Fairwinds - Ivey Ranch

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Thomas Fraser, Director of Restaurant Services. LPA then met with Executive Director Karl Miller, who arrived shortly after. All staff present at the facility had current criminal record clearances. According to the facility’s license is approved for a maximum capacity of 200 residents, 75 of which might be non-ambulatory. Interviews with staff revealed that a majority of residents required the use of an assistive device such as a walker or wheelchair and estimated that approximately 85 residents required the use of a walker or wheelchair. LPA, accompanied by staff, toured the interior and exterior of the facility and inspected all common areas and resident bedrooms. LPA interviewed residents and staff. LPA reviewed care records for all residents and personnel records for all active staff. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. (Continue at LIC809C) (continue from LIC809) The facility’s ambient internal temperature was complaint at 74 F. Hot water temperature at taps accessible to residents were all compliant: Refrigerator to preserve perishable food were also compliant in temperature. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Carbon monoxide detector, smoke detectors, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguisher had been serviced within the last twelve months. No pools/bodies of water were observed on the premises. Fire/disaster drills were performed at required intervals. There were reserve supplies of Personal Protective Equipment (PPE). There were no deficiencies during the annual inspection today. An exit interview was conducted with Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visitthe state’s words, verbatim · CDSS document, Aug 30, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with General Manager Karl Miller to discuss the purpose of the visit. Today's visit is in response to the self reported death of Resident 1 (R1 - see LIC811 Confidential Names List). R1 passed away on 07/01/2026. LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with General Manager Karl Miller, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jul 3, 2026

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to continue the annual inspection started on 8/20/2025. LPA was greeted by, identified herself to, and explained the purpose of the visit with General Manager Karl Miller. The facility has a licensed capacity of 200 residents, 75 may be non-ambulatory and has a hospice waiver for 7 residents. During today’s visit, the facility had a census of 177 residents. The Administrator for the facility is Jessica Sommer and their certificate was valid and current. During visits on 8/20/25 and 10/28/25, LPA inspected a random sampling of resident rooms and bathrooms, common areas, kitchen, and outside space. No bodies of water, delayed egress, or secured perimeter were observed on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. LPA observed linens and hygiene products for resident use. The facility’s ambient and water temperature were measured within regulatory requirements at multiple locations. LPA observed locked storage for resident medications and hazardous and/or toxic chemicals, both of which were stored separately from food supplies. According to Karl Miller, no firearms or weapons are stored on the premises. LPA observed a minimum supply of 2-days of perishable food and 7-days of non-perishable food. The refrigerator and freezer temperatures were kept within requirements. Staff present at the facility had a criminal background clearance and association. LPA reviewed multiple resident and staff records. LPA was away from the facility from 12:10pm and 1:10pm. No deficiencies were cited on today’s date. An exit interview was conducted with General Manager Karl Miller, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Oct 28, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to conduct follow up regarding an incident. LPA was greeted by, identified herself to, and explained the purpose of the visit with General Manager Karl Miller. On 10/15/2025, the Department received a self-reported incident report from the licensee that described an incident that occurred on 10/9/2025. The incident report described that Resident 1 (R1) had a fall in their room, alerted staff via call pendant, staff assessed resident and called 911. [General Manager provided with LIC811 Confidential Names List to identify R1] R1 was transported to the hospital, received medical treatment, and was admitted for multiple days. Upon returning to the facility on 10/11/25, R1 notified facility management that some jewelry was missing from their room. Facility management and R1 notified local police department's office of the alleged theft and facility management conducted multiple searches of R1's room with R1 present. During today’s visit, LPA observed residents in care, spoke with General Manager, and reviewed and obtained facility records. Additional visits may be necessary in regards to this incident. No deficiencies were cited on today’s date. An exit interview was conducted with General Manager Karl Miller, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Oct 16, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Rebecca Borunda and Jose De La Cruz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPAs were greeted by, identified themselves to, and explained the purpose of the visit with Debbie Dala, Guest Services Manager. During today's visit, LPAs toured the facility, reviewed facility records, and observed residents in care. Review of the facility’s fire clearance dated 8/1/2002 and review of the facility’s licensed capacity revealed that the facility is approved for a maximum capacity of 200 residents, 75 of which might be non-ambulatory. Interviews with staff revealed that a majority of residents required the use of an assistive device such as a walker or wheelchair and estimated that approximately 85 residents required the use of a walker or wheelchair. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. LPAs were away from the facility for approximately thirty minutes between 1:30 pm and 2:00 pm. The following deficiency for over capacity of non-ambulatory residents is cited per California Title 22 and noted on the attached LIC809-D page. Additionally, a civil penalty in the amount of $500 was assessed for over-capacity and noted on the attached LIC421IM form. An exit interview was conducted with Debbie Dala Guest Services Manager, MJ Bachelor, Health and Wellness Director, whose signature below confirms receipt of a copy of this report LIC421IM and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Aug 20, 2025

Allegation investigated: Food service was not overseen by qualified individual

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to General Manager Karl Miller. During today’s visit, LPA observed residents in care, reviewed and obtained copies of facility records, and interviewed staff. The Department’s investigation consisted of interviews with staff, records review, and a tour of the facility. It was alleged that the food service was not overseen by a qualified individual. Interviews with facility staff revealed that the menu was modified on a quarterly basis and any changes were done with input from the facility chef and cooks, the Restaurant Manager, and the General Manager and was based on resident likes and dislikes, popularity of menu items, and variety to accomodate resident dietary needs. Continued on LIC9099-D page.. Substantiated Interviews with staff revealed that prior to 2020, the facility’s menu was submitted to the facility’s corporate office for review and assessment once or twice a year. Interviews with facility management revealed that the facility has not provided their corporate office with a sample menu for review since at least 2021. Interviews with staff revealed that neither the Chef or Restaurant Manager are nutritionists, dietitians, or home economists. Review of a nutritional assessment of the facility’s menu revealed that the facility’s menu was reviewed by a dietitian on 8/15/2024. Interviews with facility management revealed that the facility’s menu had not been overseen by a dietitian, nutritionist, or home economist since at least 2018. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency for the facility menu not being overseen by a qualified individual is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. An exit interview was conducted with General Manager Karl Miller, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22). Review of the facility’s prescribed diet order form revealed that residents’ physicians are notified that the facility is only able to accommodate low sodium (GLS), limited concentrated sweets (LSC), and mechanical soft diets. Review of the facility’s dining room menu for May 2024, healthy items menu, and chef specials menus revealed that the facility offered multiple different meal items using different meats such as beef, pork, chicken, salmon, and turkey as well as a no added sugar dessert options. Review of the facility’s food guide regarding GLS revealed that sodium is restricted on that diet and residents are encouraged to limit the consumption of high salt meats such as ham, sausages, packaged seasoning mixes, soups, sauces, gravies, salad dressing, and marinades. Meals should be made with fresh herbs and soup stocks. Review of the facility’s food guide for LCS revealed that the diet is a liberalized diabetic diet and allows for residents to consume most types of food while following recommended portion sizes, except for desserts. Residents following this diet should be offered diet options of foods such as jelly, syrup, Jell-O, and pudding. Interviews with staff revealed that in August 2024, the facility began using a new electronic meal ordering system which allowed dining staff to view each resident’s dietary preferences, physician ordered modified diets, and allergies. During a visit on 8/14/2024, LPA Ruiz observed a demonstration of the new electronic ordering system which showed the resident’s name and listed the resident’s dietary preferences, modified diets, and allergies in red text under the resident’s name on an electronic tablet. The system also marked any meals in red if that meal contained ingredients or was prepared in a way that does not align with the resident’s dietary restrictions. Facility staff were able to modify meals by removing or substituting ingredients and placing sauces or dressings on the side. Once the meal has been modified to meet the resident’s dietary restrictions, the meal no longer showed red in the system. The system would print out a ticket in the kitchen that listed the resident’s name, meal order, dietary preferences, modified diets, and allergies in red text. Kitchen staff stated that they often marinate meats for entrees and will set aside a few meats that are not marinated to allow residents with dietary restrictions to order that meal. Staff stated that they are able to make modifications to most meals to allow residents to eat whichever meal the resident chose to eat but stated that there are a few times that the staff could not meet a resident’s request to eat a certain meal. Kitchen staff stated that in that case, staff would speak with the resident to explain the reason that staff cannot accommodate the resident’s dining request and offer alternative meal choices. Continued on LIC9099-C page… During interviews with dining and kitchen staff, as well as facility management revealed that residents who had a physician ordered modified diet must be willing to follow the requirements of the diet, and staff cannot force residents to choose specific meals or restrict certain meal items. The facility’s prescribed diet order form includes language to physicians that residents must be aware of the physician order diet, must be willing to follow the diet, and that the resident could not be forced to follow the diet. Interviews with dining staff and facility management provided supporting evidence that residents were not required to adhere to the physician ordered diet. Interviews of residents with modified diets did not reveal any concerns with the meals offered at the facility. Some of the residents interviewed denied that they were following any modified diets while others stated that they were modifying their diet independently without a physician order. Residents did not voice any concerns that the facility did not offer a variety of meals that allowed residents with different meal preferences or requirements to have choices in their meals. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with General Manager Karl Miller, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Sep 9, 2024 · control 08-AS-20240807150113

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(17) · Plan of correction due date: Sep 23, 2024

(b) the following food service requirements shall apply: (17) ... a full-time employee... shall be responsible for the operation of food service. If this person is not a nutritionist, a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. This requirement has not been met as evidenced by: Based on interviews and records review, the licensee did not ensure that the facility's food service was overseen by a dietitian, nutritionist, or home economist since at least 2021. This poses a potential health risk to 167 of 167 residents in care.the state’s words, verbatim · CDSS document, Sep 9, 2024

Plan of correction: The General Manager had the facility's menu assessed by a dietitian on 8/15/2024. The General Manager will submit menu changes to a dietitian for review quarterly and will ensure that the menu receives a comprensive assessment at least once a year. The General Manager will submit proof of agreement for a dietitian to review the facility's menu on a quarterly basis to the Department by POC due date of 9/23/2024.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to conduct follow up regarding a self-reported incident report. LPA was greeted by, identified herself to, and explained the purpose of the visit with General Manager Karl Miller. On 9/3/2024, the Department received an incident report and SOC341 Report of Suspected Dependent Adult/Elder Abuse from the facility that described an incident in which Resident 1 (R1) reported missing medication to facility staff. [General Manager was provided with LIC811 Confidential Names List to identify R1] Per incident report, facility management conducted a check of R1's room and interviewed R1 and relevant staff. Facility staff notified R1's responsible party. No injuries or adverse reactions were reported. During today’s visit, LPA conducted a health and safety check, observed residents in care, reviewed facility records, interviewed Resident 1. Further follow-up is necessary. No deficiencies were cited on today’s date. An exit interview was conducted with General Manager Karl Miller, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Sep 9, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Case Management - Annual Continuation visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with General Manager Karl Miller. The facility is licensed for a maximum capacity of 200 residents, 75 of which may be non-ambulatory. The facility has a waiver for 7 hospice residents. During today’s visit, the facility had a census of 164 residents. The Administrator for the facility is Jessica Sommer and their certificate was valid and current. During today’s visit, LPA toured the facility and inspected a random sampling of resident rooms, common bathrooms, facility kitchen, common areas, and outside space. LPA observed a water fountain near the facility entrance that held approximately 5 inches of standing water and was not fenced, covered or made inaccessible to residents. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured in a random sampling of resident bathrooms and common bathrooms at 119.5, 118.0, 118.5, 117.7, and 105.6 degrees Fahrenheit. The facility’s internal temperature was measured at 75 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Karl Miller, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and label. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 35 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance and were associated to the facility. Continued on LIC809-C page… LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property, and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns. The General Manager will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days. The following deficiency was cited for an accessible body of water and noted on the attached LIC809-D page. Additionally, a civil penalty in the amount of $500 was assessed for an accessible body of water and noted on the attached LIC421IM form. An exit interview was conducted with General Manager Karl Miller, whose signature below confirms receipt of a copy of this report, LIC421IM, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jun 17, 2024

Allegation investigated: Facility staff did not ensure that medications were made inaccessible to residents, resulting in hospitalization

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow-up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to General Manager Karl Miller. During today's visit, LPA observed residents in care, reviewed facility records, and spoke to staff. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that facility staff did not ensure that medications were made inaccessible to residents, resulting in the hospitalization of Resident 1 (R1). Interviews with staff and outside sources and review of assessment records dated November 2022 revealed that R1 was not diagnosed with any cognitive impairment, was able to leave the facility unassisted, was not confused or disoriented, was able to follow directions and make their needs known, and was able to administer and store their own medications. Continued on LIC9099-C page… Unsubstantiated Interviews and review of communications between the facility and R1’s physician revealed that R1 was approved to self-administer and store multiple medications, including Temazepam. Interviews and medication orders revealed that R1 was approved to self-administer Temazepam until November 10th, 2023, and that facility staff began administering R1’s Temazepam on November 10th, 2023. Interviews with staff and outside sources revealed that after R2’s eviction, R1 was relocated to another apartment within the facility. During the move, staff searched R1’s apartment for any medications and located several medication bottles which were entered into the facility’s central medication storage, including a bottle of Temazepam. Interviews with staff and outside sources revealed that prior to November 10th, 2023, R1 was permitted to reorder medications and it was possible that R1 had ordered an additional bottle of Temazepam that staff were not aware of and had not found during R1’s move to a different apartment. Additionally, R1’s prescription for Temazepam was written to be administered as needed, which allowed for the possibility for R1 to have multiple bottles of the medication if R1 ordered new bottles monthly, which R1 was approved to do. Interviews with staff and outside sources did not reveal concerns that staff had intentionally neglected to collect all medications from R1’s possession once R1 was no longer approved to self-administer and R2 had a history of hiding R1’s medications while R2 was living with R1. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with General Manager Karl Miller, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22). Review of multiple communications between R1’s physician and the facility during 2023 revealed that R1 was approved to self-administer their medications. Review of reports submitted to the Department by the facility revealed that on November 15th, 2023, R1 was hospitalized due to a suspected medication overdose. Facility generated reports and interviews with staff and outside sources revealed that at around 9:40am, R1 refused to take their medications and made suicidal comments to Staff 1 (S1). S1 questioned R1 regarding the comments but R1 did not provide any additional information. S1 informed the Health and Wellness Director (HWD) verbally, R1’s son via telephone, and R1’s physician via fax directly following the interaction with R1, and placed R1 on hourly safety checks. Interviews with S1 revealed that while R1 was placed on hourly checks, S1 visually observed R1 at around 10:00am and 10:15am during additional attempts to give R1 their medications, which R1 refused both times. At around 10:40am, R1’s son arrived at the facility and voiced concerns that R1 was not answering the telephone. Interviews with R1’s son revealed that upon entering R1’s room, R1 was observed to be non-responsive. R1’s son activated the emergency pull cord and S1 and another staff arrived promptly. Interviews did not provide clear information on if R1’s son or facility staff called 911, but interviews did confirm that 911 was contacted at around 10:45am for R1’s condition. R1 was transported to the hospital and admitted around 11:40am. While at the hospital, R1 received treatment for a medication overdose of Temazepam. R1 was discharged from the hospital and returned to the facility 10 days later, on November 25th, 2023. Interviews with staff and outside sources revealed that R1 was in a relationship with another resident, Resident 2 (R2) prior to living at the facility and they had moved into the facility together. Interviews with staff and outside sources revealed that R2 assisted R1 in medication management and storage and would occasionally accompany R1 to medical appointments. Staff and outside sources described R2 as having episodes of verbal and physical aggression towards R1 and had controlling behaviors regarding R1’s medications. R2 had a history of hiding and preventing R1 from taking prescribed medications. Interviews revealed that R2 was evicted from the facility due to R2’s aggression towards R1 approximately one month prior to R1’s medication overdose on November 15th, 2023. Staff expressed beliefs during interviews that R1 experienced some confusion and difficulty with adapting to R2’s absence after R2’s eviction. Continued on LIC9099-C page…the state’s words, verbatim · CDSS document, May 29, 2024 · control 08-AS-20231117104930

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with General Manager Karl Miller. During today's visit, LPA partially toured the facility, including a random sampling of resident rooms, reviewed facility records, observed and spoke with residents. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. No deficiencies were cited on today's date. An exit interview was conducted with General Manager Karl Miller, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, May 29, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to General Manager Karl Miller and Health and Wellness Manager Martha Grant. During today's visit, LPA provided the General Manager and Health and Wellness Manager consultation and technical assistance regarding reporting requirements, resident assessments, level of care needs, and eviction procedures. No deficiencies were observed or cited during today's visit. An exit interview was conducted with General Manager Karl Miller, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).the state’s words, verbatim · CDSS document, Nov 20, 2023