Fair Oaks Estates

Allegation investigated: -Uncleared adults are supervising residents -Licensee does not ensure records are complete -Licensee does not ensure staff are properly trained -Facility is not sufficiently staffed to meet the needs of residents in care -Staff are unable to clearly communicate with residents

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director (ED), Parveen Saroay, to deliver complaint investigation findings regarding the above stated allegations. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. The investigation is regarding concerns with staff (S1) not receiving criminal record clearance prior to receiving training at the care home. S1 received criminal record clearance and association to the facility on August 1, 2026. S1 began their initial training on August 12, 2026, which was completed on August 19, 2026. LPA reviewed S1’s employee file, which included all required initial training, criminal record clearance, 1st aid/CPR certificate, health screening and TB test. S1 completed their TB test reading on August 6, 2026 and their health screening on August 13, 2026 clearing S1 to begin working at the care home. S1 began providing care to residents on August 20, 2026. **********************************************Continued on LIC9099-C************************************************* Unsubstantiated According to staff schedules and interview with the ED, the facility staffs four (4) managers Monday-Friday and one (1) manager on weekends. There are ten (10) caregivers scheduled during the AM and PM shifts in which six (6) staff provide care in assisted living and four (4) in memory care. During both AM and PM shifts there are two (2) med techs on duty. The NOC shift has three (3) caregivers on duty and one (1) med tech that will also provide caregiving assistance. The facility currently has 24 residents receiving hospice care and a hospice waiver approved for 25 residents. In order to ensure staff are sufficient in numbers to provide appropriate care, supervision, and services to meet the residents’ individual needs, the facility will maintain their current work schedule. If there are changes in residents’ levels of care, they will adjust their staff schedule accordingly. The facility is a participant of the Assisted Living Waiver Program (ALWP), which provides a Rehabilitation Program for residents with behaviors. The facility provides small groups of residents, that would typically not be able to participate in activities, to be able to participate with increased supervision. The program also includes activities of daily living (ADLs), dining assistance, housekeeping, snacks and hydration, and laundry. The program is regulated by California Department of Health Care Services (DHCS) to ensure compliance. DHCS conducted an audit on August 20, 2026 which included, but was not limited to, facility inspection, call light response time testing, staff and resident file reviews, staffing schedule review, medication review, etc. The audit letter dated August 25, 2026 indicated that the facility was found to be compliant with the statutory assurances under the ALWP. Interviews with residents (R1, R2, R3, R4, and R5) indicated that staff treat them well and all of their care needs are being met. Interview with ED indicated that any resident related concerns are documented in the facilities High Risk Report. LPA reviewed the High Risk Report, which indicated care conferences, follow-ups with the hospital, changes in residents’ conditions, etc. The facility will indicate when a follow-up was completed as well. Interviews with R1, R2, R3, and R4 indicated that they are able to communicate their needs to care staff. R5 indicated that, although there may be somewhat of a language barrier with some staff, the staff are able to understand their needs. R1, R2, R3, R4, and R5 had no concerns regarding the facility or the care and supervision being provided. Based on interviews conducted and documentation obtained, 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. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 10, 2026 · control 59-AS-20260817130533

Allegation investigated: -Resident sustained unexplained fracture due to lack of care and supervision.

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Parveen Saroay, to deliver complaint investigation findings regarding the above stated allegation. During the course of the investigation, the department conducted interviews and obtained documentation pertinent to the investigation. According to hospital records, resident (R1) was sent to the hospital on March 5, 2026 after facility staff observed swelling of their left knee. Hospital records indicated that R1 was treated for a fractured left femur. Interviews with staff that were on duty between March 4, 2026-March 5, 2026 indicated that there was no known cause for R1's injury, such as a fall. According to staff interviews and R1's progress notes, R1 had previous falls on October 18, 2024 and January 15, 2026. Staff interviews also indicated that R1 had sufficient fall risk prevention equipment in place prior to March 5, 2026, which included a floor mat near *******************************************Continued on LIC9099-C********************************************************* Unsubstantiated their bed, a bed alarm, and a wheelchair alarm. Staff interviews indicated that R1 was receiving all the necessary care and supervision and their care needs were being met. No evidence suggested neglectful practice leading to R1's injury or provided a clear cause of R1's injury. Based on interviews conducted and documentation obtained, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 9, 2026 · control 59-AS-20260309110224

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 9/3/2026 to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 6/3/2025-6/3/2028. A copy of the Stipulation and Order is posted in a conspicuous place and is available for review. LPA met with the Executive Director (ED), Parveen Saroay. During today's visit, LPA reviewed the following stipulations of the order: 1. Care plans for all residents with restricted health conditions -LPA reviewed care plans 2. Monthly training for all staff -LPA reviewed training in accordance with Stipulation and Order 3. eMar system reports -LPA reviewed eMar system reports 4. Shift-change meetings -LPA reviewed shift-change meetings documentation LPA observed facility to be in compliance and residents receiving care. No deficiencies are being cited. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Sep 3, 2026

Allegation investigated: -Staff did not ensure resident's room was free of pests -Staff did not meet resident's laundry needs in a timely manner -Staff did not ensure medication was not accessible to residents -Staff did not ensure resident had a shower

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Parveen Saroay, to deliver complaint investigation findings regarding the above stated allegations. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. Allegation: Staff did not ensure resident's room was free of pests According to the facility's High Risk Resident Report, on February 28, 2026, care staff reported that resident (R1) was found with a few bugs on their bed. Care staff checked R1's body and hair and did not observe any bugs. R1's room was sprayed. There were several notations between March 1, 2026-March 26,2026, indicating that R1's room was checked for bugs. ***********************************************Continued on LIC9099-C************************************************ Unsubstantiated The High Risk Resident Report indicated that, on March 3, 2026, Pest Control provided services at the care home, which included R1's room. There was a suitcase and bag found under R1's bed that had garbage and some belongings that were removed to spray. On March 4, 2026, notes indicated that the suitcase was returned to R1's room. Notes from March 6, 2026 and March 11, 2026 indicated that no bugs were observed in R1's room. According to Pest Control Service Summary Report, dated March 3, 2026, services were provided in the care home including R1's room. R1 was in a shared room at the time of service. The summary report indicated that R1's room had a German roach follow up. Pest control replaced the glue boards in bathroom and near small dresser. There were dead roaches observed and exoskeletons of bedbugs discovered in a suitcase and clothing. Staff (S5) removed items from the room and spot treated. There were 2 live bed bugs found and killed in the items. Interview with staff (S1) indicated that they did observe bugs on R1's bed, however, they were not sure of the type of bug. S1 did not observe any bugs on R1's clothing. Staff (S3) indicated that they did not observe any bugs in R1's clothing or linen when doing laundry. S3 indicated that there was a small bag from a suitcase under R1's bed that they observed bugs inside. S5 indicated that they did not observe any bugs on R1's side of the room and only on resident (R2's) side. S5 indicated that the room was treated immediately. S5 stated that S1 treated the room with a spray that was recommended by the pest control company. The facility has a pest control contract that has been effective since August, 18, 2023 providing monthly and as needed treatments in the care home. The Pest Control Service Summary Report, dated April 7, 2026, indicated that pest control provided treatment in the care home including R1's room. The summary report indicated that there were no signs of bed bugs in R1's room. During a separate complaint investigation related to pest control concerns in the care home concluded on November 21, 2025, LPA interviewed the Pest Control Technician (PCT) that provides services at the care home. PCT indicated services are provided monthly and as needed. PCT indicated that the realistic goal is to keep the pests contained when providing services/treatment. PCT indicated that there is a threshold that they follow when providing services. Although there were insects observed, the facility is providing proactive pest control services monthly and as needed to ensure the facility does not become infested. *********************************************Continued on LIC9099-C********************************************** Allegation: Staff did not meet resident's laundry needs in a timely manner According to the facility's High Risk Resident Report, on February 28, 2026, care staff reported that R1 was found with a few bugs on their bed. Care staff removed all linens and clothing from R1's room to be laundered. R1 received a shower and their room was sprayed. Staff provided R1 with additional clothing while their clothing was being washed and their bed remade with clean linens. Interviews with S1, S3, S5, and staff (S2) indicated that all of R1’s linen and clothing were immediately removed from R1’s room to be laundered. S1, S2, and S3 indicated that R1 was provided clean clothing while their items were being washed. S1 indicated that some of R1’s clothing was cleaned and returned by the next day. S2 stated that R1’s clothing was changed everyday and washed. S3 stated that some of R1’s clothing was washed and returned back the same day. S4 indicated that they never witnessed R1 wearing the same clothing for multiple days. R1 stated that they put clean clothing on every time they shower. Allegation: Staff did not ensure medication was not accessible to residents On May 1, 2026, LPA observed the medication room with medication carts to be locked and medications to be inaccessible to residents in care. LPA observed medications for R1 and R2 and did not observe any medications that matched those in the images provided with the complaint. Interviews with S1, S2, and S3 indicated that they did not observe any medications in R1 and R2’s room. Interview with S4 indicated that R1 and R2 do not have any issues taking medications and are not known to refuse, pocket, or spit out medications. Allegation: Staff did not ensure resident had a shower According to the facility's High Risk Resident Report, between February 28, 2026-March 23, 2026, staff indicated that R1 took showers. S1 indicated that R1 took a shower the same day of the incident on February 28, 2026 and that staff supervised. S2 stated that R1 was showering everyday and that they stood by to ensure showering was completed. S3 stated that R1 was receiving showers and that they did standby to ensure R1 was showering. R1 stated that they were taking showers. Based on observations, interviews conducted, and documentation obtained, 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. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 13, 2026 · control 59-AS-20260302150600

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 5/13/2026 to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 6/3/2025-6/3/2028. A copy of the Stipulation and Order is posted in a conspicuous place and is available for review. LPA met with the Executive Director (ED), Parveen Saroay. During today's visit, LPA reviewed the following stipulations of the order: 1. Care plans for all residents with restricted health conditions -LPA reviewed care plans 2. Monthly training for all staff -LPA reviewed training in accordance with Stipulation and Order 3. eMar system reports -LPA reviewed eMar system reports 4. Shift-change meetings -LPA reviewed shift-change meetings documentation LPA observed facility to be in compliance and residents receiving care. No deficiencies are being cited. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, May 13, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced and met with the Executive Director, Parveen Saroay, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed four (4) bedrooms in assisted living, three (3) bedrooms in memory care, two (2) shower rooms, and common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 114 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers and first aid kits are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed four (4) resident files and also reviewed four (4) staff files. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Apr 15, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 2/25/2026 to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 6/3/2025-6/3/2028. A copy of the Stipulation and Order is posted in a conspicuous place and is available for review. LPA met with the Executive Director (ED), Parveen Saroay. During today's visit, LPA reviewed the following stipulations of the order: 1. Care plans for all residents with restricted health conditions -LPA reviewed care plans 2. Monthly training for all staff -LPA reviewed training in accordance with Stipulation and Order 3. eMar system reports -LPA reviewed eMar system reports 4. Shift-change meetings -LPA reviewed shift-change meetings documentation LPA observed facility to be in compliance and residents receiving care. No deficiencies are being cited. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Feb 25, 2026

Allegation investigated: -Staff are not addressing pests at facility -Staff did not seek timely medical attention for resident

Licensing Program Analyst (LPA) Angela Hood arrived at the care home and met with the Executive Director, Parveen Saroay, to deliver complaint investigation findings regarding the above stated allegations. LPA Sabrina Calzada began the investigation and LPA Hood concluded the investigation. During the course of the investigation, interviews were conducted, observations were made, and documentation pertinent to the investigation was obtained. According to contract and interviews conducted, the facility has had continuous pest control services. The original contract date for pest control services was signed on August 18, 2023 and was renewed with additional services on February 29, 2024. The pest control treatments are provided monthly to maintain a proactive approach to crawling insects, as well as on an as needed basis per request of the facility. ********************************************Continued on LIC9099-C************************************************ Unfounded On September 25, 2025, resident (R1's) responsible party informed facility staff of their concern regarding bedbugs and cockroaches in R1's room, causing R1 to sustain bug bites. Interview with Maintenance Director (MD) and Resident Care Director (RCD) indicated that, as soon as they were informed of the concern, they removed R1's bed from the room as well as inspected the room for evidence of pests. MD and RCD indicated that they inspected the removed bed and did not observe any evidence of pests. MD and RCD observed R1's room, as well as the roommates belongings and bed, however, did not observe any evidence of pests. Pest control was contacted and they inspected R1's room on September 30, 2025. According to pest control service summary report, they indicated "after inspection of bed and surrounding area, found no signs of bed bug activity. A few bugs captured in monitors were ext/int roaches. Replaced all glue boards and baited a few areas where roaches are known to traverse. Tech to return next Tuesday for regular scheduled services to gauge overall activity to define next steps". On October 8, 2025, pest control returned due to a callback for concern of bedbugs in R1's room. According to service summary report, "after inspecting unit, I found no signs of bedbugs, no exoskeletons, poop, or egg casings found in bedframe or mattress or along baseboards. Only thing captured in glue boards were 2 roaches, replaced all glue boards and added additional underneath bed to gauge insect activity (if any)". Interview with Pest Control Technician (PCT) indicated that they provide services every first Tuesday of the month and as needed. PCT indicated that the realistic goal is to keep the pests contained when providing services/treatment. PCT indicated that there is a threshold that they follow when providing services. PCT indicated that the MD also assists by replacing glue boards routinely. PCT indicated that they conducted a full inspection of R1's room with no indication or evidence of bedbugs. PCT indicated that, if there were bedbugs, there would be evidence not only in R1's bed but also in surrounding areas. PCT indicated that infestations do not just spring up. PCT indicated that they cannot bug bomb/fog half or partial of a building and would not risk residents' exposure to fumes due to respiratory issues and other health concerns. PCT indicated that they have other control methods such as gel baits to help control and reduce the population. On October 9, 2025, LPA Calzada observed R1's room as well as a nearby room with MD and RCD. LPA Calzada did not observe any pests and both rooms were clean. R1's Progress Notes, dated September 25, 2025, indicated that facility staff observed R1's skin. Staff indicated that there were no signs of bug bites and there was little redness from scratching dry skin. Staff indicated that they faxed R1's Primary Care Physician (PCP) and there was no need to send R1 to the Emergency Department (ER) per responsible party's agreement. Progress Notes also indicated that *********************************************Continued on LIC9099-C*********************************************** facility staff attempted to contact R1's PCP daily until they reached them on September 29, 2025. R1's PCP informed facility that, if there is open skin or bites, they need to send R1 to the ER. If not, PCP will be out in a couple days to assess. R1's progress notes indicated that staff were conducting daily skin checks from September 26, 2025-October 16, 2025 and there were no indication of bug bites. On October 9, 2025, R1 was seen by a physician who indicated that "the head to toe visit revealed no indication of lesions on the body due to bites. Xerosis (dry, flaky skin) and mild lichenification were found along the right arm and bilateral legs. It is recommended to start a daily or twice daily moisturizer that is unscented and gently on the skin". Additionally, the facility had R1's PCP visit them on October 13, 2025 who indicated that the skin issue has completely resolved and to keep on eye on the skin for any new rashes or itching. According to R1's service plan, the facility implemented applying lotion daily for R1's dry skin on September 25, 2025. Service plan also indicated for staff to continue monitoring R1's skin and report any issues to supervisor. Based on interviews conducted, documentation reviewed, and observations the above allegations are found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 21, 2025 · control 59-AS-20250929113251

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 11/21/2025 to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 6/3/2025-6/3/2028. A copy of the Stipulation and Order is posted in a conspicuous place and is available for review. LPA met with the Executive Director (ED), Parveen Saroay. During today's visit, LPA reviewed the following stipulations of the order: 1. Care plans for all residents with restricted health conditions -LPA reviewed care plans 2. Monthly training for all staff -LPA reviewed training in accordance with Stipulation and Order 3. eMar system reports -LPA reviewed eMar system reports 4. ED's 20 hours of additional training -LPA reviewed trainings 5. Shift-change meetings -LPA reviewed shift-change meetings documentation LPA observed facility to be in compliance and residents receiving care. No deficiencies are being cited. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Nov 21, 2025

Type of visit: Office

An office meeting was held on 07/23/2025 at 9:00 AM on a Microsoft Teams Meeting video conferencing system to review the Stipulation and Waiver; and Order adopted on 06/03/2025 and the next steps. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period. The following Licensing staff were present: Regional Manager Alycia Rayner, Licensing Program Manager Maribeth Senty, and Licensing Program Analyst Angela Hood The following representatives present: Licensee Kirt Hamburg and Administrator Parveen Saroay Alycia Rayner discussed the purpose and elements of this type of meeting. The Stipulation was reviewed with the Administrator and Licensee who expressed their understanding. The following items were discussed during today's meeting: Findings Revocation of License, Administrator's Certificate, and Exclusions-Stayed with Probation Needs and services plans for any clients with a restricted health conditions Monthly staff training and shift-change staff meetings Maintaining eMARs system and send reports to CCL every three months Terms of Probation Future Application for License, Registration, Certification or Approval Completion of Probationthe state’s words, verbatim · CDSS document, Jul 23, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced and met with the Executive Director, Parveen Saroay, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed four (4) bedrooms in assisted living, three (3) bedrooms in memory care, two (2) shower rooms, and common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 120 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers and first aid kits are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed four (4) resident files and also reviewed four (4) staff files. Facility provided proof of liability of insurance. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Apr 9, 2025

Allegation investigated: -Facility staff did not provide resident with medication as prescribed

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 12/17/24, and met with the Executive Director, Parveen Saroay, to deliver complaint investigation findings regarding the above stated allegation. On 12/17/24, LPA conducted a medication count for residents (R1 & R2), comparing the residents’ medication lists on file with medication centrally stored for the residents. LPA did not observe any medication errors. Interview with R1 indicated that they had issues previously with not receiving medications; however, the issues have been resolved and they are receiving all medications as prescribed. Based on medication count, interviews conducted, and documentation obtained, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 17, 2024 · control 59-AS-20241202151115

Allegation investigated: -Facility did not prevent a resident in care from eloping. -Staff did not keep facility free of insects.

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 12/11/24, and met with the Executive Director, Parveen Saroay, to deliver complaint investigation findings regarding the above listed allegations. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. Allegation: Facility did not prevent a resident in care from eloping. On 3/4/24, resident (R1) left the facility to attend day program. R1 typically returns to the facility from day program in the afternoon or evening. On 3/5/24, at approximately 1:30pm, the Executive Director was notified by the Resident Care Director (RCD) that R1 was missing. RCD contacted the Sheriff’s Department and R1’s responsible parties. R1 was wearing a tracking device monitored by the responsible parties. ********************************************Continued on LIC9099-C************************************************* Substantiated R1 was found by responsible party and taken home with them. The facility reviewed their camera’s video footage from 3/4/24 and found that R1 had returned from day program at around 4:45pm and was AWOL at 5:15pm. R1 left the facility through the front door and, although the alarm was triggered, staff turned it off without checking outside for any residents. According to facility’s internal investigation, care staff did not investigate why R1 was still on a leave of absence in their system from attending day program. All staff who did not follow facility’s protocol received disciplinary actions. A training was conducted as well. R1 was sent to the hospital upon return to the facility. On 3/7/24, R1 returned to the care home and was moved to the memory care unit. Allegation: Staff did not keep facility free of insects. On 10/10/24, LPA toured the facility, observing two (2) shared bedrooms in assisted living and two (2) shared bedrooms in memory care. LPA checked four (4) beds in assisted living and four (4) bed in memory care and did not observe any bedbugs. All rooms appeared clean and in sanitary condition with no observation of insects. There were no observations of insects throughout the tour of the care home. Interviews with residents (R2, R3, R4, and R5) indicated that they have never observed insects or bed bugs in the care home. Interviews with the Floor Manager, RCD, and S1 indicated that they have never observed bedbugs in R1’s room. LPA obtained copies of the facility’s pest control services summary reports from June 2024-November 2024, which indicated that the facility receives monthly pest control services to the interior and exterior of the care home. The July 2024 pest control services summary report indicated that R1’s room had live bedbugs, which was treated. The following months, August 2024-November 2024, indicated that there were no longer any sightings of bedbugs in R1’s room. The facility is currently being treated monthly for pests and the bedbug issue in R1’s room has been resolved; thus, no citation is being issued regarding this allegation. Based on observation, interviews conducted, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview conducted. A copy of the report and appeal rights provided. of the staff were aware of how the bruising formed. Interviews with ED, RCD, Floor Manager, and S1 indicated that R1 has aggressive behaviors. R1 attends a day program outside the facility as well. LPA reviewed all Unusual Incident/Injury Reports LIC624s regarding R1. There were no incidents reported regarding unexplained injuries sustained by R1. Allegation: Staff did not ensure resident's needs are being met. According to R1’s current care plan, dated 10/2/24, R1 requires assistance with medications, reminders dressing, a high level of staff supervision for behaviors, and incontinence care. The facility’s Service Checkoff List for the month of August 2024 indicated that R1 has been receiving all scheduled services for care assistance. R1’s Progress Notes, dated 8/15/24-10/19/24, indicated that there were several occasions that R1 refused to have staff assist with applying a physician’s ordered cream for a skin rash. According to Progress Notes and interviews with ED, RCD, Floor Manager, and S1, R1 would become aggressive with staff when attempting to assist with applying cream prescription. Progress Notes indicated that the facility had been in communication with R1’s physician and responsible parties regarding refusals. Interviews with ED and RCD indicated that R1 had been sent to the hospital several times due to aggressive behaviors and adjustments had been made to medications. Interviews with residents (R2, R3, R4, and R5) indicated that they feel that all their care needs are being met by the care home. LPA attempted to interview R1, who indicated that they were doing well and are treated well. LPA observed R1 who appeared to be well groomed and wearing clean clothing. Based on observation, interviews conducted, and documentation obtained, 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. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 11, 2024 · control 59-AS-20240903233231

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 12, 2024

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, the facility did not ensure that resident (R1) was properly supervised, resulting in AWOL, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 11, 2024

Plan of correction: Facility agrees to conduct an in-service training with all staff regarding missing residents/elopement indicating the date and time, as well as all participants to submit to LPA by the POC due date of 12/12/24. LPA extended due date to 12/13/24.

Allegation investigated: -Staff overmedicated resident

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 12/4/24, and met with the Executive Director, Parveen Saroay, to deliver complaint investigation findings into the above stated allegation. During the course of the investigation, LPA conducted interviews and obtained docuementation pertinent to the investigation. According to resident (R1's) progress notes, R1 refused medications several times between 1/30/24-4/3/24. The progress notes indicated that the facility staff contacted R1's physician on file via fax as well as communicated with R1's responsible party. Faxes provided by the faciltiy correlate with the progress notes regarding communication with R1's physician on file. ***********************************************Continued on LIC9099-C*********************************************** Unsubstantiated On 4/6/24, R1 was observed by staff to be tired, weak, confused, and had slurred speech. Due to R1 not being at baseline, they were transported to the hospital. Medical records obtained, regarding R1's 4/6/24 hospitalization, indicated that R1 was admitted for a suspected stroke. R1 was discharged on 4/12/24 and there was no indication in R1's medical records that they were being over-medicated. Based on interviews conducted and documentation obtained, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 4, 2024 · control 59-AS-20240530100229

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Angela Hood, Michael Hood, and Cassie Mikkelson arrived at the facility on December 4, 2024 for an unannounced Case Management visit. LPAs met with the Executive Director, Parveen Saroay, and the Licensee, Kirt Hamburg, to follow up on substantiated findings from a complaint investigation. On February 12, 2024, the Department concluded a complaint investigation which alleged the following: Facility did not seek timely medical treatment resulting in resident (R1) being hospitalized, and staff neglected to provide care to R1. The licensee was cited for California Code of Regulations (CCR) Section 87465(a)(1) Incidental Medical and Dental Care - Licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. The licensee was also cited for CCR Section 87464(f)(1) Basic Services - Shall at a minimum include care and supervision. At the time of the complaint visit on February 12, 2024, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code Section 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not seeking timely ***********************************************Continued on LIC809-C****************************************************** medical attention for R1, which resulted in R1’s diagnosis of severe sepsis secondary to pseudomonas bacteremia, acute kidney injury, tear to the urethral meatus and subsequent hospitalization. Today, December 4, 2024, the Department will be issuing a civil penalty per Health and Safety Code Section 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on February 12, 2024, the amount of the civil penalty issued today will be $9,500. A copy of the LIC421D was provided and originals were signed. Exit interview conducted. A copy of the report was issued. Appeal rights provided. The signature on this report acknowledges receipt of the appeal rights, found on page two of LIC421D.the state’s words, verbatim · CDSS document, Dec 4, 2024

Type of visit: Case Management - Other

On December 4, 2024, Licensing Program Analysts (LPAs) Michael Hood, Angela Hood, and Cassie Mikkelson met with Administrator Parveen Saroay of Fair Oaks Estates Inc, for a case management visit to follow up regarding a substantiated allegation that a resident sexually assaulted other residents in care. On May 4, 2023, the Department concluded a complaint investigation alleging that a resident (R1) sexually assaulted other residents in care. The allegation was substantiated and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c), and California Code of Regulations (CCR) Title 22, § 87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. On May 4, 2023, the issuance of an immediate civil penalty for $500 was issued and Licensee was informed that a civil penalty per Health and Safety Code Section §1569.49(f) is under review and a determination is pending. The Department has concluded an analysis and has determined that a civil penalty is warranted for physical abuse. Per Welfare and Institutions Code Section 15610.63(e), “’Physical abuse’ means any of the following: (e) Sexual assault, that means any of the following (1) Sexual battery, as defined in Section 243.4 of the Penal Code.” This is evidenced by the facility management being aware of R1’s sexually abusive behaviors towards others and not properly supervising R1, resulting in R1 sexually assaulting four (4) residents. ** Report continued on 809-C ** An interview with a staff member (S1) indicated that the licensee and administrator were informed of a residents (R1) history of sexually inappropriate behavior before R1's admission to the facility. An interview with R1's responsible party confirmed that this extensive history was disclosed to the administrator prior to placement. Despite awareness of R1’s behaviors, R1 was admitted to the facility without documentation of these behaviors in R1’s Admission Agreement or care plan. Department interviews with staff confirmed that, on November 12, 2022, R1 engaged in sexually inappropriate contact by touching two residents (R2 and R3), on their bare chests. Following this incident, facility staff and the licensee were notified of R1’s need for one-on-one supervision to ensure the safety of other residents. After R1 was taken to the hospital and returned to the facility, an increased level of supervision was added to R1’s care plan. However, R1 continued to move around the facility unsupervised, ultimately resulting in additional incidents where R1 inappropriately touched two more residents (R4 and R5), on December 12, 2022. Today, December 4, 2024, the Department will be issuing a civil penalty per Health and Safety code § 1569.49 in the amount of $10,000 for a violation that the department determines was caused by the absence of one-on-one supervision as required by statute or regulation, resulting in multiple residents being sexually assaulted. However, since an immediate civil penalty of $500 was issued on May 4, 2023, the amount today will be $9,500. A copy of the LIC 421D was given to Administrator and originals were signed. Exit interview conducted. Appeal Rights provided. A copy of the report issued. Signature on this report acknowledges receipt of these rights, found on page 2 of the LIC 421D.the state’s words, verbatim · CDSS document, Dec 4, 2024

Allegation investigated: -Staff did not dispense medication to resident as prescribed. -Staff did not provide resident with personal care supplies.

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 10/24/24, and met with the Executive Director, Parveen Saroay, to deliver complaint investigation findings into the above stated allegations. During the course of the investigation, LPA conducted interivews, medication counts, and obtained documentation pertinent to the investigation. ******************************************Continued on LIC9099-C************************************************* Unsubstantiated Allegation: Staff did not dispense medication to resident as prescribed. On 10/16/24 and 10/24/24, LPA conducted a medication count for residents (R6 & R7), comparing the residents’ medication lists on file with medication centrally stored for the residents. LPA did not observe any medication errors. Interviews with residents (R2, R3, R4, and R5) indicated that they receive all their medications as prescribed. LPA reviewed R1’s medication sheet for the dates that they resided at the care home. The medication sheet indicated that R1 received medication while at the care home. LPA was unable to complete a medication count for R1 as they no longer reside at the care home. Allegation: Staff did not provide resident with personal care supplies. Interview with Executive Director indicated that all residents receive a welcome packet with personal care supplies upon move in to the facility. Interviews with R2, R3, and R4 indicated that they received personal care supplies from the facility upon move in. Interviews with R2, R3, R4, and R5 indicated that they provide their own personal care supplies, however, the facility will provide supplies, if needed. Interview with R1 indicated that they did not receive a towel when requested. Interviews with the Resident Care Director and Memory Care Coordinator indicated that they never received a request for a towel from R1. Interviews with Resident Care Director and Resident Care Coordinator indicated that the facility has towels available to residents in care that they keep in the linen closet and laundry room. LPA observed the linen supply at the care home. Care home has an ample supply of linens to provide to residents in care. Based on observation, interviews conducted, medication count, and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 59-AS-20240813150626

Type of visit: Office

On 06/12/2024, a non-compliance conference was conducted. The purpose of this conference meeting was to address non-compliance at the facility after being issued 10 Type A citations and 7 substantiated complaint allegations since May 2023. Present in the meeting was CCLD staff, including Regional Manager Alycia Berryman, Licensing Program Managers Maribeth Senty and Anthony Perez, Licensing Program Analysts Angela Hood and Michael Hood, and facility staff, including the Licensee Kirt Hamburg, Administrator Parveen Saroay, and Resident Care Director Amardip Singh. The conference process was explained during this meeting. Issues discussed during this meeting were: · An overview of non-compliance at the facility regarding 10 Type A citations, 7 substantiated complaint allegations, and multiple civil penalties since May 2023 · Repeat violations regarding medication errors - medication management The facility has stated that they will do the following to achieve continued and substantial compliance: · Conduct regular audits of medications and care notes · Ensure staffing is sufficient to meet the needs of the residents in care · Ensure documentation is current and accurate to reflect the conditions of the residents in care · Ensure communication with all necessary parties regarding changes in the residents occurs Facility was notified that the Department may increase monitoring at the facility and the completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager. Exit interview was conducted and a copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jun 12, 2024

Allegation investigated: -Resident sustained an unexplained fracture while in care. -Resident was left on floor for an extended period of time. -Staff do not communicate resident's incidents to responsible party. -Facility floors are not clean and sanitized.

Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 4/18/24, and met with the Executive Director (ED), Parveen Saroay, to deliver complaint investigation findings into the above stated allegations. During the course of the investigation, the Department conducted interviews, toured the facility, and obtained documentation pertinent to the investigation. Allegation: Resident sustained an unexplained fracture while in care. According to interviews with facility staff and documentation obtained, resident (R1) required assistance with all activities of daily living (ADLs). R1 resided in the memory care unit of the care home. R1 had no history of falls while residing at the facility. According to Unusual Incident/Injury Report and interviews conducted ***********************************************Continued on LIC9099-C************************************************ Unsubstantiated with staff, while R1 was receiving assistance with ADLs on 6/18/23, R1 gestured to staff of pain in their left side. Staff indicated that they did not observe any bruises or any other injuries. Staff indicated that they did not witness any incidents prior to R1 gesturing that they were experiencing pain. Unusual Incident/Injury Report and interviews with staff indicated that R1’s responsible party was notified regarding R1’s complaint of pain. Staff indicated that they informed R1’s responsible party that they would like to send R1 to the hospital to be evaluated. Staff indicated that R1’s responsible party instructed the facility that they would schedule an appointment with R1’s primary care physician (PCP). According to Unusual Incident/Injury Report and interviews conducted, R1 was seen by their PCP on 6/22/23 and R1 was discovered to have fractured ribs on their left side. Medical records indicated that R1’s responsible party contacted the hospital, on 6/18/23, requesting a checkup for R1. R1 was taken to their scheduled appointment on 6/22/23. Medical Records indicated that R1 had complained of pain and no fall was reported. R1 was found to have minimally displaced left anterior lateral seventh, eighth, ninth, and tenth rib fractures. Interviews with residents, who had recently sustained falls at the care home, indicated that staff go out of their way to ensure residents are given medical treatment, when needed. No residents had any complaints regarding staff and the care being provided. Allegation: Resident was left on floor for an extended period of time. Interviews with ED and multiple staff indicated that R1 was not a fall risk and had no incidents of falls while at the care home. Interviews indicated that R1 was good at walking. Interviews also indicated that R1 did not require any mobility devices. Progress notes dated 5/15/23-7/27/23 indicated on multiple entries that R1 was walking independently and there were no notations of R1 falling while residing at the care home. The facility did not have any incidents indicating R1 had any falls. Allegation: Staff do not communicate resident's incidents to responsible party. Interview with ED indicated that R1 only had one incident while residing at the care home, which occurred on 6/18/23. The 6/18/23 incident was regarding R1 gesturing to staff that they were experiencing pain in their left side. Unusual Incident/Injury Report indicated that staff contacted R1’s responsible party, as well as the responsible party would set up a doctor’s appointment for R1. Interview with S1 indicated that when R1 was *************************************************Continued LIC9099-C****************************************************** found, on 6/25/23, in R2’s room no injuries were observed or noted. S1 indicated that it did not appear that R1 had fallen and that they had one knee on the floor. S1 indicated that, if there was something unusual with a resident, they would contact the family and physician. Interviews with ED and S1 indicated that R1’s normal behavior was wandering into other residents’ rooms and that R1’s responsible party was aware of R1’s behaviors. Allegation: Facility floors are not clean and sanitized. On 8/15/23, 4/3/24, and 4/11/24, LPA observed the memory care unit of the facility. The memory care unit has hard floors, which appeared to be clean and sanitized during the visits. On 4/11/24, LPA conducted an annual inspection of the care home and toured the facility. During the visit, LPA observed staff cleaning the floors several times throughout the day and the floors appeared to be clean and sanitized. Based on observations, interviews conducted, and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided. of the care home. According to interviews and documentation obtained by the Department, R1 did not have an altercation with R2 and did not require medical attention. Interviews conducted with ED and staff (S1) indicated that R1 had a habit of wandering into other residents’ rooms frequently and required redirection. Interview with S1 indicated that they were present and witnessed R1 in R2’s room on 6/25/23. S1 indicated that R1 was not screaming in pain. S1 indicated that R1 was yelling at R2 and R2 was telling R1 to leave their room while holding R1’s hand. Interviews with ED and S1 indicated that R1 was frequently agitated. Progress Notes dated 5/15/23-7/27/23, indicated multiple instances of R1 expressing agitation and exhibiting wandering behaviors requiring redirection. Physician’s Report LIC602A dated 4/14/23 indicated that R1 has sundowning, wandering, and aggressive behaviors. Based on interviews conducted and documentation reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 18, 2024 · control 59-AS-20230815094803

Allegation investigated: -Licensee is not keeping the facility free from pests

Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 4/11/24, and met with the Executive Director, Parveen Saroay, to deliver complaint investigation findings into the above stated allegation. During the course of the investigation, LPA inspected the facility, conducted interviews, and obtained documentation pertinent to the investigation. There was a previous Substantiated complaint with findings delivered on 8/10/23 indicating that the facility had an issue with cockroaches. Since those findings, the facility has hired a professional pest control company to provide pest control services monthly and as needed. The pest control service company provides routine indoor and outdoor services as well as additional services checking/spraying 4 resident bedrooms. The facility provided invoices indicating that pest control services were provided on 3/5/24 and 4/2/24. *******************************************Continued on LIC9099-C********************************************** Unsubstantiated On 3/26/24, LPA observed 2 residents' (R2, R3, R4, and R5) bedrooms and the dining area. LPA did not observe any signs of pests in the bedrooms or dining room area. Interviews with R2 and R5 indicated that they have never seen pests in the care home. Interview with R3 indicated that they had seen cockroaches at the care home but have not seen any since the last three sprays that the pest control company provided. Interview with staff (S1) indicated that they have not seen any pests in the care home. Interview with the Executive Director and staff (S2) indicated that the pest control company provides services monthly and will be contacted for any additional services, if needed. Interviews also indicated that facility will select 4 residents' rooms to be sprayed for pests monthly. On 4/11/24, LPA conducted an annual inspection of the care home and did not observe any signs of pests. LPA observed resident (R1's) room. R1's room had four traps for pests. LPA observed 3 gnats on one trap and no pests on the other traps. R1's room has double doors that lead to an outdoor patio that can be utilized by R1. Based on observation, interviews conducted, and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 11, 2024 · control 59-AS-20240322100504

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 4/11/24 and met with the Executive Director, Parveen Saroay, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed four (4) bedrooms in assisted living, three (3) bedrooms in memory care, two (2) shower rooms, and common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 113.9 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers and first aid kits are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed four (4) resident files and also reviewed three (3) staff files. Facility provided proof of liability of insurance. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Apr 11, 2024

Allegation investigated: -Staff neglect resulted in resident developing multiple medical conditions -Staff did not address incontinent issues with appropriate representative

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 4/8/24, and met with the Executive Director, Parveen Saroay, to deliver complaint investigation findings into the allegations listed above. During the course of the investigation, the Department conducted interviews and obtained documentation pertinent to the investigation. Allegation: Staff neglect resulted in multiple medical conditions. Resident (R1’s) responsible party indicated that R1 had frequent falls, was on a strict diet, had plenty of water to drink, and had not had a Urinary Tract Infection (UTI) for several years prior to moving into the facility. Responsible party indicated that, within the first two weeks of R1 residing at the facility, they were witnessed eating sugary snacks, drinking sugary drinks and coffee, and only drinking approximately four ounces of water with their medications. It is believed by the responsible party that R1’s decline is due to their diet. ******************************************Continued on LIC9099-C**************************************************** Substantiated Facility staff noted that R1 had several falls, decreased energy levels, and increased confusion. Facility staff also noted that R1 was skipping meals. Facility contacted R1’s Primary Care Physician (PCP) and reported R1’s change in condition, however, did not hear back from the PCP prior to R1’s hospitalization. Interviews conducted by the Department with staff indicated that none of the facility staff members were aware that R1 had a stage three pressure wound on their right heel despite R1 requiring one on one assistance with dressing and bathing. Facility staff noted that R1 had dry flaky skin on their right heel on 10/22/2023. Staff interviews also indicated that none of the staff were aware of any signs or symptoms of infection or any redness or swelling. R1 was hospitalized from 11/9/2023-11/19/2023. Hospital records indicated that R1 was diagnosed with a UTI, severe sepsis, several fractured ribs, hypoglycemia, and a stage three pressure wound on their right heel upon arrival. Allegation: Staff did not address incontinent issues with appropriate representative. Interview with Resident Care Director (RCD) indicated that, prior to R1 being sent to the hospital on 11/9/23, R1 was placed on a 72-hour watch to observe for any changes in R1’s condition. The facility noted that R1 was experiencing confusion on 11/7/23, which continued on 11/8/23. RCD stated that, during the 72-hour period, the facility provided courtesy services to R1 if any changes in condition were observed. RCD indicated that, as part of the courtesy services, facility staff were providing R1 assistance with toileting as incontinence issues were observed. According to R1’s Assessment dated 9/29/23, R1 was not incontinent. RCD stated that R1 was originally independent with toileting. RCD indicated that R1’s responsible party was not notified during the 72-hour period that the incontinence issues were observed. Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. As a result of the resident’s serious bodily injury, an immediate civil penalty per Health and Safety Code § 1548 in the amount of $500 for the date of 4/8/24 is assessed for a violation that the Department determines resulted in the injury or illness of a person in care. An additional civil penalty assessment is under review and a determination is pending. LPA will return on a future date to assess an additional civil penalty if warranted. Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledge receipt of these documents. Allegation: Staff unlawfully evicted resident. According to medical records and interviews with the ED and Resident Care Director (RCD), R1 was discharged from the hospital on 11/19/23 to a skilled nursing facility. Interview with RCD indicated that, when they assessed R1 at the skilled nursing facility, R1 was not at baseline and had a change in condition. According to R1’s Assessment conducted by RCD, dated 11/29/23, R1’s condition had changed in comparison to R1’s Assessment conducted on 9/29/23. Interviews with RCD and ED indicated that R1 would require a higher level of care and was not accepted back to the facility from the skilled nursing facility. ED stated that R1 was not evicted from the facility and no eviction notice was issued. Allegation: Staff overcharged a resident for services not received. According to facility invoices and R1’s transaction history, R1 was charged for 1 day in December 2023 pending R1’s property removal from the facility. Interviews with ED and the Business Office Manager indicated that R1 was not charged for services that were not received. Based on interviews conducted and documentation reviewed, the above allegations are found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.the state’s words, verbatim · CDSS document, Apr 8, 2024 · control 59-AS-20231213090351

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Apr 9, 2024

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted facility staff did not observe resident (R1) in accordance with their care plan resulting in R1 sustaining a stage three pressure injury, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2024

Plan of correction: Facility will conduct in-service training for staff regarding observation of residents. Facility will submit to LPA information regarding in-service training, including time and date of in-service and training material, by POC due date of 4/9/24. An immediate civil penalty of $500 was assessed today per Health and Safety Code § 1548 due to a violation that the department determines resulted in the injury or illness of a person in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(b) · Plan of correction due date: Apr 22, 2024

87463 Reappraisals (b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted facility staff did not notify R1's responsible party of changes in R1's incontinence care needs that were observed, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2024

Plan of correction: Facility will conduct in-service training for staff regarding the importance of notifying a residents physician and responsible party when changes in condition are observed. Facility will submit to LPA information regarding in-service training , including time and date of in-service and training material, by POC due date of 4/22/24.

Allegation investigated: -Personal Rights

Licensing Program Analsyt (LPA) Angela Hood arrived unannounced at the care home today, 2/21/24, and met with the Resident Care Director, Amardip Singh, to deliver complaint investigation findings regarding the above stated allegation. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. ********************************************Continued on LIC9099-C**************************************************** Unsubstantiated Interview with resident (R1) indicated that they have no complaints against the facility. R1 stated that there were two instances where residents with Dementia made them feel uncomfortable. R1 indicated that staff intervened. R1 indicated that staff have been accommodating. R1 stated that staff (S1) visits them weekly, which has been helpful. Interviews with S1 and staff (S2) indicated that they and other staff are providing R1 with accommodations to make them feel comfortable at the care home. S1 and S2 stated that R1 has been dining in the dining area and participating in more activities. R1 stated that they are not being held in their room by facility staff. According to R1's progress notes dated 2/17/24, R1 informed S1 that they are being treated well and that staff have been helpful. R1 indicated to S1 that they are happy with the care team. Based on interviews conducted and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 21, 2024 · control 59-AS-20240208132207

Allegation investigated: Facility staff are not addressing the resident's mental health needs.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the investigation and issue findings to a complaint received on 12/06/23. LPA met with Parveen Saroay, Administrator, and stated the reason for the inspection. During today's inspection, LPA interviewed the Administrator, Care Coordinator, and Resident Care Director. LPA also interviewed a representative from the placement agency who has assisted resident (R1) and reviewed R1's physician's report and charting notes. LPA also discussed the allegation with another LPA. The results of the investigation are as follows: cont on 9099C-1... Unfounded 9099C-1..Allegation: Facility staff are not addressing the resident's mental health needs. The allegation states (R1) is isolated 24/7, neglected with nobody to talk to about her fears and nobody cares. The allegation also states that (R1) has been offered mental health services, but (R1) has declined and that (R1) shares a room with another resident who has recently provided her 30-day notice to leave the facility. Resident moved in on/around 11/30/23 with a diagnosis of PTSD, low appetite, arthritis, and anxiety. The physician's report states resident can also be depressed. The Administrator stated (R1) was very happy to move in to the community after taking a lengthy tour and wanted to move in immediately. Staff interviews indicated that resident is independent with all activities of daily living (ADL's) and can schedule and attend her own medical appointments. Regarding (R1) being isolated 24/7 and neglected Charting notes dated 12/11/23 state resident doesn't feel the community is appropriate and wants the community to help her find a more suitable place for her needs. Charting notes from 12/12/23 document a care conference was held with facility managers and the Ombudsman and resident expressed that she would like to have someone to talk to about any concerns, so the Care Coordinator was assigned to meet weekly with her for 30 minutes. Notes entered on 1/13/24 state resident expressed concerns about having nightmares and was advised by facility staff to contact her primary doctor. Additional notes show staff has consistently taken follow up action to address concerns brought to their attention, including repairs in resident's room and with food service. Notes entered on 2/13/24 state resident was frustrated with her situation of trying to get an answer on her eligibility for a particular program, and resident was referred to the assigned LPA to discuss her concerns. LPA Hood confirmed she spoke in length with resident on/around 2/13/24. All facility interviews confirmed that when resident first moved in, she would stay in her room, including during meals, and would not participate in activities or socialize with the other residents. These interviews also confirmed that resident has made significant progress since moving in and will now eat meals in the dining room, is willing to talk to other residents, participates in some activities and has been going to the Wednesday in-house store. Staff indicated that resident has changed her behavior based largely on the trust built from the weekly 1:1 meetings with the Care Coordinator. In addition, phone calls to the front desk have significantly decreased along with complaints made. Resident was not available to speak to LPA during today's inspection. cont on 9099C-2.. 9099C-2. Charting notes from 12/12/23 state resident felt she has no one to talk to, wants someone to talk to and the facility offered a support group they have, and resident declined. Facility staff confirmed that, in addition to providing a weekly 1:1 staff to listen to resident's concerns, shortly after resident moved in, they have offered to assist resident in any other way she has asked. This includes assisting her in finding another community, contacting her doctor or placement agency, and suggesting she contact her health care plan for available services. A representative from the placement agency stated that resident was offered mental health services on three occasions but declined. Facility staff interviews concluded that resident had more issues with the placement agency in not being able to assist her as quickly as she would like, than with the facility. Interviews confirmed that although resident liked the staff and community in general, she wishes to reside at a community with younger adults, close to her in age. Regarding resident sharing a room with another resident who recently provided a 30-day notice- all interviews conducted confirmed that (R1) has not had a roommate since moving to the facility. Interviews confirmed resident has anxiety about having a shared room but may need to move into shared room in the near future. Based on information obtained, LPA finds the allegation: Facility staff are not addressing the resident's mental health needs, to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Feb 16, 2024 · control 59-AS-20231206083022

Allegation investigated: -Failure to seek timely medical treatment resulted in resident being hospitalized. -Staff neglected to provide care to resident

Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 2/12/24, and met with the Executive Director, Parveen Saroay, to deliver complaint investigation findings into the above stated allegations. During the course of the investigation, the Department conducted interviews and obtained documentation pertinent to the investigation. ************************************************Continued on LIC9099-C*************************************************** Substantiated According to records reviewed and staff interviews, resident (R1’s) catheter was observed to be leaking on 8/15/23 for an unknown reason and Home Health was notified. On 8/16/23, Home Health did not conduct a visit with R1. On 8/16/23, staff reported to facility manager that R1 had a decrease in urine output, which was not common. However, no further attempts were made by the facility to contact Home Health. Also, the facility did not seek medical attention for R1’s decrease in urine output or the leaking catheter. On 8/17/23, staff reported R1 continued to have a decrease in urine output and appeared pale and ill. Despite R1’s symptoms, R1 was transported to day program and the facility did not communicate the reported information to Home Health, R1’s day program, or R1’s responsible party. Upon arrival to day program, the program staff immediately observed R1 was ill and had no urine output in their catheter. Day program staff notified R1’s responsible party. Subsequently, R1 was sent to the hospital and diagnosed with severe sepsis secondary to pseudomonas bacteremia, an acute kidney injury, and a tear at the urethral meatus. The facility’s Catheter Care Policy states that staff will “monitor skin area where catheter is inserted for any redness or swollen discharge, if any of those indication appear you must notify Med Tech immediately.” Home Health records and interview with Home Health nurse indicated that staff were trained to wash the catheter, including the bag, tubing, and penis daily, checking for signs of infection such as discharge or leaking urine. However, multiple staff interviews indicated that staff were not trained to check or wash the area where R1’s catheter was inserted in the penis. Multiple staff indicated that they did not conduct regular checks on R1’s catheter insertion site and did not observe a tear in R1’s urethral meatus. Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. As a result of the resident’s serious bodily injury, an immediate civil penalty per Health and Safety Code § 1548 in the amount of $500 for the date of 2/12/24 is assessed for a violation that the Department determines resulted in the injury or illness of a person in care. An additional civil penalty assessment is under review and a determination is pending. LPA will return on a future date to assess an additional civil penalty if warranted. Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Feb 12, 2024 · control 59-AS-20230825082432

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Feb 13, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure resident (R1) received timely medical care for their leaking catheter and lack of urine output, which posed an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2024

Plan of correction: Facility agrees to create a plan to ensure that, when a resident has a change in condition, the facility will arrange or assist in arranging appropriate medical care. Facility will also conduct a training with staff regarding the importance of resident observation and seeking timely medical attention and submit to LPA by the POC due date of 2/13/24. An immediate civil penalty of $500 was assessed today per Health and Safety Code § 1548 due to a violation that the Department determines resulted in the injury or illness of a person in care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 13, 2024

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility staff did not conduct regular checks on R1’s catheter insertion site as instructed by home health and facility policy, which posed an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2024

Plan of correction: Facility agrees to complete a statement of understanding as well as conduct a training with staff regarding the importance of following home health instructions and facility policies and submit to LPA by the POC due date of 2/13/24.

Allegation investigated: Residents smoke illegal drugs inside of the facility Staff serve residents contaminated foods Neglect and lack of care and supervision resulting in resident sexually assaulting other residents and staff.

On 2/7/24, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Administrator. The department conducted records review and extensive interviews. The department is unable to find and or meet the preponderance, per policy. The department interviewed several staff members, all staff denied witnessing a resident (R1) smoke illegal drugs while on facility property. Staff have witnessed R1 smoke in designated smoking areas. Staff denied witnessing any sort of behaviors from R1, in which a person under the influence of illegal drugs would demonstrate. The department interviewed R1. R1 denied smoking illegal drugs on facility property. R1 stated that they only smoke in designated smoking areas of the facility. The department interviewed several residents, all residents interviewed denied witnessing R1 smoke any illegal drugs. Unsubstantiated While the department had previously investigated, from 6/9/23- 8/10/23, and issued citations for food storage and kitchen cleanliness on 8/10/23, there was not additional information found that the deficiencies resulted in contaminated foods being served to or consumed by residents. The department interviewed several staff members regarding R2 and the allegation of their sexually assaulting others. This allegation was previously investigated 6/1/23- 8/1/23. That investigation resulted in a citation for residents’ personal rights having been violated by R2. Subsequent from the previous investigation until the conclusion of this investigation, a new care plan has been implemented to have R1 have reduced physical proximity access to other residents resulting in R2 no longer being able to reach out and grab people, the inappropriate behaviors have completely stopped. Thus, although the incidents did occur in the past, the department could not find an incident between 8/1/23 and 1/16/24 in which the staff was neglectful or failing to supervise R2 which resulted in R2 touching another resident. Therefore, the allegation is Unsubstantiated. As a result of this investigation, LPA finds allegation to be (US)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. Exit interview with administrator report copy provided.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 59-AS-20230629125021

Allegation investigated: -Staff do not administer residents' medications as prescribed

Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 1/29/24, and met with the Resident Care Director, Amardip Singh, to deliver complaint investigation findings into the above stated allegation. During the course of the investigation, LPA conducted a medication count, conducted interviews, and obtained documentation pertinent to the investigation. *********************************************Continued on LIC9099-C**************************************************** Substantiated During a visit conducted on 12/8/23, LPA conducted a medication count for residents (R1, R2, R3, & R4), comparing the residents' medication lists on file with medication centrally stored for the residents. LPA observed two (2) medications for R1 that were over the amount documented. There was also one (1) medication for R1 that could not be counted as the bottle could not be located during the visit. LPA observed two (2) medications for R2 that were over the amount documented. The facility indicated that, for one (1) of the medications, it was found that a staff member falsified medication documentation information and disciplinary action was taken against the staff member. LPA observed that nine (9) medications for R3 were over the amount documented and one (1) medication was under the documented amount. The facility indicated that, for one (1) of the medications, it was found that a staff member falsified medication documentation information and disciplinary action was taken against the staff member. Based on a medication count and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jan 29, 2024 · control 59-AS-20231013081845

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 30, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication count and records reviewed, the facility did not ensure that residents (R1, R2, & R3) were receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2024

Plan of correction: Facility agrees to have all med-techs sign a statement of understanding of job duties to address medication management to submit to LPA by the POC due date of 1/30/24. Faciliy will also complete bi-weekly audits of all medications for the next month and submit to LPA.