Emory Terrace

Allegation investigated: Staff did not ensure that resident was adequately fed. Staff did not ensure that resident received sufficient fluids to prevent dehydration.

Licensing Program Analysts (LPA) E.Conchas conducted an unnannounced visit for the purpose of delivering findings on the allegations stated above. LPA met with caregiver Tiffany Colantonio and explained the purpose of the visit. On 01/08/2026, the Department received a complaint regarding the allegations stated above. The Department’s investigation consisted of interviews, review of hospice documentation, hospital records, and facility records. Allegation Staff did not ensure that resident was adequately fed. Record review indicates that on 01/02/2026, R1 was admitted to the hospital for altered level of consciousness. Witness (W1) reported that on 01/04/2026, Witness (W2) expressed concerns of potential neglect due to R1 appearing cachectic and clinically dehydrated. Contiue to LIC9099-C Unsubstantiated On 01/05/2026, W2 met with W3 at the hospital. A speech therapist evaluated R1 and determined R1 was unlikely to consume sufficient nutrition or fluids orally to sustain life. The dietitian expressed concern regarding R1’s nutritional status. W2 informed W3 that a placement of a feeding tube would be necessary to consume nutrition or fluids to sustain life; however, W3 declined artificial nutrition, choosing to continue comfort care under hospice services. R1 was discharged from the hospital and returned to the facility on 01/07/2026. Review of hospice documentation revealed that as early as 11/04/2025, R1 was unable to consume nutritional food or fluids and was placed on aspiration precautions, pureed diet, and thickened liquids. Documentation from 11/11/2025 indicated muscle wasting and meal refusals, with intake limited to small sips of water. A hospice assessment dated 11/20/2025 documented cachexia, prominent bony features, and extremely limited intake. Hospice notes dated 01/01/2026 indicated continued poor intake despite caregiver efforts. R1 was discharged from hospice on 01/02/2026 due to hospitalization and readmitted on 01/07/2026. Based on record review and interviews, R1’s nutritional decline was consistent with terminal medical conditions and end of life status under hospice care—not due to lack of care or neglect by the facility. This allegation is UNSUBSTANTIATED. Allegation Staff did not ensure that resident received sufficient fluids to prevent dehydration. Interview with S1 confirmed R1 had been receiving hospice services since early November of 2025. S1 stated that staff made multiple attempts to offer fluids and documented refusals after the third attempt, consistent with facility practice. Hospice assessments dated 11/04/2025, 11/11/2025, and 11/20/2025 documented clinical dehydration, cachexia, and thickened liquid/aspiration precautions. Hospice notes dated 01/01/2026 indicated continued poor fluid intake despite caregiver encouragement. Evidence reflects R1’s poor fluid intake was directly related to medical decline associated with hospice care, including limited tolerance for fluids, difficulty swallowing, and end stage cachexia. There is no evidence that insufficient care or lack of intervention by the facility contributed to R1’s condition. This allegation is UNSUBSTANTIATED. Based on interviews, record review, hospice documentation, and hospital records, the Department finds that both allegations are UNSUBSTANTIATED: meaning that 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. An exit interview was conducted where this report was discussed and a copy was provided to the care staff Tiffany at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 30, 2026 · control 56-AS-20260108163849

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Edith Conchas and Renese-Howell Small made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Assisting Administrator, Elizabeth Zarate, was granted entry, and discussed the purpose for the visit. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (6), and a current census of (5). LPA conducted a general inspection of facility, which included, but was not limited to, the following: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor activity space, art supplies, books, and board games for residents in care. Outdoor activity space is enclosed with a latching gate. The facility is maintained at a comfortable temperature of 75 degrees F. Resident bedrooms were furnished with beds, night stands, chairs, bed linen and lighting. Resident bathroom equipment were operating properly and bathrooms were equipped with grab rails and slip mats. The hot water temperatures in the bathrooms measured at 125 degrees F, a deficiency was issued. The facility is equipped with operating smoke detectors and carbon monoxide alarms, fully charged fire extinguishers (2), laundry equipment, and telephone service. The facility has posted in a common area Community Care Licensing complaint poster, Ombudsman poster, facility license, Personal rights. The facility staff schedule reflects 24 hours a day, 7 days a week staff coverage. Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply was sufficient for number of residents in care. Cups, plates, and utensils were sufficient for number of residents in care. The facility’s refrigerator and freezer were operating properly. **continued on next page** The facility maintains record of resident’s medications and medications were centrally stored in a locked room and cabinet. LPA observed one medication without physician order, a deficiency was issued. LIC 809-C The facility has an emergency and disaster drill for review. The last emergency drill conducted with staff was on 03/2026. Resident files reviewed had (2) incomplete admissions agreements, a technical was issued. A physician’s reports, appraisals, emergency contact list, and care plans. Review of staff files reveals, (3) staff did not have a health screening completed verifying good physical health on file for review. A technical was issued. 1 staff file reviewed did not have current CPR, a technical was issued. Deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted were this report was discussed and copy provided with appeal rights to the Assisting Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 23, 2026

The state marks this report as 8 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Assisting Administrator, Elizabeth Zarate, was granted entry, and discussed the purpose for the visit. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (6), and a current census of (5). LPA conducted a general inspection of facility, which included, but was not limited to, the following: Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor activity space, art supplies, books, and board games for residents in care. Outdoor activity space is enclosed with a latching gate. LPA observed a bent butter knife in the passageway leading to the backyard gate. The facility is maintained at a comfortable temperature of 74 degrees F. Four (4) Resident bedrooms were furnished with beds, night stands, chairs, bed linen and lighting. One (1) bedroom was not inspected due resident being assisted by outside nurse. Resident bathroom equipment were operating properly and bathrooms were equipped with grab rails and slip mats. The hot water temperatures in the bathrooms measured at 110 degrees F. LPA observed in designated visitors bathroom cleaning solutions stored underneath an unlocked bathroom sink and on the bath tub. The facility is equipped with operating smoke detectors and carbon monoxide alarms, fully charged fire extinguishers, laundry equipment, and telephone service. The facility has posted in a common area Community Care Licensing complaint poster, Ombudsman poster, facility license, and evacuation plan. The facility staff schedule reflects 24 hours a day, 7 days a week staff coverage. Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply was sufficient for number of residents in care. Cups, plates, and utensils were sufficient for number of residents in care. The facility’s refrigerator and freezer were operating properly. **continued on next page** Health Related Services: The facility maintains record of resident’s medications and medications were centrally stored in a locked room and cabinet. Record Review: The facility has an emergency and disaster drill for review. The last emergency drill conducted with staff was on 02/27/25. Resident files reviewed had admissions agreements, physician’s reports, appraisals, emergency contact list, and care plans. Review of three (3) staff files reveals, Administrator's Raymond Chu did not have a current record of their administrator's certificate (expired in 2022) and did not have a health screening verifying Administrator's good physical health on file for review. Deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted were this report was discussed and copy provided with appeal rights to the Assisting Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 4, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Elizabeth Zarate, Assisting Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6), a current census of (6) residents, and a hospice waiver for (2). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. The facility's backyard area is sufficient for resident activities and is enclosed with a self-latching gate. Resident’s showers, toilets, and hand washing areas were operating in a safe and sanitary condition. Resident bathrooms were equipped with grab rails and non-skid flooring or non-skid mats. The hot water temperature in residents' bathrooms measured 111 degrees F. Resident’s bedrooms had beds, chairs, night stands, sufficient lighting and maintained at a comfortable temperature. The facility had operating carbon monoxide alarms, laundry equipment, and telephone service. The facility had sufficient linen, towels, and personal hygiene items for residents. The facility had sufficient activity supplies for residents in care. The facility's fire place is kept covered. Disinfectants and cleaning solutions were kept locked and inaccessible to residents in care. The facility has posted in a common area, Ombudsman poster, facility license, and evacuation exit plan sketch; However, the facility did not have posted, a list of emergency telephone numbers and a Residential Care Facility complaint poster. Deficiency cited. Care & Supervision: Facility has 24-hour, 7 days a week direct care staff. Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps were kept locked and inaccessible to residents in care. Record Review: Review of (5) staff files reveal: staff#1 (1), staff#2 (S2), staff#3 (3), staff#4 (S4), staff#5 (S5) did not have documentation of in-service annual Dementia training on file. S1 and S5 did not have documentation of CPR/First Aid training on file. Review of (5) resident files reveal: resident #1 (R1) did have a pre-admission appraisal on file. The facility did not maintain record of a current quarterly drill conducted with staff. The facility’s last fire/earthquake drill on file was conducted on 12/14/2022. Deficiency cited. Medical Related Services: Resident’s medications are labeled and centrally stored in a locked room. The facility had sufficient first aid supplies. A first aid manual is kept at the facility. Based on observations and record review, deficiencies are being cited per Title 22, of The California Code of Regulations and Health and Safety Codes. This report was reviewed with the Assisting Administrator and a copy with Appeal Rights was provided to the Assisting Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 18, 2024

The state marks this report as 10 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.