Finest Living at Crestwood

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit. LPA was greeted by staff upon arrival and LPA explained the reason for today's visit. Administrator Adelaida (Aida) Cruz arrived at 03:45PM. Entrance interview conducted. Beginning at 03:57PM LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers are fully charged and last serviced on 01/26/2025. RECORD REVIEW: Began at 03:35PM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Four (4) staff files observed were in compliance with regulation. Five (5) resident files were reviewed. None (0) of the five (5) resident files had completed reappraisals. COMMON AREAS: This includes the living room, family room, and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. The facility has two (2) fireplaces - one (1) in the living room and one (1) in the family room. Both were observed to be adequately screened. BATHROOMS: There are three (3) bathrooms; two (2) are shared and one is in a private bathroom. Restrooms were observed to be equipped with slip-resistant surfaces. Grab bars were observed in the bathrooms. At 04:05PM, water temperature measured at 137.5 degrees Fahrenheit in the hall bathroom. Report Continued on LIC 809-C BEDROOMS: There are seven (7) total bedrooms in the facility; six (6) bedrooms are designated for private resident use and there is one (1) staff room. The staff room is kept locked. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. GARAGE: Garage was observed locked and contained laundry area, extra perishable food, PPE, incontinence supplies, and additional chemical storage. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises. KITCHEN: LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Cleaning supplies are stored under the sink in a locked cabinet. Knives are stored in a locked drawer in the kitchen. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly. Emergency disaster plan was observed to be complete and updated annually, as required. MEDICATION REVIEW: Began at 04:58PM. Medications for two (2) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. INTERVIEWS: During today's visit, LPA interviewed two (2) staff and two (2) residents. No concerns were noted. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 27, 2026

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit. LPA met with Administraor Adelaida Cruz and explained the reason for the visit. Beginning at 1:24 p.m. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers are fully charged and last serviced on 1/17/2024. Smoke detectors and carbon monoxide detector were tested and functioned properly during today's visit. KITCHEN: LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable food, however there was an insufficient supply of non-perishable food (at least seven (7) days) and water (need a minimum of 18 gallons at all times). Cleaning supplies are stored under the sink in a locked cabinet. Knives are stored in a locked drawer in the kitchen. Daily medications are stored in a locked drawer in the kitchen. COMMON AREAS: This includes the living room, family room, and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. The facility has two (2) fireplaces - one (1) in the living room and one (1) in the family room. Both were observed to be adequately screened. BATHROOMS: There are three (3) bathrooms; two (2) are shared and one is in a private room. Restrooms were observed to be equipped with nonskid surfaces. Grab bars were observed in the bathrooms. The water temperature was measured and was found to be in compliance with regulation. Report Continued on LIC 809-C Report Continued from LIC 809 BEDROOMS: There are seven (7) total bedrooms in the facility; six (6) bedrooms are designated for private resident use and there is one (1) staff room. The staff room is kept locked. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. GARAGE: Garage was observed locked and contained laundry area, extra perishable food, PPE, incontinence supplies, and additional chemical storage. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises. RECORD REVIEW: Began at 2:45 p.m. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Four (4) staff files and six (6) resident files observed were in compliance with regulation. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill conducted in 1/5/2025. Emergency disaster plan was observed to be complete and updated annually, as required. MEDICATION REVIEW: Began at 3:30 p.m. Medications for two (2) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. INTERVIEWS: During today's visit, LPA interviewed two (2) staff, two (2) residents, and one (1) visitor. There were no concerns. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 9, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Questionable death. Staff did not properly care for resident's pressure injury. Resident sustained unexplained wound while in care.

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with the Administrator, Adelaida Cruz and explained the reason for the visit. Entrance interview. On 01/18/2024, the Department received a complaint regarding an allegation of questionable death. It was alleged that although Resident #1 (R1) was in hospice, R1 died as a result of poor care as R1 had a fever that could have been managed. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Rocio Flores to obtain additional pertinent documents. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... The initial 10-day complaint visit was conducted on 01/19/2024 by LPA B. Balisi, and subsequent visits were conducted by LPA M. Arroyo on 08/01/2024 and 10/17/2024. On 01/19/2024, LPA Balisi conducted a plant tour, interviewed staff and residents, and reviewed and obtained copies of pertinent documents at approximately 10:30 a.m. On 08/01/2024, LPA Arroyo conducted a plant tour, conducted interviews with the administrator and two staff between 10:35 a.m. and 12:15 p.m., and conducted a file review and obtained copies of pertinent documents starting at approximately 12:20 p.m. On 10/17/2024, LPA Arroyo conducted interviews with two staff and two residents between 11:25 a.m. and 12:05 p.m., and conducted a file review and obtained copies of pertinent documents at approximately 10:50 a.m. Hospice and Home Health records were also obtained and reviewed. Additionally, on 02/26/2024, Investigator Flores obtained a copy of R1’s death certificate. Records review and interviews conducted revealed Resident #1 (R1) was admitted to the facility on 04/26/2022 and expired on 01/16/2024. R1’s physician’s report, dated 04/25/2022, listed R1’s primary diagnosis as left distal femur fracture with a secondary diagnosis of dementia and paraplegia. R1 was identified as being confused/disoriented yet able to follow basic instructions. The report indicated R1 was not able to bathe, dress/groom, care for own toileting needs, and manage own cash resources. Additionally, R1’s ambulatory status was listed as bedridden. Information obtained from the hospice records revealed that on 01/10/2024, R1’s temperature measured 100.5 degrees Fahrenheit, and on 01/11/2024, R1’s temperature had gone up to 104.7 degrees Fahrenheit. On 01/11/2024, hospice nurse administered 1000mg of Tylenol as well as apply cooling measures such as ice behind the neck on the head, by the groin, and on trunk. One (1) hour later, hospice nurse checked R1’s temperature again and it had dropped down to 102.2 degrees Fahrenheit. Hospice nurse educated caregivers to continue cooling measures and give R1 Tylenol every four (4) hours instead of six (6) hours before leaving for the day. Hospice nurse continued checking R1’s temperature every day until R1’s passing on 01/16/2024. On 01/15/2024, R1’s temperature measured 99.9 degrees Fahrenheit, and on 01/16/2024, R1’s temperature measured 98.3 degrees Fahrenheit indicating R1 no longer had a fever days before their passing. Interviews conducted with staff revealed that residents are getting all their medications as prescribed as residents have not refused their medications when administered. Staff also stated that prior to R1’s passing, R1 was eating very little as they were having difficulty swallowing and drinking. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Furthermore, R1’s death certificate listed R1’s cause of death as Alzheimer’s disease, vascular dementia, atherosclerosis of the aorta and hyperlipidemia. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation, “questionable death” is deemed Unsubstantiated at this time. It was also alleged that staff did not properly care for resident’s pressure injury. It was reported that R1 had a stage 1 pressure wound on their bottom; however, on the date of R1’s death, the wound was at stage 3 as R1 was not being rotated accordingly. Per R1’s physician’s report, dated 04/25/2022, R1 had a history of skin condition or breakdown. Report also stated that R1 had a stage 2 pressure injury on right buttock upon admission to the facility. Similarly, per hospice notes, R1 was at risk for skin breakdown per Braden Scale assessment and the goal was to maintain skin integrity and be free from infection. Hospice nurse encouraged repositioning every two hours as tolerated by the resident to which the facility staff verbalized understanding. On the recertification, dated 10/06/2023, it indicated that R1 had three (3) open wounds; the first wound on the right buttock, stage 2; and two (2) more wounds on the sacrum which were a deep tissue injury and stage 2 from 08/19/2023, but were now classified as “closed” with surrounding tissue intact. Additionally, report stated that sacrum wound/skin tear had healed with no further intervention required by the nurse; however, would continue to monitor. On nurse visit, dated 10/09/2023 and 12/26/2023, wounds were assessed on R1, and hospice indicated on report that only one (1) wound remained open on the right buttock and was a stage 2. Additionally, during staff interviews, staff reported understanding and acknowledging both hospice and home health nurse advice and directions given to reposition all residents at least once every two (2) hours to prevent pressure injuries from forming or getting worst. Furthermore, interviews conducted with residents revealed that staff are constantly checking on them throughout the day. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation, “staff did not properly care for resident’s pressure injury” is deemed Unsubstantiated at this time. Report Continued on LIC 9099C... Report Continued from LIC 9099C... It was further alleged that resident sustained unexplained wound while in care. It was reported that R1 had a cut on their right arm which had not been patched up and it was unknown as to how R1 had sustained the cut. Record review of R1’s physician’s report and hospice notes revealed that R1 was at risk for skin breakdown. Staff was transparent and communicated with the hospice nurse every day during their visit as displayed on visit dated 01/10/2024, which stated staff reported to hospice that R1 had a change of condition. Also, per hospice notes, dated 01/14/2024, though it confirmed that R1 had a cut on their right elbow that measured 1.8 cm which the hospice nurse cleansed, dried, and covered with drey dressing. Upon arrival of the hospice nurse, they observed R1 lying on a hospital bed in a semi fowler position, with no pain, no shortness of breath, and R1 was tolerating procedure being conducted by hospice nurse well. This indicated that R1 was most likely unaware of the cut themselves. Additionally, although staff was unable to determine where the cut on R1’s arm came from, there were no signs of abuse by staff. Furthermore, resident interviews revealed they have no concerns with staff or living at the facility. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation, “Resident sustained unexplained wound while in care” is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy issued.the state’s words, verbatim · CDSS document, Nov 15, 2024 · control 29-AS-20240118100032

Allegation investigated: Staff is sleeping during shift.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial visit was conducted on 01/19/2024 by LPA B. Balisi. On today's visit, LPA Arroyo met with Administrator, Adelaida Cruz. Entrance interview. During the initial visit on 01/19/2024, LPA Balisi conducted a plant tour, interviewed staff, residents, and reviewed and obtained copies of pertinent documents at approximately 10:30 a.m. It was alleged that staff is sleeping during shift. It was reported that Staff #1 (S1) was sleeping on the couch on 01/11/2024. Information obtained during the course of the investigation reflected that S1 was indeed sleeping during their shift at the facility while they were supposed to be caring for R1. Report Continued on LIC 9099C... Substantiated Report Continued from LIC 9099... Additionally, LPA obtained photos which reflected S1 sleeping on the couch on the morning of 01/11/2024. Furthermore, interviews conducted with residents revealed that they have previously observed S1 sleeping on the couch multiple times while living at the facility. LPA attempted to contact S1 however, was unable to do so given S1 is no longer employed at the facility. Based on the information obtained and reviewed, the Department has sufficient evidence to support the allegation of “staff is sleeping during shift”. Therefore, this allegation is being deemed Substantiated at this time. Exit interview conducted. Report was reviewed, copy of report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 15, 2024 · control 29-AS-20240112085223

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 22, 2024

In addition to the rights listed in Section 87468.1, residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above, as S1 was sleeping during their shift, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2024

Plan of correction: The licensee will review and write a statement of understanding of regulations 87468.1 and 87468.2 and submit to CCL no later than 11/22/2024.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20240118100032). The purpose of the visit is to issue a citation for a deficiency observed during the initial complaint investigation. During the visit on 08/01/2024, interviews conducted with the administrator and staff revealed that Resident #1 (R1) moved into Room #3 when they were admitted to the facility 04/26/2022 and stayed in the same room until they expired on 01/16/2024. Per R1’s physician’s report, dated 04/25/2022, it lists R1’s ambulatory status as bedridden. However, the facility has an approved fire clearance to have one (1) bedridden resident in bedroom #5 only. Additionally, per report, it states R1 had dementia upon admission to the facility and R1 did not have an updated yearly medical assessment and reappraisal as stated per regulation. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 15, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Nov 22, 2024

All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as R1's resided in room #3 and is bedridden, but room #5 is the only room approved for bedridden, which posed an immediate health, safety or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Nov 15, 2024

Plan of correction: The licensee will review and write a statement of understanding of regulation 87202 and submit to CCL no later than 11/22/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(5) · Plan of correction due date: Nov 22, 2024

Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as R1 was admitted with a diagnosis on dementia and had not had a new medical assessment or reappraisal conducted since moving in, which posed a potential health and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2024

Plan of correction: The licensee will review and write a statement of understanding of regulation 87705 and submit to CCL no later than 11/22/2024.

Allegation investigated: Staff did not keep facility free of insects.

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit for the allegations listed above. Upon arrival LPA met with Alice Resolme and explained the reason for the visit. Licensee Adelaida Cruz could not be onsite at this time , but was contacted during the visit and stated Alice can sign in their place. At approx. 10:30am, LPA conducted physical plant, interviewed staff, residents and reviewed and obtained copies of pertinent documentation relevant to the investigation. It was reported that Staff did not keep facility free of insects, as it was alleged that there is an infestation of spiders and termites in Room #3, Resident #1 (R1)'s closet. During physical plant, LPA observed spider webs and four (4) spiders along the railing of R1's closet. LPA also observed multiple spider webs in room #5. LPA did not observe any evidence of termite infestation in any room. Substantiated continued from 9099 LPA did not observe spider webs in other four (4) bedrooms. LPA's interview with two (2) out of (4) residents revealed one resident observes spiders often, but staff are informed and they dispatch the spider immediately. One other resident interviewed stated they have never observed spiders or termites. The other two (2) residents declined to be interviewed. Based on information gathered during the visit, the Department has sufficient evidence to determine this allegation occurred. Therefore the allegation of Staff did not keep facility free of insects has been substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted and copy of the report and appeal rights provided to Licensee.the state’s words, verbatim · CDSS document, Jan 19, 2024 · control 29-AS-20240112085223

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 26, 2024

87303(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times...safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by Based on interviews and observations, the licensee failed to comply with the section cited above as evidence of spiders and spider webs were observed in multiple rooms, which poses a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 19, 2024

Plan of correction: Staff immediatly cleared spider webs and dispatched spiders. POC cleared during the visit.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At 10:05 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff Alex Garcia and informed them of the reason for the visit. Licensee Adelaida Cruz arrived shortly. At 10:22 a.m. the LPA conducted a tour of the physical plant with the staff and Licensee to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of two (2) living rooms, six (6) resident bedrooms, one (1) staff room, one (1) laundry room, two (2) communal restrooms and one (1) private resident restroom. The LPA observed fire extinguishers which were fully charged, however they were last serviced in October 2022. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings. Kitchen: During the facility tour at 10:22 a.m. the kitchen appeared clean and the appliances and fixtures functional. LPA observed sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are always available for the residents. Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. At 10:37 a.m. the auditory alarm on the exit door to the backyard in room #5 was observed to not be working. During the tour the LPA observed hygiene/grooming items in rooms #2 ,#3, and #4, and all rooms in the facility were unlocked and open. The facility serves residents with dementia and residents who are at risk if allowed direct contact with grooming/hygiene items. At 10:40 a.m. the LPA observed Aquaphor healing ointment in room #4. At 10:46 a.m. the LPA observed, stained walls, stained bed sheets, two boxes of powdered Vitamin C, and a tube of athletes foot ointment in room #3. Report will continue on LIC809-C. Bathrooms: The LPA observed all bathrooms with functional fixtures, grab bars and non-skid mats. At 10:33 a.m. the LPA observed a bottle of Lysol toilet bowl cleaner in the communal resident bathroom, and observed the restroom to be unkempt with stains in the toilet, walls and upswept floor. At 10:50 a.m. the LPA observed the restroom inside room #3 unkempt with stains and residue in the shower floor, toilet and on the floor. At 11:24 a.m. water temperature in resident’s restroom was measured at 120 degrees Fahrenheit. Common Areas: These included the living rooms and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in both livings room, which were covered with a screen. The facility maintained a comfortable temperature of 70 degrees. There were no obstructions and/or tripping hazards throughout the facility. At 11:16 a.m. the LPA observed the living room screen door not properly installed , and observed the auditory alarm on the sliding glass door to not be properly working. The garage & Laundry room: The LPA observed the laundry room locked. The laundry room is connected to the garage and attic, which are both being used for storage. Cleaning supplies and disinfectants are kept in locked cabinets. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. Infection Control: The home has an adequate supply of Personal Protection Equipment (PPE) and can obtain additional supplies. Record Review: At 11:30 p.m. a review of facility files was initiated. The LPA reviewed five (5) out of six (6) resident files. The LPA identified that one out of five residents (R1) requires an updated physician’s report (LIC602), and an updated appraisal needs and service plan due to the diagnosis of dementia. Two (2) out of five (5) residents (R2,R3) require an updated appraisal/ needs and service plan LIC625. The LPA reviewed five (5) of five (5) staff files. One out of five staff (S1) did not have Tuberculosis test results on file. Interviews: The LPA conducted two (2) resident Interviews. No immediate concerns were voiced. Due to time constraints the LPA will return to complete the annual at a later date. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Licensee.the state’s words, verbatim · CDSS document, Jan 9, 2024