication for two days, R4’s family was not notified, and the doctors were not aware. S6 states, “Staff are not properly trained.” Staff are not adequately supervising resident(s) in care. On 03/04/25, S8 documented on R1’s progress notes that R1 was found outside by the corner of the facility. Records and interviews with S1, S2, S5, S6, S7 and W2 revealed that R1 has exited Memory Care and had wandering behaviors in March and April of 2025. On 04/14/25, R1 exited from Memory care to the 1st floor without any staff witnessing the elopement. On 04/28/25, W2 requested that R1 take a stroll with the Care Companion (1:1), action was denied by S1 and S5. S2 confirmed that R1 was unable to leave with the 1:1 because the staff were trying to get R1 acclimated to residing in Memory Care. Licensee does not ensure that medical staff are able to communicate with staff regarding residents in care. W1, and S5 stated that the fax machine was not working but was not able to confirm the fax number; W1 stated the date was around January 2025. LPA confirmed that the fax number 510-788-XXXX is not working per the notification on the fax cover sheet from the facility dated 04/2025. W1 was not able to confirm the correct fax number because the facility had not given W1 any advance notification. LPA confirmed that 510-705-XXXX is a working fax, and was last tested 01/28/25 per records reviewed. Continued on LIC9099C. ...continued from LIC9099C. Facility fax is in disrepair. W1, and S5 stated that the fax machine was not working but was able to confirm the fax number. LPA confirmed that the fax number 510-788-XXXX is not working per the notification on the fax cover sheet from the facility. W1 was not able to confirm the correct fax number because the facility had not given W1 any advance notification. LPA confirmed that 510-705-XXXX is a working fax and was tested on 01/28/25. 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 a copy of this report provided to Justin Zackzewski, Director of Hospitality.the state’s words, verbatim · CDSS document, Jun 11, 2025 · control 15-AS-20250422160308

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(d) · Plan of correction due date: Jun 13, 2025

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication...unable to communicate his/her symptoms clearly, facility staff designated by the licensee... assist the resident with self-administration... -This requirement is not met as evidenced by: Based on interviews and records reviewed, Licensee did not assure residents received administration of medication(s).the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Licensee/ED to assure that trained staff are available to assist residents as needed with medications, follow physician’s orders, perform staff training for all personnel that administers medication. Submit names of attendees to CCLD by POC.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411 · Plan of correction due date: Jun 13, 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 assist R1 with exit seeking behaviors per R1's physician's report.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Licensee/ED 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.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.80 · Plan of correction due date: Jun 13, 2025

1569.80 Care and services decision making; meeting; written record (b) Once prepared, the written record...to determine the care and services provided to the resident written record shall be sent by the facility to that physician.-This requirement is not met as evidenced by: Licensee/ED did not confirm contact information was correct for notifications of residents' services from physicians and pharmacies.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Licensee/ED to inform all physicians and pharmacies of the correct form of communication by fax, email and landline. Provide proof of notification to CCLD on or before completion date of 06/18/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303 · Plan of correction due date: Jun 11, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.-This requirement is not met as evidenced by: Licensee/ED presented two different fax cover sheets and could not confirm when fax number 510-788-XXXX was no longer working.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: LPA tested and confirmed that the fax machine is working.

Type of visit: POC

On 05/20/2025 around 9:15 AM, Licensing Program Analysts (LPA) L. Holmes arrived unannounced to conduct a proof of correction (POC) inspection. LPA met with Justin Zackzewski, Director of Hospitality and explained the purpose of the visit. Facility has the following deficiencies that were not cleared, and deficiencies were issued on 05/02/2025 from California Code of Regulations, Title 22: - 87303 (b)(3): Licensee/ED to assess HVAC system, thermostat, and make repairs. Consult R1 about temperature range, provide proof of training with signatures, and invoices by POC date. - 1569.80 (b) Licensee/ED to inform R1's physician by written communication, provide proof of notice to CCLD, review regulation, and certify with signatures by POC. - 87468.2 (a)(2) Licensee/ED to review regulation and ensure that all residents records are presented and maintained with confidentiality. Provide in-service training for Care Staff, and signatures as proof. Civil penalties of $1100.00 are assessed for the period of 05/10/25 to 05/20/25 for failure to correct each above deficiency. Total civil penalties in the amount of $3300 are being assessed today. Facility is subject to ongoing civil penalties until deficiencies are corrected. Exit interview conducted. A copy of this report, civil penalties, and appeal rights provided.the state’s words, verbatim · CDSS document, May 20, 2025

Allegation investigated: Staff did not do a proper reassessment of residents care needs Staff did not ensure residents thermostat was working properly

On 05/02/2025 around 05:00 PM Licensing Program Analyst (LPA) L. Holmes arrived unannounced and delivered the complaint findings for the allegations. LPA met with Annemarie Domizio, Executive Director and presented the allegations. LPA interviewed Staff (S1, S2, S3, S4, S5, S6, S7, S8), Resident #1 (R1, R2), and requested the following documents for March - April 2025: Staff Schedule, Resident Roster, Maintenance receipts/reports for facility repairs, ID/Emergency Contact information, LIC 602, Preappraisal, current Appraisal Needs and Services, Functional Evaluation, and Admission Agreement and for Residents R1. Continued on LIC9099C... Substantiated ...continued from LIC9099. Allegation: Substantiated Staff did not ensure residents thermostat was working properly Interviews with staff indicated the following: On 04/22/25, S2 stated. “One of the units on the roof didn't have Freon. It affected about 3 apartments; it was the AC and the heater, and this was to regulate the temperature. On the third floor there were maybe 2 apartments affected.” S4 stated “I will admit that the temperature has been an ongoing issue and that's been about two months. S3 stated that he/she performed periodic checks in R1’s room, and that the centralized system that regulates the temperature did not indicate any fault in R1’s apartment. LPA and S4 attempted to adjust the temperature on R1’s thermostat below 77 degrees F. and thermostat continually defaulted to 77 degrees F. LPA immediately placed a service request with the concierge. On 04/30/25 S1 stated. “The HVAC system has been fixed for well over a week, we have the tech coming out tomorrow for an unrelated project and I will have him stop by the unit once again.” LPA, S3 and S2 attempted to adjust the thermostat to 80 degrees F. LPA returned after an hour and the thermostat increased 1 degree from 78 to 79, but not 80. In addition, R1’s filter needs to be cleaned. Allegation: Substantiated Staff did not do a proper reassessment of residents care needs A Functional Evaluation was conduct for R1 on 10/17/25 by S2, and on 04/08/25 by S3. The 04/08/25 evaluation was initiated by S1 and R1 disagrees. The records reviewed by LPA and R1 revealed that S1, S2 and S3 did not include written record from the facility informing R1’s regular physician of the results of either functional evaluation for R1’s care needs. Based on LPA’s interviews and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. Deficiency is 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, and a copy of this report provided to Tsedey Mekonnen, Concierge.the state’s words, verbatim · CDSS document, May 2, 2025 · control 15-AS-20250418151506

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(3) · Plan of correction due date: May 9, 2025

87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (3) Nothing in this section shall prohibit residents from adjusting individual thermostatic controls. -This requirement is not met as evidenced by: Licensee/ED did not ensure the facility maintained a comfortable temperature for all residents at all times.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: Licensee/ED to assess HVAC system, thermostat, and make repairs. Consult R1 about temperture range, provide proof of training with signatures, and invoices by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.80(b) · Plan of correction due date: May 9, 2025

1569.80 Care and services decision making; meeting; written record (b) Once prepared, the written record...to determine the care and services provided to the resident written record shall be sent by the facility to that physician. Licensee/ED did not provide written record to R1's physician for the decision making for care and services.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: Licensee/ED to inform R1's physician by written communication, provide proof of notice to CCLD, review regulation, and certiy with signatures by POC.

Allegation investigated: Staff did not keep all information or records regarding the resident confidential

On 05/02/2025 around 11:00 AM, Licensing Program Analyst (LPA) L. Holmes conducted a case management as result of an unannounced initial 10-day complaint dated 04/30/2025 #15-AS-20250430171112. LPA met with Justin Zackzewski, Director of Hospitality. Allegation: SUBSTANTIATED Staff did not keep all information or records regarding the resident confidential LPA interviewed Staff (S1, S2, S3), Witnesses (W1, W2) and requested the following documents: LIC501, Resident Roster, ID/Emergency Contact information, LIC 602, Preappraisal, current Appraisal Needs and Services, and Admission Agreement for R1. ...continued from LIC9099. Substantiated ...continued from LIC9099. On 04/21/25, S1 submitted an LIC 624 stating. “The community will be seeking a three-day discharge” for R1; no Eviction Notice was provided to CCLD at that time. On 04/24/25, LPA requested the Eviction Notice that was provided to R1. On 04/28/25, S1 emailed LPA a 30-day notice of discharge addressed to W1 dated 04/22/25. On 04/29/25, LPA advised S1, S2, and S3 via email, W1 by voicemail on 04/29/25 and by phone conversation on 04/30/25 that the Notice of Eviction presented to R1 was unlawful, and that the facility’s Licensee would be required to provide notification to R1 and R1’s responsible party that the notice would be rescinded immediately. W1 was unaware of the notice, the details, and had not received any written Eviction Notice from any representatives from the facility. W1 provided proof of a formal notice hand delivered to R1 while in the community amongst other residents. R1 is currently admitted in Memory Care (MC) and the notice contained confidential information signed by residents R2, R3, and R4, other than R1. S2 confirmed that he.she was instructed by S1 to hand deliver the notice to R1 in the presence of other residents. Based on LPA’s interviews and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. Deficiency is 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, appeal rights and a copy of this report provided to Tsedey Mekonnen, Concierge..the state’s words, verbatim · CDSS document, May 2, 2025 · control 15-AS-20250430171112

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: May 9, 2025

87468.2...Personal Rights of Residents in Privately Operated Facilities (a) ...Residents in All Facilities...shall have all of the following personal rights: (2) To have their records and personal information remain confidential... -This requirement is not met as evidenced by: Licensee/ED did not ensure that R1's and RP's records be presented and maintained with confidentiality.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: Licensee/ED to review regulation and ensure that all residents records are presented and maintained with confidentiality. Provide in-service training for Care Staff, and signatures as proof.

Type of visit: Case Management - Deficiencies

On 05/02/2025 around 01:00 PM, Licensing Program Analyst (LPA) L. Holmes conducted a case management as result of a complaint dated 04/22/2025 #15-AS-20250422160308 and UIRs. LPA met with Justin Zackzewski, Director of Hospitality. In addition to the complaint, LPA received LIC 624 dated 04/24/25 stating that R1 was sent out (to the hospital) for repeated exit seeking. On 05/02/2025 around 1:10 PM, LPA toured the perimeter of the facility and observed a gray, cable wired, combination lock on the side gate. This gate exits from the facility's court yard. LPA advised S1 to remove the lock. On 04/21/25, S1 submitted an LIC 624 stating. “The community will be seeking a three-day discharge” for R1; no Eviction Notice was provided to CCLD at that time. On 04/24/25, LPA requested the Eviction Notice that was provided to R1. On 04/28/25, S1 emailed LPA a 30-day notice of discharge addressed to W1 dated 04/22/25. On 04/29/25, LPA advised S1, S2, and S3 via email, W1 by voicemail on 04/29/25 and by phone conversation on 04/30/25 that the Notice of Eviction presented to R1 was unlawful, and that the facility’s Licensee would be required to provide notification to R1 and R1’s responsible party that the notice would be rescinded immediately. Continued on LIC 809C... ...continued from LIC 809. On 04/29/25, LPA advised S1, S2 and S3 that the notice and the previously noticed deadlines for eviction were invalid. LPA reviewed the eviction notice. Per Title 22 87224 Eviction Procedures, 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. In addition, the exact statement as specified in Title 22 for an unlawful detainer shall be documented; these items were not documented. *An immediate civil penalty of $500.00 will be assessed on today's day for fingerprint clearance* Deficiency cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (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. A copy of the LIC421M, appeal rights, and this report provided.the state’s words, verbatim · CDSS document, May 2, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: May 2, 2025

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. -This requirement is not met as evidenced by: Licensee to review the regulation, provide training to staff and submit proof to CCLD by POC. Locks removed from two gates during the visit to allow emergency exiting on both sides.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: Based on observation, interviews, and record review the licensee did not comply with the section cited by having a gray, cable wired, combination lock on the side gate which poses an immediate health, safety or personal rights risk to persons in care. ED removed during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87224(f) · Plan of correction due date: May 2, 2025

87224 Eviction Procedures (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. -This requirement is not met as evidenced by: Licensee did not provide the notice of eviction in a timely matter to CCLD. The notice provided to R1's RP was unlawful.the state’s words, verbatim · CDSS document, May 2, 2025

Plan of correction: Licensee/ED to immediately inform the resident & their representative, both verbally and in writing to disregard the previously issued notice. Review regulation, provide signatures and rescinded notice as proof.

Type of visit: Case Management - Other

On 05/02/2025 around 11:00 AM, Licensing Program Analyst (LPA) L. Holmes conducted a case management as result of an unannounced initial 10-day complaint dated 04/30/2025 #15-AS-20250430171112. LPA met with Justin Zackzewski, Director of Hospitality. LPA and S1 discussed the above complaint. S1 to provide LPA with emails and/or correspondences regarding R1's admission at the facility. LPA referenced Title 22, Division 6 Chapter 8 Article 06. Background Check and Title 22, Division 6 Chapter 8 Article 07. Personnel 87412 Personnel Records. This conversation was related to S1, S2, S3 and all other employees that are responsible for administration, direct supervision of staff, and care for residents. Exit interview conducted, and a copy of this report provided to Tsedey Mekonnen, Concierge.the state’s words, verbatim · CDSS document, May 2, 2025

Allegation investigated: Staff allowed a resident to be soiled while in care Staff mishandled a resident's medication while in care

On 03/28/25 around 09:00 AM L. Holmes, Licensing Program Analyst (LPA), arrived unannounced to deliver the finding for the above allegation. LPA met with Director of Hospitalitys, Justin Zackzewski and explained the purpose for the visit; Concierge stated that Annemarie Domizio, Executive Director should arrive around 10:00 AM. During the course of the investigation and visit, LPA and S1 toured the facility on 12/20/24; LPA requested, and reviewed the following, but not limited to staff roster, resident roster, resident records, including but not limited to Residents' (R1, R2, R3): LIC602, ID/Emergency Contact information, Progress Notes, Centrally Stored Medications/Destruction Records, Medication Sheet, Functional Evaluations, and Physician's Orders. LPA conducted resident, staff and witness interviews. Continued on LIC9099C... Substantiated ...continued from LIC9099. Staff allowed a resident to be soiled while in care W2 reported he/she arrived at the facility for his/her shift t and found R1 was left in soiled clothing and sheets with feces. W2 report the incident to W1. W2 stated he/she saw S5, and S6 that morning and was not sure why no one had responded to R1. W2 stated all the caregivers or housekeeping would have had to do is put R1 in the shower. It was about 9:00 AM when S10 was passing the medications. It took S10 about 3 hours to comeback regarding R1’s ingrown toenails. W2 asked S10 to please give R1 the Imodium A-D for diarrhea; R1 was having stomach issues. W2 stated. “The one thing that is wrong with the facility for sure is that there are no nurses.” S4 was not at the facility that day. According to W2, S10 finally called someone, and it was about 1:00 – 2:00 PM before R1 received the medication to relieve the diarrhea. LPA interviewed W3, and W4, and both stated that they have had incontinence concerns with the facility also. Staff mishandled a resident's medication while in care Records requested and interviews with W1 and W2 revealed that R1 is prescribed Imodium A-D. The Medication Sheet has two separate and different entries for R1’s Centrally Stored Medication; neither were notated as being administered for 12/2024. LPA reviewed R1’s Physician’s Report (LIC602); LPA reviewed R1’s Progress Notes and there was not any notation or refusal for the month 12/2024. Interviews with W1 and W2 reveal that R1 had an incident with diarrhea and vomiting on or around 12/16/24. S10 administered Imodium (A-D); however, the time, date and dosage is unknown and was not recorded on any day of R1's Medication Sheet for the month 12/2024. Based on LPA’s observations, interviews and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. Deficiency is 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, appeal rights and a copy of this report provided to Justin Zackzewski, Director of Hospitality.the state’s words, verbatim · CDSS document, Mar 28, 2025 · control 15-AS-20241216095924

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

Personnel Requirements-General 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. -This requirement is not met as evidenced by: Based on interviews and records reviewed, the license did not comply with the section above by not having sufficient and competent number of staff to meet bowel and incontinence care needs.the state’s words, verbatim · CDSS document, Mar 28, 2025

Plan of correction: Licensee/ED to review all residents’ appraisals and care plans to ensure there is sufficient number of staff to provide adequate care and supervision to all residents. ED to review regulations, self-certify and provide CCLD a current/updated schedule for each shift by POC date.

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

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication...unable to communicate his/her symptoms clearly, facility staff designated by the licensee... -This requirement is not met as evidenced by: Based on interviews and records reviewed, Licensee did not assure residents received administration of medication(s).the state’s words, verbatim · CDSS document, Mar 28, 2025

Plan of correction: Licensee/ED to assure trained staff are available to assist residents as needed with medications, document refusal date, time, follow physician’s orders, reconcile medication lists, & perform staff training for all personnel that administers medication. Submit proof of procedures with names of attendees to CCLD by POC.

Allegation investigated: Staff did not provide resident medication as requested.

On 03/28/25 around 09:00 AM L. Holmes, Licensing Program Analyst (LPA), arrived unannounced to deliver the finding for the above allegation. LPA met with Staff, Justin Zackzewski and explained the purpose for the visit; Concierge stated that Annemarie Domizio, Executive Director should arrive around 10:00 AM. During the course of the investigation and visit, LPA and Licensing Program Manager (LPM) Y. Flores-Larios met with Interim Executive Director (ED) and onboarding Executive Director (ED) Annemarie Domizio on 01/14/25. LPA and ED toured the facility, LPA and LPM requested, and reviewed the following, but not limited to staff roster, resident roster, resident records, including but not limited to Residents' (R1, R2, R3): LIC602, ID/Emergency Contact information, Progress Notes, Centrally Stored Medications/Destruction Records, Medication Sheet, Functional Evaluations, and Physician's Orders. LPA conducted resident, staff and witness interviews. Continued on LIC9099C... Unsubstantiated ...continued from LIC9099. Staff did not provide resident medication as requested. LPA reviewed a sample of two dates from R1’s Medication Notes, and Progress Notes before around the alleged time frame that R1’s medication was mishandled during December 2024. R1 is prescribed Milk of Magnesia (PRN) for nighttime. On 12/18/24, the Medication Sheet revealed that S11 administered PRN at 03:24 AM; progress notes revealed that PRN was requested by R1 at 9:00 PM but not administer by S8 which is noted on the Medication Sheet. On 12/19/24, S12 administered PRN at 08:53 PM and noted that R1 requested PRN again at 11:00 PM. Records do not reflect that there was any medication administered in error, and R1 was administered his/her prescribed Metamucil for the entire month of December as prescribed except when R1 refused on 12/18/2024. R1 and W1 could not identify specific PRNs and/or prescribed medications that weren’t administered when requested according to the physician’s orders. Based on LPA’s observations, interviews and records reviewed, the preponderance of evidence standard has not been met; therefore, the above allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 28, 2025 · control 15-AS-20250108114401

Type of visit: Case Management - Other

On 02/05/2025 around 01:35 PM, LPA amended complaints 15-AS-20241223152240 and 15-AS-20241223091751 to update the continuation pages. Executive Director (ED), Annemarie Domizio suggested that Licensing Program Analyst (LPA) L. Holmes meet with Claudia Ridditt, Director of Business Administration (S1) due to ED's time constraints. LPA interviewed S5 to review the coding for the Medication Administration Records (MAR) and confirmed there will be initials for administration of medication, an 'X' or a blank space with progress notes for an explanation. On 01/21/2025, LPA requested ED provide proof that Residents (R2, R3, R4, R5) and their responsible parties were provided with a current incontinence care plan for the plan or correction on complaint 15-AS-20240917163033. On 01/28/25, LPA received the POC for training and updated care plans; however there were not any emails, faxes, or signed incontinence care plans from residents and RPs to confirm they were aware of the updates; during the visit, S1 and LPA reviewed signed copies for R1 and R3. S1 stated that they were awaiting the signed electronic documents from R5, and R2 had passed away. - Around 3:15 PM, LPA requested a Death Report (LIC624A) that revealed R2's date of death was 01/02/2025 and was reported to Community Care Licensing (CCL) 01/21/2025. 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 date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, a copy of the appeal rights, and this report provided Claudia Redditt, Director of Business Administration (S1)the state’s words, verbatim · CDSS document, Feb 5, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Feb 10, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency ... (1) A written report ... within seven days of the occurrence of any of the events specified in (A) through (D) below ... (A) Death of any resident -This requirement is not met as evidenced by: Based on interviews and records reviewed, the Interim ED did not comply with the section above by not providing a written report of death for R2 within seven (7) days which poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2025

Plan of correction: ED to review the regulation, self-certify, and provide proof to CCL by POC date.

Allegation investigated: Staff left residents in soiled diapers for an extended period of time resulting in injury Staff sleeping during work hours Staff screamed at resident

On 1/14/2025 around 10:00 AM, Licensing Program Analyst (LPA) L. Holmes and Licensing Program Manager (LPM) Yvonne Flores-Larios arrived unannounced to deliver the findings for the above allegations. LPA and LPM met with Douglas Blake, Interim Executive Director (ED) and Executive Director (ED) Annemarie Domizio and explained the purpose for the visit. During the course of the investigation and visits, LPA and LPM requested an updated staff and resident roster, reviewed staff schedules and training records, and requested documentation for Staff #7 (S7's). Personnel job descriptions & specifications, and contact information for staff. LPA and LPM requested residents' (R1, R2, R3, R4, R5) LIC602's, ID/Emergency Contact Information, Progress Notes and Centrally Store Medication and Destruction Reports. LPA and LPM interviewed staff (ED, S1, S2, S3, S4, S5, S16, S17, S18) and Witnesses (W2, W3, W4). Continued on 9099C... Substantiated ...continued from 9099. Staff left residents in soiled diapers for an extended period of time resulting in injury S17 reported he/she has often arrived for his/her shift to find residents were left wet, dirty, full of feces, and with red bottoms, specifically R6 and their family members were complaining directly to S17. S2 stated he/she has been the only one on his/her PM shift showering residents and has complained to S5. S2 has sometimes witnessed unkept faces, clothes, bedding, and soiled sheets because the AM shift hadn't changed the linen, redness in private areas from being soiled, and resident wounds in memory care. S3 stated that he/she is a Med. Tech. and have found residents on the couch with their entire bottom wet, or dried feces, and redness on their private areas. LPA interviewed W2, W2 stated there's been multiple times where R3's briefs and pants have been wet. On 01/03/24, W2 emailed ED and S8 requesting toileting every three (3) to four (4) hours for R3. W2 discovered there was urine on R3’s depends, pants, and wheelchair seat during a music session and that those discoveries were happening too often and was unacceptable. W3 states that R5 wreaks of urine. W3 changed R5’s soiled wheelchair cushion but was still unsure if the smell was coming from R5’s catheter or colostomy bag. W4 stated that R1’s sheets were soiled on a past occasions; therefore, W4 purchased additional sheets. The facility allowed R5 to leave the facility with another family and there was a hygiene issue. W4 didn't elaborate but was quite upset about the occurrence and it was concerning. W4 thought the incident was a form of neglect. W4 stated that if R1 was in his/her right mind, being constantly clean would be very important for R1. Continued on LIC9099C... ...continued from LIC9099C Staff sleeping during work hours ED stated that S7 may have been sleeping on the second floor during his/her 15-minute break and that S7 has a medical condition. S17 and S18 reported they’ve both seen S7 sleeping when S7 should have been working, and that their co-workers may also be calling to make complaints. LPA and LPM interviewed S18 and he/she stated that a resident was walking by and S7 was snoring, and S18 reported the incident to ED and S5. Although S2 never saw S7 sleeping, S2 stated residents don't want S7 on their assignments and when S7 is working, he/she is also on the phone or watching television in the common areas. LPA reviewed S7's file and did not find any approved accommodations from the facility. Staff screamed at resident S2 said that there was screaming on the second floor coming from S15 who was not treating the residents on the floor with respect. S5 said that there’s no policies about the residents. S18 stated that he/she did not like the way S9 was talking to R2. S18 said that R2 is slow to respond sometimes and maybe the staff needs to be training on how to deal with residents. S18 further stated that another staff, S19, was screaming at a resident R2 on 09/17/24 at 11:30am. S18 stated that resident was refusing to go downstairs to the dining room and S19 started screaming, “You need to go now.” Based on LPA and LPM observations, interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are SUBSTANTIATED. Deficiencies are 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, appeal rights and a copy of this report provided to interim ED. ...continued from LIC9099A. Staff are eating residents food S17 alleged that S7 was eating R6’s food. ED and S16 were not aware of the allegation. LPA and LPM interviewed S1. S1 stated that he/she helps residents with lunch and dinner. S2 stated they’ve never seen anyone eating any residents’ food. LPA interviewed Witnesses; W2 stated that he/she didn’t have any other concerns about abuse or the staff's skill level or appropriate treatment. W3 stated it's hard to find someone at the facility sometimes and W3 hasn’t seen anything, W4 feels that the care staff are lovely. Staff is not allowing resident to watch TV S18 alleged that S7 puts the television (TV) on, and watches what S7 wants to watch and not what the residents want to watch. The facility has individual apartments and communal areas with televisions. LPA toured the facility, including the second floor on 09/24/24, 10/24/24 and 12/23/24. Multiple residents were not watching TV; instead, they were primarily engaged in other activities facilitated by the care staff. The second floor is memory care (MC). Residents that are able to communicate, can retreat to their individual apartments or sit in the lounge area where the television is located. A finding that the complaints are UNSUBSTANTIATED mean that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted, appeal rights and a copy of this report provided to ED.the state’s words, verbatim · CDSS document, Jan 14, 2025 · control 15-AS-20240917163033

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jan 27, 2025

Personnel Requirements-General 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. -This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee and ADM did not comply with the section above by not having sufficient and competent number of staff to meet R1, R2, R3, and R5’s incontinence care needs.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: Licensee and administrator (ADM) to review all residents appraisals and care plans to ensure there is sufficient number of staff to provide adequate care and supervision to all residents. ADM to provide R2, R3, R4, R5 and their responsible parties a current incontinence care plan. ADM to provide to CCLD a current updated schedule for each shift by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(f) · Plan of correction due date: Jan 27, 2025

87411 Personnel Requirements – General (f) All personnel ... shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified…signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents…Personnel with evidence of physical illness ... relieved of their duties. -This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, S7 was asleep in the common area where other staff and residents could see. The incident did not result in injury; however, all staff should be capable or performing assigned task at the facility without cause for concern.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: ADM to require an S7’s updated Health Screening to indicate S7 is physically qualified to perform the duties as they are assigned. ADM to remind staff that sleeping is not allowed in the common areas. ADM to provide updated Health Screening for S7 to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(10) · Plan of correction due date: Jan 27, 2025

(a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section above by care staff screaming/yelling at residents which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 14, 2025

Plan of correction: Licensee, ADM and all care staff are to read the Regulations, obtain personal rights training from a CCLD approved vendor. Screaming and/or yelling shall cease immediately. Proof of completed training by those listed above to be submitted by POC date.

Allegation investigated: Staff did not prevent resident from harassing another resident.

On 02/05/2025 around 01:35 PM, LPA amended complaints 15-AS-20241223152240 and 15-AS-20241223091751 to update the continuation pages. Executive Director (ED), Annemarie Domizio suggested that Licensing Program Analyst (LPA) L. Holmes meet with Claudia Redditt, Director of Business Administration (S1) due to ED's time constraints. On 01/02/2024 around 09:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a 10-day investigation for the above allegation. LPA met with Douglas Blake, Interim Executive Director (ED) and explained the purpose for the visit. Allegation: Staff did not prevent resident from harassing another resident. UNSUBSTANTIATED. During the course of the investigation and visit, LPA conducted interviews with Resident #1 (R1), Staff (S1, S2, S3, S4, S5) and Witness #1 (W1). LPA reviewed the facility's Face Sheet and Physician's Report (LIC602) for R1 & R2, and requested an updated staff and resident roster. Report continued on LIC9099C... Unsubstantiated ... amendment continued from LIC9099. For the above allegation, R1 stated that R2 was verbally harassing him/her multiple times and just prior to the complaint is when R2 used a curse word towards R1. R1 could not identify any witnesses, R1 stated that the incident was reported to S1 and S2. S1 stated that R1 did not report that specific incident and S1 would have recalled something like that; R2 does have occasional outburst which may be due to a medical condition, but never anything abusive. S1 stated that he/she spoke to R1 regarding R2 allegedly glaring at R1. S1 suggested R1 and R2 sitting away from each other and/or repositioning R1's chair for avoidance. R1 requested LPA to allow him/her to remain anonymous with R2; therefore, LPA did not interview R2. S2 stated that there had been discussions on 01/02/24 about R1 and other residents having disagreements, and R1's disruptive behavior; R1 never reported the specific incident nor had S2 seen any verbal harassment. S3 did not remember ANYTHING reported like the allegation. S3 stated that he/she wouldn't have had a problem saying something or approaching R2. S4 stated that the allegation is not surprising because R1 will go behind the bistro bar even though R1 is not suppose enter the area, and R1 does not want R2 or S4 to say anything about it him/her. S4 stated that R1 goes out of his/her way to provoke R2, and R1 is taking things out of proportion. W1 has visited the facility 2-3 times weekly over the last two (2) years and has never witnessed any verbal harassment. S1 and S2 have agreed to speak with R1 and R2 individually about the facility's expectations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation; therefore, it is UNSUBSTANTIATED. No citations issued during visit. Exit interview conducted and a copy of this report provided to Claudia Redditt, Director of Business Administrationthe state’s words, verbatim · CDSS document, Jan 2, 2025 · control 15-AS-20241223091751

Allegation investigated: Staff did not store an adequate amount of milk for residents.

On 02/05/2025 around 01:35 PM, LPA amended complaints 15-AS-20241223152240 and 15-AS-20241223091751 to update the continuation pages. Executive Director (ED), Annemarie Domizio suggested that Licensing Program Analyst (LPA) L. Holmes meet with Claudia Redditt, Director of Business Administration (S1) due to ED's time constraints. On 01/02/2024 around 09:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a 10-day investigation for the above allegation. LPA met with Douglas Blake, Interim Executive Director (ED) and explained the purpose for the visit. Allegation: Staff did not store an adequate amount of milk for residents. UNSUBSTANTIATED. During the course of the investigation and visit, LPA and ED toured the bistro bar and kitchen, freezer, cold and dry storage area. LPA interviewed Staff (S1, S2, S3, S4, S5, S6, S7, S8). LPA requested and reviewed the facility's vendor purchase orders from Newport Fish Co, PA-Vesta San Francisco, and Sysco-San Francisco. Report continued on LIC9099C... Unsubstantiated ...amendment continued from LIC9099. For the above allegation, W1 reported that on 12/23/24 he/she learned from about four (4) care staff that the residents were being served cereal with milk that had water inside of the milk. S2 stated that a new chef has been hired, and in the interim S2 is assisting the kitchen and has made purchases specifically for milk on 12/23/24 from Mi Tierra Foods located adjacent to the facility, the prior purchase was from the vendor Sysco-San Francisco on 12/21/24, and the following purchases were made 12/28/24 and 01/02/24. While touring the facility there was a half of a gallon milk present; however, the delivery arrived during the visit just after the purchase from Mi Tierra Foods around 11:00 AM on 01/02/24. S6 stated that the milk was probably low-fat. S7 stated that the facility does not do that, does serve milk with have the cream, whole milk or 2% fat. S8 stated the milk is probably 2% fat. S4 and S5 said they've never heard of the milk being watered down. S1 stated that the local Ombudsman toured the facility on 12/31/24 to view the dry and cold storage goods without any further recommendations. To date the facility has a sufficient variety, quality and quantity of perishable and non-perishable foods on the premises to meet the dietary needs of the residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation; therefore, it is UNSUBSTANTIATED. No citations issued during visit. Exit interview conducted and a copy of this report provided to Claudia Redditt, Director of Business Administration.the state’s words, verbatim · CDSS document, Jan 2, 2025 · control 15-AS-20241223152240

Type of visit: Case Management - Incident

On 12/12/2024 around 04:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a case management for an Unusual Incident Report received regarding Resident #1 (R1). LPA met with Mary Anne Watral, Operations Specialist (OS) LPA interviewed OP and S2. LPA requested and reviewed R1's Physician's Report (LIC602), Functional Evaluation, Resident Appraisal needs and UIR dated 12/11/24. LPA confirmed that R1 can leave the facility unassisted. R1 was locked out of the facility, was able to contact his/her daughter from a passerby, and was returned to the facility on 12/04/24. As a result of R1's confusion, R1 to follow-up with the Primary Care Physician on 12/13/24. The facility has contracted an agency (RTF) to install a keyless entry pad along with a notification system at the front entrance. LPA and OP discussed recent incidents with Residents (R1, R2, R3, R4); incident reports will follow. OP self reported that an internal investigation is underway for S1 and R4. All required parties have been notified of the incidents. No deficiencies cited, exit interview conducted, and a copy of this report provided to OP.the state’s words, verbatim · CDSS document, Dec 12, 2024

Allegation investigated: Staff did not ensure residents room was kept safe, clean, and sanitary Staff did not ensure residents personal belongings were safely secured Staff did not ensure residents records were properly maintained Staff did not ensure residents medications were properly managed Staff did not ensure residents medications were dispensed as prescribed

On 11/20/2024 around 09:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the complaint findings for the above allegations. LPA met with Mary Anne Watral, Operations Specialist (OP) and Interim-Douglas Blake, Executive Director (ED) and explained the purpose of the visit. During the course of the investigation and visit, LPA toured the facility conducted interviews with ED, OP, Staff, and Witness #1. LPA requested R1's file including, but not limited to the following documents: Current Personnel Report (LIC 500), Resident Roster, copies of R1's Centrally Stored Medication Log, medication records, housekeeping schedule, blood sugar record, LIC602, and Admission Agreement. Continued in LIC9099C... Substantiated ...continued from LIC9099. Allegations: SUBSTANTIATED Staff did not ensure residents room was kept safe, clean, and sanitary Staff did not ensure residents personal belongings were safely secured Staff did not ensure residents records were properly maintained Staff did not ensure residents medications were properly managed Staff did not ensure residents medications were dispensed as prescribed Staff did not ensure residents room was kept safe, clean, and sanitary. W1 reported during a visit the weekend of May 17, 2024, R1's room was found with the waste basket overflowing with used depends, clothes and papers strewn over the bed, the room hadn't been vacuumed, laundry was undone, the bedding hadn’t been changed, and there was mold growing on R1’s plates that were left in the kitchen sink and open containers of food on the counter tops. S2 stated that it should not had mattered if cleaning is the job of housekeeping, R1’s room was untidy and R1 needed to be relocated for cleaning March 2024. S12 reported that the staff keep reporting things to S1 and nothing was being done, therefore the allegation is substantiated. Staff did not ensure residents personal belongings were safely secured. The above allegation refers to the facility not having an adequate policy in place to track residents’ laundry to prevent frequent losses of R1’s clothing which were either never returned or mistakenly worn by other residents according to W1. W1 and S2 stated that on that day of R1’s move-out, the caregivers on duty did not know which laundered items belonged to R1. The items are supposed to be labeled but normally are not, therefore the allegation is substantiated. Staff did not ensure residents records were properly maintained. R1 is diabetic and R1’s Functional Evaluation states that the MedTech is to cue R1 to perform a Finger Stick Blood Glucose (FSBG) test twice daily and there’s not any record of performance or denials of FSBG. The document created by S3 to capture R1’s blood sugar, only recorded the dates from 06/24/2024 to 07/23/24 out of the entire time of R1’s residential agreement from 11/22/23 to 08/10/24 therefore the allegation is substantiated. Continued on 9099C... ...continued from 9099C. Staff did not ensure residents medications were properly managed. Per W1, S1 stated that R1’s critical medical documents were faxed to an unsecured public area. LPA, LPM and S7 toured the facility and there are not any facsimiles that were accessible to the public. S1 is no longer employed at the facility; however, LPA was able to review R1’s records and confirmed that a document for R1’s blood sugar was created by S3 per W1, S2, and S7; the document captured the dates of 06/24/2024 to 07/23/24 during R1’s residential agreement from 11/22/23 to 08/10/24 and there are no other documents for R1, therefore the allegation is substantiated. Staff did not ensure residents medications were dispensed as prescribed. Per W1, S1 stated that R1’s critical medical documents were faxed to an unsecured public area. LPA, LPM and S7 toured the facility and there were not any facsimiles that were accessible to the public. S1 is no longer employed at the facility; however, LPA was able to review R1’s records and confirmed that a document for R1’s blood sugar was created by S3 per W1, S2, and S7. S3 provided the electronic Centrally Stored Medication and Destruction Records for March 2024; when compared with the Medication Sheet for March 2024 it is inconsistent for the medication (Metformin) being dispensed or refused on the following dates of 03/19 - 03/25/2024 and 03/27 - 03/31/2024 therefore the allegation is substantiated. Continued on 9099C... ...continued from 9099C. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. An immediate civil penalty of $250 is hereby assessed for a repeat violation times two (2). Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalties. Exit interview conducted, Appeal Rights, and a copy of this report provided to ED. ...continued from 9099. Staff did not ensure resident received adequate laundry services. W1 presented photos of R1’s room the weekend of May 17, 2024, and none of the photo’s presented not laundered clothing or bedding. S12 presented photos of R1’s room on March 2, 2024, and none of the photo’s presented not laundered clothing or bedding. Although the bedding had clothes and paper strewn on top, LPA could not confirm or deny if the clothes or bedding were not laundered. After interviewing S2, S12 and W1. Interviews revealed the primary complaint was R1’s kitchen being uncleaned, therefore the allegation is unsubstantiated. Staff did not ensure resident received personal mail parcels. LPA observed S13 sorting mail. LPA had a conversation with S13 about trying to catch-up on all the different mail that came in over the weekend. W1 stated that R1's Google camera was missing and never delivered to R1 and provided a tracking number. LPA requested proof of delivery to the facility from W1. S1 is no longer employed for an interview regarding investigation of the missing parcel. After file review, LPA did not observe any complaints or a history of missing parcels, therefore the allegation is unsubstantiated. Staff did not ensure residents dietary care plan was properly followed. LPA toured the facility and observed a white board and dietary binder that listed the names and conditions of residents with dietary restrictions. S10 was aware that R1 was diabetic, and confirmed that S1, S10 and the kitchen staff met monthly to determine if meals needed to be modified or changed. S10 confirmed that the staff could not deny residents food but would steer them from carbohydrates, therefore 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. No deficiencies cited. Exit interview conducted, Appeal Rights, and a copy of this report provided to ED.the state’s words, verbatim · CDSS document, Nov 20, 2024 · control 15-AS-20240815084759

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(d)(2) · Plan of correction due date: Dec 3, 2024

87303 Maintenance and Operation (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. -This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee did not comply with the section above by not properly maintaining R1’s bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 20, 2024

Plan of correction: Executive Director to provide training by a third-party vendor and submit copy of training topic(s) with attendees signatures by 12/03/24

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Dec 3, 2024

87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff..... -This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section above by not safeguarding R1's clothing items which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 20, 2024

Plan of correction: Executive Director to provide in service training and submit a copy of training topic(s) with attendees signatures by 12/03/24

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(11) · Plan of correction due date: Dec 3, 2024

87506 Resident Records (b) Each resident’s record shall contain at least the following information: (11) The documentation required by Section 87611 for residents with an allowable health condition.-This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section above by not safeguarding R1's clothing items which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 20, 2024

Plan of correction: Executive Director to provide training by a third-party vendor and submit a copy of training topic(s) with attendees signatures by 12/03/24

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 3, 2024

87465 Incidental Medical and Dental Care (a) A plan...shall be developed by each facility... encourage routine medical and dental care and provide for assistance...by compliance with...(4) The licensee shall assist residents with self-administered medications as needed, -This requirement is not met as evidenced by: Based on interviews and records reviewed, Licensee did not ensure R1's blood sugar and/or medications were documented which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 20, 2024

Plan of correction: Executive Director to provide training by a third-party vendor for all staff that administer medication and submit a copy of training topic(s) with attendees signatures by 12/03/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(b)(2) · Plan of correction due date: Nov 21, 2024

87628 Diabetes (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible...(2) Ensuring that sufficient amounts of medicines, testing equipment...other supplies...as specified in Section 87465(c)..-This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee did not comply with the section above by not testing R1's blood sugar and dispensing R1's medication as prescribed which poses/posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 20, 2024

Plan of correction: Executive Director to provide training by a third-party vendor on or before for all staff that administer medication and submit a copy of training topic(s) with attendees signatures by 11/21/24 for in-service training.

Allegation investigated: Staff did not provide resident's medication as prescribed Staff did not monitor resident's blood pressure to ensure it was safe for resident to take medication Staff are billing resident for services not being rendered Staff are not adequately trained to meet resident needs

On 10/24/2024 around 09:30 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a needs further investigation for the above allegations. LPA met with Douglas Blake, Executive Director (ED) and explained the purpose for the visit. During the course of the investigation and visit, LPA conducted interviews with ED, Resident #1 (R1). LPA requested R1’s current medication list, billing statement and the following documents were reviewed from previous complaint #15-AS-20240830161138 on 08/30/24: Current Personnel Report (LIC 500), UIR's, R1’s Physician’s Reports, Case Notes, Medication Administration Records, Centrally Stored Medication lists, and faxes. Continued on LIC9099C... Unsubstantiated ...continued from LIC9099. Allegations: UNSUBSTANTIATED Staff did not provide resident's medication as prescribed Staff did not monitor resident's blood pressure to ensure it was safe for resident to take medication Staff are not adequately trained to meet resident needs LPA interviewed R1, and R1 stated that he/she was concerned that S1 hadn't been fired. S1 never apologized for doing anything wrong and is still passing medications. On 09/09/24, R1 received a doctor's order to administer his/her own medication, and S2 performed a Medication Self Administration evaluation on 10/02/24 after R1 presented S2 with the physician's note. The license was cited on complaint 15-AS-20240830161136 received 08/30/24 and provided proof of corrections for the above allegations. Allegation: UNSUBSTANTIATED Staff are billing resident for services not being rendered. ED stated that he/she was unaware of a billing issue or dispute related to R1. ED had not received any written or oral communications from R1 regarding billing. ED provided LPA with proof of R1's transaction history for 10/2024 that shows a credit for services, and explained it was effective 10/02/2024 when S2 performed a Medication Self Administration evaluation for R1. ED will provide an explanation and notification to R1 on or before 11/04/2024. 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. No deficiency cited, exit interview conducted, a copy of this report and appeal rights provided to Douglas Blake, ED.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 15-AS-20241015162638

Type of visit: Case Management - Deficiencies

On 10/24/2024 around 09:30 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a needs further investigation, open a complaint and completed a case management regarding Resident #1 (R1). LPA met with Douglas Blake, Executive Director (ED) and explained the purpose for the visit. During the course of the investigation and visit, LPA conducted an interview with ED and confirmed that R1's reappraisal was due on 09/10/24 as a result of a case management on 09/03/24. A Functional Evaluation was not completed until 10/02/24. Deficiency is cited from Title 22 California Code of Regulations and listed on LIC 9099D. 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 provided to ED.the state’s words, verbatim · CDSS document, Oct 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87705(c)(5) · Plan of correction due date: Oct 29, 2024

87705 Care of Persons with Dementia (c) Licensees who...retain residents with dementia shall be...ensuring the following:(5) ...annual medical assessment...reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. -This requirement is not met as evidenced by Based on observation, interviews and record review, the licensee did not comply with the section cited above by R1 not having reappraisal by the POC which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: ED to reappraisal R1 on or before 10/29/2024; LIC 625 (10/24) – Appraisal/Needs and Services Plan and rpovide CCLD a plan for R1 to store and safeguard medications.

Allegation investigated: Staff did not prevent a resident from eloping. Staff do not distribute residents' medications as prescribed.

On 09/16/2024 around 01:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit and closed the complaint for the above allegations. LPA met with Douglas Blake, Interim-Executive Director (ED) and explained the purpose of the visit. ALLEGATIONS: Staff did not prevent a resident from eloping. Staff do not distribute residents' medications as prescribed. SUBSTANTIATED Deficiencies were cited on a Case Management LIC809D and Complaint #15-AS-20240830161136 LIC 9099D on 09/11/24. Exit interview conducted. A copy of this report and appeal rights were provided to ED. Substantiatedthe state’s words, verbatim · CDSS document, Sep 16, 2024 · control 15-AS-20240911142042

Allegation investigated: Staff not administering medications to resident on multiple dates.

On 09/16/2024 around 01:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit and closed the complaint for the above allegation. LPA met with Douglas Blake, Interim-Executive Director (ED) and explained the purpose of the visit. ALLEGATIONS: Staff not administering medications to resident on multiple dates. SUBSTANTIATED During the course of the investigation and visit, LPA conducted interviews with Reporting Party (RP), ED, Staff (S1) LPA requested Resident (R1)’s file including, but not limited to the following documents: Current Personnel Report (LIC 500), UIR's, R1’s Physician’s Reports, Case Notes, Medication Administration Records, Centrally Stored Medication lists, and faxes. Continued on LIC9099C... Substantiated ...continued from LIC9099. For the allegation, Staff not administering medications to resident on multiple dates refers to dates 4/29/24, 7/4/24, 7/21/24, 7/26/24-7/29/24, 8/9/24, 8/20/24 for R1. Based on interviews with RP, ED and review of R1’s MD notification Form, Medication Administration Records and Centrally Stored Medication lists; the medications are inconsistent and there is not a clear legend to identify what the entries mean for each day entered. Licensee did not assure R1 received his/her prescribed medication on the noted dates. 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, Sep 16, 2024 · control 15-AS-20240913165153

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(d) · Plan of correction due date: Sep 19, 2024

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication...unable to communicate his/her symptoms clearly, facility staff designated by the licensee... assist the resident with self-administration... -This requirement is not met as evidenced by: Based on interviews and records reviewed, Licensee did not assure residents received administration of medication(s).the state’s words, verbatim · CDSS document, Sep 16, 2024

Plan of correction: ED to assure that trained staff are available to assist residents as needed with medications, document refusal date and time, follow physician’s orders, reconcile R1's medication list, perform staff training for all personnel that administers medication. Submit proof of procedures with names of attendees to CCLD by COB 09/19/24.

Type of visit: Case Management - Other

On 09/16/2024 around 01:50 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit and conducted a case management as a result. LPA met with Douglas Blake, Interim-Executive Director (ED) and explained the purpose of the visit. During the course of the visit, LPA conducted interviews with RP, ED and requested Resident (R1)’s file including, but not limited to the following documents from R1’s file: Physician’s Reports, Case Notes, Medication Administration Records, Centrally Stored Medication lists, UIR’s and faxes. -At 03:00 PM, LPA confirmed that Licensee did not report blood in R1’s urine on different occasions in April, July and August of 2024. -At 03:10 PM, LPA confirmed that R1 who has Dementia did not have an updated Physician’s Report (LIC602) or Reappraisal since 09/29/2022. -At 03:15 PM, LPA confirmed that there were medication errors on R1’s Medication Notification List faxed to the physician on 08/22/24. Staff did not report medication error to CCLD. -At 03:40 PM, LPA confirmed that there were medication errors on R1’s Medication sheet dated August 2024. Staff did not hold (discontinue) R1's medication starting 08/12/24 per physician's order. An immediate civil penalty of $250 is hereby assessed for the day of 09/16/24. Deficiencies cited from Title 22 California Code of Regulations and listed on LIC809D. 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.the state’s words, verbatim · CDSS document, Sep 16, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(5) · Plan of correction due date: Sep 18, 2024

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. Based on observation, interviews and record review, the licensee did not comply with the section cited above by person, Resident (R1) not an update annual medical assessment and reappraisal which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 16, 2024

Plan of correction: ED to coordinate with R1’s Responsible Party/Conservator to schedule a medical assessment and reappraisal on or before 09/18/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87211(a) · Plan of correction due date: Sep 18, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(2) Occurrences, such as epidemic outbreaks, shall be reported within 24 hours either by telephone or facsimile to the licensing... -This requirement is not met as evidenced by Based on observation, interviews and record review, the Licensee did not comply with the section cited above by not reporting R1’s UIR's to CCLD.the state’s words, verbatim · CDSS document, Sep 16, 2024

Plan of correction: ED agreed to report all major occurrences within 24 hours and submit incident reports within seven days to CCLD.

Allegation investigated: Staff mismanaged resident's medications.

On 09/11/2024 around 11:15 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the finding for the above allegation. LPA met with Douglas Blake, Executive Director (ED) and Keoni Myles, Director of Health and Wellness, and explained the purpose for the visit. Allegation: Staff mismanaged resident's medications. During the course of the investigation and visit, LPA conducted interviews with ED, Staff (S1) and Resident #1 (R1)'s. LPA requested R1’s file including, but not limited to the following documents: Current Personnel Report (LIC 500), UIR's, R1’s Physician’s Reports, Case Notes, Medication Administration Records, Centrally Stored Medication lists, and faxes. Continued on LIC9099C... Substantiated continued from LIC9099. During the course of the investigation, interviews and records reviewed revealed that on 09/07/23 and 10/21/23, S2 and S3 faxed notices to R1’s physician stating that R1 had been refusing to take his/her medication and requested that the physician advise R1. R1’s medication lists dated 09/20/23, 04/26/24 and 09/03/24 states that R1 has routine medication in the morning and evening (9:00 AM and 6:00 PM) and as needed based on R1’s systolic blood pressure. Records reviewied and interviews revealed that the facility did not have any record of R1’s refusal for medication, record of times of medication administration and there was not any notation or records of R1’s blood pressure. ED attempted to locate the information but stated that they were unable to recover the online data that was managed by a third-party vendor and a MAR was not utilized. 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. Deficiency is cited from Title 22 California Code of Regulations and listed on LIC 9099D. 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.the state’s words, verbatim · CDSS document, Sep 11, 2024 · control 15-AS-20240830161136

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(b)(10) · Plan of correction due date: Sep 13, 2024

87506 Resident Records(b) Each resident’s record shall contain at least the following information:(10) Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions.-This requirement is not met as evidenced by Based on interviews and records reviewed, the licensee did not comply with the section above when R1's refusals, blood pressure, and medication administered with all three dates and times were not documented posed an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2024

Plan of correction: ED to coordinate with R1’s physician’s to consolidate R1’s medication lists, document refusals date and time, follow physician’s orders, and perform staff training for all personnel that administer medication and submit proof with names of attendees to CCLD on or before 09/13/24.

Type of visit: Case Management - Incident

On 09/11/2024 around 9:50 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a case management. LPA met with Douglas Blake, Executive Director (ED) and explained the purpose for the visit. On 09/10/24, Licensing Program Analyst (LPA) L. Holmes requested R1’s LIC602 and LIC624 related to the R1’s Elopement. On 09/09/24, Licensing Program Analyst (LPA) T. Syess-Gibson conducted a phone interview per the request of Licensing Program Manager (LPM) to inquire about an AWOL that took place on 09/08/24 around 4:30 PM. LPA T. Syess-Gibson spoke with (S1), and explained the purpose of call. S1 offered to take the number and have Douglas Blake, Executive Director (ED) call back. At around 11:05 AM LPA T. Syess-Gibson received a call from Douglas Blake, Executive Director advising that the AWOL happened on 09/08/2024 at approximately 4:30pm with an Assisted Living Resident #1 (R1). S2 noticed R1 was missing and had left the community without signing out. The Berkeley Fire Department found the resident around 6:45-7:30 PM, and took the R1 to Alta Bates Hospital for observation hospital for observation. Per ED, the Aftercare Summary Report indicated a change in condition for R1 as an altered mental status. ED state that he has a call scheduled with the family to discuss R1’s long term care needs. LPA T. Syess-Gibson advised ED to send in the incident report as soon as possible. LPA T. Syess-Gibson provided ED with her email address and the office’s general email address. On 09/11/24 during the visit, ED confirmed that R1 can't leave unassisted and R1 may have left during the change of shifts at the Concierge area. Training on policies and procedures took place on 09/11/24. Unannounced drills will follow monthly along with bringing the teams together to review the policies, procedures, timelines, and debriefing regarding AWOLs/Elopements. continued on LIC809C... continued from LIC809... R1's responsible party and Berkeley Police Department were alerted immediately; however, Community Care Licensing was not notified until 09/09/24. -At 12:10 PM, LPA interviewed S2 and confirmed that S3 stated that he/she tested positive for COVID on or around 09/07/24; the incident was not reported to CCLD via telephone or fax. Based on information obtained, deficiencies are cited from Title 22 California Code of Regulations and listed on LIC 9099D. 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. An immediate civil penalty was assessed of $250 is hereby assessed on 09/11/2024. Exit interview conducted, Appeal Rights, and a copy of this report provided to Douglas Blake, Executive Director.the state’s words, verbatim · CDSS document, Sep 11, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Sep 18, 2024

87705 Care of Persons with Dementia (b) In addition...specified in Section 87208…(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. -This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section above when R1 in Assisted Living was able to leave unassisted and unnoticed which posed an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2024

Plan of correction: ED completed the following and will submit proof by 09/13/24. 1. In-service the staff training 2. Inform Concierge staff of residents are unable to leave the facility unassisted.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(2) · Plan of correction due date: Sep 18, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(2) Occurrences, such as epidemic outbreaks, shall be reported within 24 hours either by telephone or facsimile to the licensing... -This requirement is not met as evidenced by Based on observation and record review, the Licensee did not comply with the section cited above inthe state’s words, verbatim · CDSS document, Sep 11, 2024

Plan of correction: Administrator agreed to report all major occurrences within 24 hours and submit incident reports within seven days to CCLD by POC date.

Type of visit: Case Management - Deficiencies

On 09/03/2024 around 12:00 PM, Licensing Program Analyst (LPA) L. Holmes conducted a case management as result of an unannounced initial 10-day complaint visit. LPA met Douglas Blake, Executive Director (ED). During the course of the investigation and visit, LPA conducted interviews and requested R1's file including, but not limited to the following documents: Centrally Stored Medication Log, Medication Administration Records and Physician's Report (LIC602). -At 10:50 AM, LPA and ED reviewed R1's latest LIC 602 dated 06/06/2023. Deficiency cited to LIC D. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided to ED.the state’s words, verbatim · CDSS document, Sep 3, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Sep 10, 2024

87705 Care of Persons with Dementia (c) Licensees who...retain residents with dementia shall be...ensuring the following:(5) ...annual medical assessment...reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. -This requirement is not met as evidenced by Based on observation, interviews and record review, the licensee did not comply with the section cited above by person, Resident (R1) not having an updated annual medical assessment and reappraisal which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 3, 2024

Plan of correction: ED to coordinate with R1 and R1’s Responsible Party to schedule a medical assessment and reappraisal on or before 09/10/2024.

Allegation investigated: Uncleared adults on the premises

On 09/16/2024 Amended report to correct the allegation: On 08/21/2024 around 09:30 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit and closed the complaint for the above allegation. LPA met with Mary Anne Watral, Operations Specialist (OP) and Douglas Blake, Executive Director (ED) and explained the purpose of the visit. ALLEGATION: Uncleared adults on the premises SUBSTANTIATED Deficiency was cited on LIC809D on 08/21/24 under the annual inspection. Exit interview conducted. A copy of this report and appeal rights were provided to ED. Substantiatedthe state’s words, verbatim · CDSS document, Aug 21, 2024 · control 15-AS-20240814132320

Allegation investigated: Facility does not have an administrator on the premises

On 09/16/2024 Amended report to correct the allegation: On 08/21/2024 around 09:30 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit and closed the complaint for the above allegation. LPA met with Mary Anne Watral, Operations Specialist (OP) and Douglas Blake, Executive Director (ED) and explained the purpose of the visit. ALLEGATION: Facility does not have an administrator on the premises UNSUBSTANTIATED LPA conducted an annual inspection on 08/21/24 prior the the investigation. LPA toured the facility conducted interviews with ED and OP. Continued from LIC9099C... Unsubstantiated ...continued from LIC9099. LPA had received written notice from the facility that the former ED has resigned and was aware that there would be an interim staff (S2, #6066818740 exp: 01/22/25) as the administrator for the allegation the facility does not have an administrator on the premises; therefore the allegation was unsubstantiated. Exit interview conducted. A copy of this report and appeal rights were provided to ED.the state’s words, verbatim · CDSS document, Aug 21, 2024 · control 15-AS-20240814132320

Type of visit: Required - 1 Year

On 08/21/2024 around 09:30 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced for a required annual inspection. LPA met with Mary Anne Watral, Operations Specialist (OP) and Douglas Blake, Executive Director (ED) and explained the purpose of the visit. The facility’s fire clearance was approved for two hundred twenty-five (225) non-ambulatory residents; fifty (50) may be bedridden. Upon arrival, LPA observed one (1) staff attending the receptionist desk, and several residents visiting in the facility's common area along with others eating breakfast. LPA toured the facility with OP and ED. The areas included but were not limited to, common areas, dining room, bathroom, kitchen, med tech room, fitness center and courtyards. The facility consists of individual apartments housed by the residents and has a monitored unit for memory care. All outdoor and indoor passageways were free of obstruction. There were no bodies of water present. A comfortable temperature was maintained at 73 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. The hot water temperature in the shared restroom on the 2nd floor was measured at 117.1 degrees (F). The shared restroom had paper towels, soap and garbage cans; all areas were safe and sanitary. PPE, sanitizer, and paper goods remain sufficient. There is a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. ...continued on LIC9099C. ...continued from LIC9099. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was observed full and serviced 07/16/24. Emergency Disaster Plan is updated. Safety drills are rotational between monthly. LPA reviewed five (5) staff files, and seven (7) resident files. -At 10:15 AM, LPA confirmed through Guardian, and CCLD staff support that ED did not have criminal record clearance on file and was not associated to the facility. -At 01:25 PM, LPA confirmed through observation and review that seven (7) out of seven (7) personnel records were incomplete. OP and ED to review and update all files. Deficiencies are being cited on the attached LIC 809D. Civil penalty was assessed for $100.00/day Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided to OP and ED.the state’s words, verbatim · CDSS document, Aug 21, 2024

Allegation investigated: Facility did not provide family with requested resident records.

On 07/30/2024 around 10:30 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the finding for the above allegationa and to conduct a case management. LPA met with Robert Coe, Executive Director (ED) and explained the purpose for the visit. Allegations: Facility did not follow COVID procedures. Facility did not provide family with requested resident records. During the course of the investigation and visit, LPA conducted interviews with ED, Staff (S1) and Respsonsible Party (RP). LPA requested resident #1 (R1)'s file including, but not limited to the following documents: Current Personnel Report (LIC 500), LIC 500 dated 09/2023 and 06/2024, Resident Roster, facility’s COVID-19 protocol for 09/2023 & 10/2024 along with email, UIR's or copies of family notification for COVID-19 cases. Continued on LIC9099C... Substantiated Continued from LIC9099 R1’s ID/Emergency contact information, most recent Physician’s Reports and the report that the covers 09/2023 along with After Visit Summaries, Case Notes, and Centrally Stored Medication lists for 09/2023 - 10/2023; facility’s emails, faxes, call logs and/or any other correspondences with R1's Responsible Party (RP) and Primary Care Physician for 09/2023 and 10/2023. Allegation: Facility did not provide family with requested resident records. SUBSTANTIATED R1’s Responsible Party (RP) stated that on October 13, 16, 20, 21, and 24, 2023, that she/he had requested records pertaining to R1 and never received a response. ED does not have record of who the request was sent to at the facility. ED did not have who the POA was on record. On 06/14/24, interviews with Staff (ED and S1) revealed that R1’s resident files had not been provided to RP and there was not a POA on record. LPA spoke to ED and S1 on 07/16/24 and both stated that R1’s records would be sent to CCLD by the end of July. The facility did not provide family with requested resident records; therefore, the allegation is substantiated. 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. Deficiency is cited from Title 22 California Code of Regulations and listed on LIC 9099D. 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, Appeal Rights, and a copy of this report provided to Robert Coe, Executive Director. ...continued fron LIC9099. R1’s ID/Emergency contact information, most recent Physician’s Reports and the report that the covers 09/2023 along with After Visit Summaries, Case Notes, and Centrally Stored Medication lists for 09/2023 - 10/2023; facility’s emails, faxes, call logs and/or any other correspondences with R1's Responsible Party (RP) and Primary Care Physician for 09/2023 and 10/2023. Allegation: Facility did not follow COVID procedures. UNSUBSTANTIATED On 04/06/23 California Department of Social Services (CDSS) presented PIN 23-07-ASC related to the COVID-19 pandemic following the end of the COVID-19 State of Emergency (SOE) on February 28, 2023, as guidance and to update licensees of Adult and Senior Care (ASC) facilities. On March 3, 2023, the California Department of Public Health (CDPH) terminated several State Public Health Officer Orders. Screening for COVID-19 signs, symptoms, and exposure were recommended for residents and visitors through passive screening measures but was not required. According to PIN 23-13-ASC, the licensee followed regulations related to infection control, prevention and mitigation for communicable diseases by maintaining an Infection Control Plan (ICP) and reporting the incident to Community Care Licensing (CCLD) on September 13, 2023; therefore, the facility did follow the COVID-19 procedures, and the allegation is unsubstantiated. No deficiency cited. Exit interview conducted and a copy of this report provided to Robert Coe, Executive Director.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 15-AS-20240611092951

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(1) · Plan of correction due date: Jul 30, 2024

87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential...(1) The licensee shall...reveal or make available...upon the resident's written consent or that of his designated representative. -This requirement is not met as evidenced by -Based on interviews and observation, the Licensee did not comply with the section above by not providing R1’s RP with the resident’s records.the state’s words, verbatim · CDSS document, Jul 30, 2024

Plan of correction: Executive Director/Licensee to read the regulations, provide training to staff, submit proof of attendee’s signatures, and devise a plan to ensure that proper notification is provided to residents and residents’ responsible party’s in a timely matter of 72 hours. Executive Director/Licensee to provide R1’s records to the RP. -R1's records provided to LPA by ED during visit on 07/30/2024.

Type of visit: Case Management - Other

On 07/30/24 around 10:30 AM, L. Holmes Licensing Program Analyst (LPA) arrived unannounced to conduct a case management for an "Elopement" of Resident #1 (R1). LPA met with Robert Coe, Executive Director (ED) and explained the purpose of the visit. On 07/29/24, ED reported that there had been an elopement of R1 on that same day, an Unusual Incident Report (UIR) would follow, R1's son returned R1 to the facility, and R1 now resides in Memory Support. R1 was admitted to the Assisted Living (AL) unit of the facility on 07/26/24. R1’s family was to assist with R1 transitioning from home to the facility throughout the weekend. On 07/29/24, R1 left the facility walking his/her dog but the facility staff was unaware that R1 was alone. While out of the facility in the community, R1 started feeling faint and asked a passerby to use their phone. The Berkeley Fire Department (BFD) was contacted and in turn BFD alerted W1 and the facility that R1 would be transported to Alta Bates Hospital in Berkeley, CA for further observation. W1 contacted ED regarding R1’s assessment and returned R1 to the facility the same day. Staff (S2) reassessed R1, completed a new functional evaluation that now includes wandering, exit seeking behaviors, MCI and a terminal illness that qualifies R1 for Memory Support that further includes photos of new resident's at the front desk, photos at the assisted living and memory support units, photos on the E-MAR and on the file face sheets. No deficiencies cited. Exit interview conducted and a copy of this report provided to Robert Coe, Executive Director.the state’s words, verbatim · CDSS document, Jul 30, 2024

Allegation investigated: Facility staff did not provide adequate supervision resulting in a resident eloping from the facility.

On 5/2/2024 at 10:30 AM, Licensing Program Analyst (LPA) J. Sampair arrived at the facility unannounced to deliver the findings pertaining to the allegation above. Upon entry, the LPA informed Executive Director (ED) Robert Coe of the purpose of the visit. The complaint alleges that facility staff did not provide adequate supervision resulting in a resident eloping from the facility. On 3/8/2024 and 3/28/2024, LPAs G. Luk, L. Holmes, and J. Sampair visited the facility and interviewed the ED and 3 staff members, collected and reviewed resident and facility reports, examined the egress doors the "Safely You" alert devices, and the alarm added by the facility after the elopement. The ED stated that there had never been a problem with anyone exiting through the service elevator before and that R1 did not exhibit exit seeking behavior. Report Continued on LIC9099-C... Unsubstantiated ...Report Continued from LIC9099 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 citations issued during visit. Exit interview conducted with ED. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, May 2, 2024 · control 15-AS-20240304111743

Allegation investigated: -Staff allow a resident to be in soiled clothing for extended periods of time. -Staff do not properly maintain resident's bedroom. -Staff do not meet a resident's incontinence needs while in care. -Staff did not safeguard resident's personal belongings. -Staff do not properly maintain the facility grounds. -Staff inappropriately removed a resident's hygiene products while in care. -Staff did not provide adequate supervision to a resident while in care.

At 11:40 a.m. on this day, 4/25/24 , Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Director of Health and Wellness LaTiana James, and informed the reason for visit. LPA called and left message on Executive Director Robert Coe's voicemail. On 9/05/23, LPA Gregory Clark conducted the 10-day complaint visit. On 3/05/24, Licensing Program Manager (LPM) Jeremy Fong conducted a subsequent investigation. During the course of investigation, LPA Clark obtained copies of resident roster and staff schedule. LPA Clark and LPM Fong toured the facility and obtained copies of residents including but not limited to the following documents: Admission Agreement; Identification and Emergency Contact Information; LIC602A Physician's Report (MD Report); Needs and Services Plan; incident reports. LPM Fong also conducted interviews. ......continued on 9099C (page 2) Substantiated Page 2 Staff allow a resident to be in soiled clothing for extended periods of time At complaint intake on August 30, 2023, the RP reported that on multiple occasions the RP had visited R1 and found R1 to be soaked in urine. On March 4, 2024, LPM Fong spoke with the RP who reiterated that R1 was found to be soaked in urine on multiple occasions and that this was brought to the attention of S4. On March 5, 2024, LPM Fong conducted a continuing complaint visit and observed that R1s MD report and intake Appraisal indicated that R1 was independent in toileting. On that same date, LPM Fong interviewed S2, S3, and S4 – all of whom were confirmed to have been employed during the subject time period. S2 reported having no knowledge of the issue, however, S4 acknowledged that family reported coming to the facility to find R1 soaked in urine. An internal investigation was performed, and it was determined that R1 had been left in urine soaked garments and bed for an extended amount of time. Updated Needs and Services documents from August, 2023, indicated that R1 did require incontinence undergarments and changing. Therefore, the allegation is substantiated. Staff do not properly maintain resident’s bedroom. At complaint intake on August 30, 2023, the RP reported that during multiple visits, R1's room was found to have urine soaked clothing and bedding strewn about and with strong urine smell. On March 5, 2024, LPM Fong interviewed S2, S3, and S4 – each stated having no knowledge of R1s room not being properly maintained, cleaned, or serviced. On March 8, 2024, LPM Fong spoke with W1 (neutral witness) who reported having visited R1 at the facility mid-morning and found the room to smell strong of urine – to the point where W1 could not stay in the room. W1 also reported that the laundry basket was full of urine soaked items and that W1 pulled the basket out of the room and requested staff to remove and launder. Therefore, the allegation is substantiated. ......continued on 9099C (page 3) Page 3 Staff do not meet a resident’s incontinence needs while in care. Per the above, at intake the RP reported that R1s incontinence needs were not being maintained. On March 5, 2024, LPM Fong interviewed S2, S3, and S4. S3 reported being on the early morning shift and on multiple occasions immediately found R1 to have been left in urine soaked clothing and bedding. S3 stated that the NOC shift had not properly checked and changed R1 as needed prior to S3’s arrival, therefore, the allegation is substantiated. Staff did not safeguard resident’s personal belongings. At complaint intake, RP reported that R1s undergarments and assistive walking devices had gone missing, with no explanation. On March 5, 2024, LPM Fong interviewed S2, S3, and S4. S2 and S4 reported having no knowledge any items belonging to R1 going missing. However, S3, reported that on multiple occasions staff found that R1s assistive walking device was missing – sometimes it was found, other times it was not, or was found having been destroyed. S3 confirmed that family had to purchase a new assistive walking device, therefore the allegation is substantiated. Staff do not properly maintain the facility grounds. At complaint intake, the RP reported visiting the facility on multiple occasions and observing urine smell in common areas. On March 4, 2024, LPM Fong interviewed S1, S2, S3, and S4 who denied knowledge of urine smell or other maintenance issues. On that same day, LPM Fong observed a strong urine smell in the common area near the secondary/back exit from Memory Care. Therefore, the allegation is substantiated. Staff inappropriately removed a resident’s hygiene products while in care. At complaint intake, the RP reported having visited the facility and found that all of R1s personal hygiene products had been removed from the room. On March 5, 2024, LPM Fong interviewed S2, S3, and S4 – with S2 and S4 stating that there had been staff persons who took it upon themselves to remove and lock the residents’ hygiene products. R1’s Service Plan indicated R1 is able to keep non-toxic products (hand and body soap, toothpaste, shampoo) in R1’s room Therefore, the allegation is substantiated. .......continued on 9099C (page 4) Page 4 Staff did not provide adequate supervision to a resident while in care. At complaint intake, the RP reported that on December 5, 2023, RP found R1 half-naked and wedged between the bed and the wall and that R1 had been able to exit the facility unsupervised (from the Memory Care Unit). On March 5, 2024, LPM Fong interviewed S2, S3, and S4, with all stating having no knowledge of either incident. No witnesses were identified. On that same day, LPM Fong observed that an incident report dated April 11, 2023, was submitted to CCLD indicating that 3 residents (including R1) had been able to exit the Memory Care unit on April 5, 2023. Two of the residents were found in the stairwell; however, R1 was not observed until 15 minutes later when staff noted R1 outside of the facility. LPM Fong reviewed the MD report which confirmed that R1 could not leave unassisted. 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. Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalties. Deficiencies and plan and proof of correction were discussed with the LaTiana James. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. Page 2 At complaint intake, the RP reported that R1 had been able to exit the Memory Care unit and the building without supervision. RP further reported being able to exit Memory Care by pushing the door, and that it was not secure. On March 5, 2024, LPM Fong observed that the main entry to Memory Care is accessed by taking the elevator to the second floor, and that an electronic key fob is needed to release the entry/exit door. From the inside, LPM Fong again found that the key fob is required to release the door. LPM Fong found that there is a second, back door exit leading to a stairwell that exits at the ground level. This secondary door was found to be a delayed egress. During interview, S1, S2, S3, and S4 stated having no knowledge of there being a maintenance issue with the Memory Care unit doors and no other witnesses were identified. It is undetermined whether R1 had been able to exit specifically due to failure to secure the facility grounds. Based on information gathered, the allegation 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 occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Apr 25, 2024 · control 15-AS-20230830095706

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Apr 26, 2024

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208......... (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. -This requirement is not met as evidenced by: -Based on interviews and records review, the licensee did not comply with the section above when 3 residents in Memory Care Unit were able to leave unassisted/unnoticed which posed an immediate safety risks to persons in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Executive Director to do the following and submit proof by 4/26/24. 1. In-service the staff. 2. Informed front desk staff of residents who can not the facility unassisted.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2) · Plan of correction due date: May 9, 2024

87625 Managed Incontinence (b) .... the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. -This requirement is not met as evidenced by: -Based on interviews and records review, the licensee did not comply with the section above in R1 being left in urine soaked clothing for extended period of time which posed a potential health and/or personal rights risks to person in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Executive Director to in-service the staff and submit copy of training topic(s) with attendees signatures by 5/09/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1a(2) · Plan of correction due date: May 9, 2024

87468.1 Personal Rights of Residents in All Facilities: (a)....... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. -This requirement is not met as evidenced by: -Based on interviews and records review, the licensee did not comply with the section above in not properly upkeeping R1’s bedroom.which posed a potential personal rights risks to person in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Executive Director to add to in-service training and submit copy of training topic(s) with attendees signatures by 5/09/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: May 9, 2024

87468.1 Personal Rights of Residents in All Facilities: (a)...... (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. -This requirement is not met as evidenced by -Based in interviews, the licensee did not comply with the section above in not meeting R1's incontinence care needs which posed personal rights risk to person in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Executive Director to add to in-service training and submit copy of training topic(s) with attendees signatures by 5/09/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: May 9, 2024

87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff..... -This requirement is not met as evidenced by: -Based in interviews, the licensee did not comply with the section above in not safeguarding R1's personal belogings whiich posed personal rights risk to person in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Executive Director to add to in-service training and submit copy of training topic(s) with attendees signatures by 5/09/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 9, 2024

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by: -Based in interviews and observation, the licensee did not comply with the section above in facilty having strong smell of urine which pose personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Executive Director to do the following and submit proof by 5/09/24: 1. Ensure proper housekeeping is maintained. 2. Conduct in-service training and submit copy of training topic(s) with attendees signatures.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(12) · Plan of correction due date: May 9, 2024

87468.1 Personal Rights of Residents in All Facilities: (a)..... (12) To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money. -This requirement is not met as evidenced by: -Based in interviews, the licensee did not comply with the section above when staff removed R1's hygiene items which posed a potential personal rights risk to person in care.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Executive Director to in-service the staff and submit copy of training topic(s) with attendees signatures by 5/09/24,

Allegation investigated: Unlawful eviction Staff did not provide resident's POA with requested documents

On 3/28/2024 at 11:15 AM, Licensing Program Analysts (LPAs) J. Sampair and L. Holmes arrived at the facility unannounced to deliver the findings pertaining to the allegations above. Upon entry, the LPAs informed Executive Director (ED) Robert Coe of the purpose of the visit. The complaint alleges that residents were being unlawfully evicted. Review of the eviction letter dated 12/5/2023 by the LPAs revealed that it was unlawful. Report Continued on LIC9099-C... Substantiated ...Report Continued from LIC9099 The complaint alleges that staff did not provide resident's POA with requested documents. Review of R1’s Admissions Agreement dated 11/18/2022 by the LPAs revealed that it was missing the Resident Handbook and that communications by the facility with R1’s POA did not provide the requested documents. The preponderance of the evidence standard has been met, and the allegation is SUBSTANTIATED. Deficiency is cited under the California Health and Safety Code listed on LIC9099-D. 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 with ED Coe. Appeal Rights and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Mar 28, 2024 · control 15-AS-20240102100222

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(f) · Plan of correction due date: Apr 4, 2024

87224 Eviction Procedures (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above because no copy of the letter to evict dated 3/7/2024 was sent to the licensing agency, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 28, 2024

Plan of correction: On or before the due date, the Licensee shall inform the POA that the 3/7/2024 letter to evict was not valid. The ED shall inform the Department when this has been done.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(8) · Plan of correction due date: Apr 4, 2024

87507 Admission Agreements (g) Admission agreements shall specify the following: (8) General facility policies that are for the purpose of making it possible for residents to live together. This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above because the Resident Handbook is missing from the Admissions Agreement as an Addendum and no copy was sent to the POA, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 28, 2024

Plan of correction: On or before the due date, the Licensee shall create the Resident Handbook that includes all of the policies toi fulfill this Title 22 regulation. The ED shall inform the Department when this has been done.

Allegation investigated: Staff are not rendering services as agreed in the resident's Admission Agreement Staff are not providing daily activities for residents

On 3/28/2024 at 11:15 AM, Licensing Program Analysts (LPAs) J. Sampair and L. Holmes arrived at the facility unannounced to conduct the initial 10-day complaint investigation of the allegations above. Upon entry, the LPAs informed Executive Director (ED) Robert Coe of the purpose of the visit. The complaint alleges that staff are not rendering services as agreed in the resident's Admission Agreement. On 3/28/2024, the LPAs observed Resident R1, R1’s dog Cloud, R1’s room and the Memory Support area, interviewed the ED and Director of Health and Wellness Tea James, reviewed R1’s Admissions Agreement dated 11/18/2022, Functional Evaluation dated 10/5/2023, Service Plan dated 3/28/2024, and the Operations Procedures issued 4/1/2023 and revised 10/15/2023 entitled “Pets Residing In or Visiting Community”. Based on these document reviews, interviews, and observations, the LPAs concluded that staff are rendering services as agreed in the resident's Admission Agreement. Report Continued on LIC9099-C... Unsubstantiated ...Report Continued from LIC9099 The complaint alleges that staff are not providing daily activities for residents. On 3/28/2024, the LPAs interviewed the ED and Director of Health and Wellness Tea James, reviewed the facility’s March 2024 Activities calendars for Assisted Living and Memory Support, and observed 20 residents in Memory Support interacting with 10 Staff Members. Based on these interviews and observations, the LPAs concluded that daily activities are being provided. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED. Exit interview conducted with ED Coe and Director James. Appeal Rights and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Mar 28, 2024 · control 15-AS-20240320153953