Elite Retirement Residence

Allegation investigated: Staff did not allow residents to have private conversations Staff did not provide resident adequate food service Staff did not provide resident with comfortable living accomodations Staff did not ensure residents were provided daily activities

On 12/23/25, at 7:50am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Caregiver, Martha Detloff. The Caregiver called the Administrator and they arrived shortly after. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 12/23/25, LPA Saucedo asked for the census, staff, and resident rosters. On 12/23/25, at 8:15am, LPA Saucedo conducted a physical tour, interviewed staff and attempted to interview residents. LPA also obtained Resident #1 (R1)'s, Admission Agreement, Medical Assessement, Preplacement Plan and Appraisal Needs/Services Plan. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not provide sufficient notice prior to increasing resident's rent. It is being alleged that resident #1 (R1)’s was issued a 30-day notice increase from $6,500 to $9,000. LPA interviewed R1, and asked why the rent had increased but R1 did not know. R1 stated, “I just moved in August 31 and my rent was $6500.00.” LPA asked how much notice did you receive and R1 stated, “I didn’t receive a notice my daughter did.” LPA interviewed R1’s daughter via telephone and R1’s daughter stated, “I received a written 30-day notice. LPA received and reviewed the 30-day notice that was given to R1’s daughter. LPA interviewed staff #1 (S1) that admitted a 30-day notice had been given to R1’s daughter because R1 was demanding more help. Therefore, based on the LPA’s interviews and record review the allegation(s) are SUBSTANTIATED at this time. Regarding the allegation: Staff did not provide a detailed itemized explanation of the additional services to be provided in resident's rental increase. During LPA's interview with staff #1 (S1), S1 did not have a detailed itemized explanation of the additional services to raise resident #1 (R1)'s rent. LPA asked staff #2 if anything had changed with R1's services since R1's admission to the facility in August of 2025 and S2 confirmed there was no changes to R1 and that R1's health had actually improved since they arrived to the facility. Therefore, based on the LPA’s interviews and record review the allegation(s) are SUBSTANTIATED at this time. Regarding the allegation: Staff did not appraise resident as needed to determine resident's required level of service. It is being alleged that resident #1 (R1) did not get the appraisals for a change in condition. During LPA’s interview with R1, LPA asked if any resident reappraisals were conducted and/or did anything change with their condition and R1 stated, “no, I wasn’t even there for three (3) months, nothing has changed.” During LPA’s interview with R1’s daughter, LPA asked if R1 was ever reappraised and/or did any health condition, functional capabilities, physician’s report/medical assessment change and R1’s daughter stated, “nothing has changed with R1 since their arrival to the facility.” LPA interviewed staff #1 (S1) and staff # 2 (S2) and asked for the resident’s reappraisal’s, changes in functional capabilities and/or physician’s report/medical assessment showing that R1 needed increased level of care but there was no change to R1's health requiring higher level of care. S1 did not have any updated paperwork since R1’s arrival to the facility on August 2025. Therefore, based on the LPA’s interviews and record review the allegation(s) are SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued for the above allegation(s), appeals rights provided,a copy of this report was given to the Administrator/Licensee. Regarding the allegation: Staff did not allow residents to have private conversations. It is being alleged that the residents don’t have confidential calls. During LPA's interview with staff # 1, 2 and 3, they all confirmed that resident #1 (R1) could not hear well and R1 would sit in the living room and talk loudly on the phone. During LPA interview with R1, R1 did admit they cannot hear well. During LPA's record review of Preplacement Appraisal and Appraisal/Needs and Services Plan it does show that R1 has a hearing problem. Therefore, based on the LPA’s interviews and record review the allegation(s) are UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not provide resident adequate food service. It is being alleged that there are no snacks provided for the residents. During LPA's interview with staff # 1, 2 and 3, they all confirmed that resident #1 (R1) ate several meals throughout the day. There is no designated time for residents to eat. Residents are provided three (3) meals a day with food in between if they get hungry. During LPA's interview with R1, R1 did confirm that they never asked for any snacks. Therefore, based on the LPA’s interviews and food menu review the allegation(s) are UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not provide resident with comfortable living accommodations. It being alleged that the mattress for resident #1 (R1) gave R1 back issues. During LPA's interview with staff # 1, 2 and 3, they all confirmed that resident #1 (R1) was not happy with their bed upon their admission but they did change it. Staff 1and 2 did confirm that R1's bed was changed twice since they had lived at the facility. During LPA's interview with R1, R1 did confirm that they were comfortable at the end of their stay at the above facility. Therefore, based on the LPA’s interviews, the allegation(s) are UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not ensure residents were provided daily activities. It is being alleged that there are no scheduled activities. During LPA's interview with staff # 1, 2 and 3, they all confirmed that all residents are provided different activities. Staff # 2 confirmed that resident # 1 and resident #2 would play checkers all the time. During LPA's interview with R1, R1 confirmed that all residents like to stay in their room including them so they didn't participate in all, only some activities. Therefore, based on the LPA’s interviews, the allegation(s) are UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), a copy of this report was given to the Administrator/Licensee.the state’s words, verbatim · CDSS document, Dec 23, 2025 · control 31-AS-20251218215152

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655(a) · Plan of correction due date: Jan 6, 2026

(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents...the licensee shall provide no less than 90 days’ prior written notice to the residents or the residents’ representatives setting forth the amount of the increase and the reason or reasons for the increase, including a description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident. This requriement is not met by: Based on the LPA's observations the licensee/administrator failed to ensure that the facility gave a proper notice to resident #1 for rent increase. This posed an potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: The licensee/Administrator shall provide training to all staff to update all paperwork for higher level of care such as resident reappraisals to increase rent. POC Due Date: 01/06/26

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(3)(b)(2) · Plan of correction due date: Jan 6, 2026

Payment provisions, including the following: (B) Rate for additional items and services, including:2. A separate charge for an item or service may be assessed only if that charge is included in and authorized by the admission agreement. This requirement was not met by: Based on the LPA's observations the licensee/administrator failed to ensure that a separate charge for an item/service was not included in the admission agreemment changing their rate. This posed an potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: The licensee/Administrator shall provide a separate charge for additional services not included in the admission agreement to resident and/or resident's guardian with proper notice. POC Due Date: 01/06/26

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

The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes... For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement was not met by: Based on the LPA's observations the licensee/administrator failed to ensure that the facility reappraised resident #1. This posed an potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: The licensee/Administrator shall update/provide resident reappraisals for all residents upon changes of resident's conditions. POC Due Date: 01/06/26

Type of visit: Required - 1 Year

At approximately 12:30 p.m. on 09/26/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and disclosed the reason for the visit. The facility was last visited on 07/31/2024 for an annual inspection. It is a single story building with six (06) bedrooms, four (04) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) residents, of which four (04) may be ambulatory and two (02) may be non-ambulatory with one (01) bedridden in Bedroom #5. Approved hospice waivers for three (03). At the main entrance, LPA observed a maintained front yard. Postings for resident rights, confidential complaint contacts, ombudsman contacts, facility sketch, and license were observed near the front. A binder contained additional required postings. A screening station contained hand sanitizer, masks, and a visitor log. The facility has six (06) bedrooms. One (01) bedroom is designated as a staff room. The staff room was free of hazards. Bedrooms contained beds with adequate bedding, chairs, nightstands, night lights, and sufficient storage space. All furnishings were clean and in good condition. Beds had wheels in the locked position. The facility has four (04) bathrooms. Bathrooms contained liquid soap, paper towels or personal towels, trash can, grab bars near the toilet and shower, commodes, shower chairs, and a non-skid surface in the shower. At approximately 12:45 p.m. LPA measured the water temperature to be 108 degrees Fahrenheit in the front bathroom. A hallway closet contained adequate amounts of fresh linens and hygiene supplies. At approximately 12:50 p.m., the room temperature was measured to be 72 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator. At 1:10 p.m. the refrigerator and freezer temperatures were measured to be 35 and -2 degrees Fahrenheit, respectively. The stove hood was clean. Appliances were new and in good condition. Sharps, cleaning solutions, and a complete first aid kit were locked below the counter. Medications were locked above the counter top. At approximately 1:15 p.m. LPA observed a fully charged fire extinguisher in the kitchen with a receipt attached. A washing machine and dryer were located near the kitchen. Both were in working order. Detergents were locked in the laundry room with the appliances. Walls, floors, windows, screens, and blinds were clean and in good repair. LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. The ramp leading out from the bedridden room was free of hazards and had secure handrails. The emergency exit path was free from obstructions. The exit gate was unlocked with self-closing latches. Evacuation routes were posted. At approximately 2:45 p.m., smoke and carbon monoxide detectors were tested and operational. At approximately 1:30 p.m., LPA conducted a record review of resident and personnel files. Staff files were incomplete and not all available for audit. A deficiency are issued for the licensee not maintaining complete records for all staff. Additionally, a review of Guardian at approximately 2:00 p.m. revealed that only the licensee and administrator were associated to the facility. The administrator noted that all staff have fingerprints and background checks, but most staff files were at the agency. The staff present was not associated to the facility and had worked for about one month. An additional deficiency is issued today along with a civil penalty of $500 for staff present in the facility without an association to the facility. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 26, 2025

Type of visit: Required - 1 Year

At 9:15 a.m. on 07/31/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the licensee and disclosed the reason for the visit. LPA and licensee toured the facility inside and out. The facility was last visited on 06/14/23 for a prelicensing visit. It is a single story building with six (06) bedrooms, four (04) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) residents, of which four (04) may be ambulatory and two (02) may be non-ambulatory with one (01) bedridden in Bedroom #5. Approved hospice waivers for three (03). At the main entrance, LPA observed a maintained front yard. Postings for resident rights, confidential complaint contacts, ombudsman contacts, and facility sketch and license were observed near the front. A binder contained additional required postings. LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator. At 9:35 a.m. the refrigerator and freezer temperatures were measured to be 37 and 0 degrees Fahrenheit, respectively. The stove hood was clean. Appliances were new and in good condition. Sharps, cleaning solutions, and a complete first aid kit were locked below the counter. Medications were locked above the counter top. At approximately 9:45 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It had a receipt posted from 06/23/24. A washing machine and dryer were located near the kitchen. Both were in working order. Detergents were locked in the laundry room with the appliances. Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:55 a.m. LPA measured the room temperature to be 74 degrees Fahrenheit. At approximately 10:00 a.m., the licensee explained that there are zero (00) staff and zero (00) currently at the facility. The facility has yet to admit their first resident. Only the licensee’s family member and their private caregiver were observed at the facility. The facility has six (06) bedrooms. One (01) bedroom is designated as a staff room. The staff room was free of hazards. Bedrooms contained beds with adequate bedding and sufficient storage space. All furnishings were clean and in good condition. The facility has four (04) bathrooms. Bathrooms contained liquid soap, paper towels, trash can, grab bars near the toilet and shower, and a non-skid surface in the shower. At approximately 11:00 a.m. LPA measured the water temperature to be 108.8 degrees Fahrenheit in the front bathroom. LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. The ramp leading out from the bedridden room was free of hazards and had secure handrails. The emergency exit path was free from obstructions. Exit gates were unlocked with self-closing latches. Evacuation routes were posted. At approximately 11:15 a.m., smoke and carbon monoxide detectors were tested and operational. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 31, 2024