Foothill Village Senior Living

Allegation investigated: Staff did not meet the resident's toileting care needs Staff did not provide proper supervision to resident in care Staff did not provide proper food service to resident in care

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to this facility to deliver complaint findings. LPA Lund met with Excutive Director Viridiana Ortiz Rangel and explained the purpose of the visit. Census 73 Staff did not meet the resident's toileting care needs- LPA Lund reviewed facility paperwork, interviewed reporting party, staff, and witness. Based on reviewed facility paperwork, interviews with staff, reporting party, and witness. LPA Lund reviewed hourly bathroom charts for Resident (R1) from 2/5/2026 from 5/26/2026 which states that staff did hourly checks on R1 to see if R1 is wet or dry. Staff interviewed stated that they would do hourly checks on R1 to see if R1 was wet or not. Reporting Party and witness stated that R1”s toileting care needs are being met. Unsubstantiated Based on reviewed facility paperwork, interviews with staff, reporting party, and witness, on the information provided, it was unclear if staff did not meet the resident's toileting care needs, therefore the allegation was deemed UNSUBSTANTIATED. Staff did not provide proper supervision to resident in care- LPA Lund reviewed facility paperwork, interviewed reporting party, staff, and witness. Based on reviewed facility paperwork, interviews with staff, reporting party, and witness. LPA Lund reviewed hourly bathroom charts for Resident (R1) from 2/5/2026 from 5/26/2026 which states that staff did hourly checks on R1. Staff interviewed stated that they would do hourly checks on R1. Reporting Party and witness stated that the facility is providing supervision to R1. Based on reviewed facility paperwork, interviews with staff, reporting party, and witness, on the information provided, it was unclear if staff did not provide proper supervision to resident in care, therefore the allegation was deemed UNSUBSTANTIATED. Staff did not provide proper food service to resident in care- LPA Lund reviewed facility paperwork, interviewed reporting party, staff, and witness. Based on reviewed facility paperwork, interviews with staff, reporting party, and witness. LPA Lund reviewed meal tracking form from 4/2/2026 through 5/25/2026 for Resident (R1) which would state if R1 would eat or not. Reporting Party and witness stated that R1 needs including meals are being met from the facility. Based on reviewed facility paperwork, interviews with staff, reporting party, and witness, on the information provided, it was unclear if staff did not provide proper food service to resident in care, therefore the allegation was deemed UNSUBSTANTIATED. As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of 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 conducted and report left.the state’s words, verbatim · CDSS document, Aug 20, 2026 · control 27-AS-20260205082556

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jason Lund arrived at the facility unannounced to conduct a one year required visit. LPA Lund explained the reason for the visit to Director of Community Business of Care Viridiana Ortiz Rangel. Census: 78 This facility is a four-story apartment building that is licensed to serve 78 residents. The first floor has memory care and the second and third floors have assisted living. The fourth floor is independent living. LPA Lund and Director of Community Business of Care Viridiana Ortiz Rangel tour/inspected the facility. The inspection included the interior and exterior areas of the facility. The physical plant inspection includes the dining area, kitchen, storage rooms, common areas, resident bedrooms and bathrooms, laundry rooms, and outside patios to ensure compliance with Title 22 regulations. LPA Lund inspected the kitchen and observed two-day supply of perishable food and seven-day supply of non-perishable food, located in a storage room, walk-in freezer, and walk-in refrigerator. Food is properly stored. Appliances are in working order. LPA Lund inspected the common areas intended for resident use. These were clean and odor-free. These areas have adequate furnishing, lamps, and lighting, as well as decorations on the wall. The outside patios on both the assisted living and memory care floors have outdoor chairs and tables in good repair, with views of the surrounding trees and hills. LPA Lund inspected the resident living quarters. These are clean and odor-free. Apartment units have updated appliances and fixtures, operable and intact windows and doors, and flooring in good repair. The water fixtures work, toilets flush, grab bars are present and sturdy, and non-slip mats are in good condition. Hot water temperature was measured at 117.4 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit. LPA Lund inspected the locked central medication storage area. All medication is in a locked medication cart. LPA Lund reviewed eight resident files and five staff files. Each staff file contained the required documentation, including First Aid/CPR certification, criminal background clearance, and TB test results. Each resident file contained the required documentation, including pre-appraisals, admission agreements, and physician reports. Inside temperature was within the required regulatory range. Carbon monoxide detectors and fire extinguisher (7/10/2025) in working condition and in compliance. There were evacuation chairs in the stairwells on each floor. The elevators were inspected on 08/08/2026. No deficiencies were cited during this visit. An exit interview was held and report left.the state’s words, verbatim · CDSS document, May 27, 2026

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

A Noncompliance Conference (NCC) was conducted today on May, 12,2026, via Microsoft Teams. The purpose of the NCC was to discuss the complaints since licensure. Present at today’s NCC were the Sacramento South Regional Office Adult and Senior Staff, Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Lisa Rios, Licensing Program Analyst (LPA) Jason Lund. Present from Foothill Village Senior Living, Shayan Gheisar, Executive Director, Wyatt Mello, CEO, Andrea Hoffman, Director of Clinical, and Joel Goldman, Counsel. The non-compliance conference process was explained during this meeting to include the administrative process. The NCC is being held due to non-compliance. Since facility licensure on 5/18/2021 the facility has a total of 9 complaints, with 2 case management with Deficiencies visits. The facility has had 5 Type A citations with 3 under appeal and 7 Type B citations. The deficiencies noted are: Deficiencies: Incidental and Medical, Reporting Requirements, Managed Incontinence, Basic Services Requirements, Personal Rights, Personnel Requirements, Resident Records, Infection Control, Care of Persons with Dementia, Buildings and Grounds, Care and Supervision, and Food Service. Issues discussed during the Non-Compliance Conference were: · Personal Rights of Residents · Administrator- Qualifications and Duties · Emergency Disaster Plan · Building and Grounds The facility has stated they will do the following to achieve continued and substantial compliance: · Licensee will conduct inspections of all resident rooms to ensure all non-surge protected multi-plut outlet extenders are removed from resident rooms. · Licensee will conduct inspections of all resident rooms to ensure all space heaters are removed from resident rooms. · Licensee will develop an emergency disaster plan that includes procedures for assistive medical devices for oxygen equipment. · Facility staff will email CCLD facility plans to achieve compliance by 05/22/2026 5:00 PM. In addition, all requested above documents shall be emailed to CCLD by 05/22/2026 5:00 PM. The department has requested documents regarding the new administrator the following documents: A letter from the licensee and/or Board appointing the individual as the Administrator. · LIC308 · Copy of your current Administrator Certificate · Any documentation that meets the education and/or experience requirements, if applicable · A check of guardian/LIS is conducted to ensure the appointed individual is fingerprinted and associated to the facility. · LIC 200 signed by the licensee or designee. · LIC 500 to indicate the days/hours the Administrator is in the facility. · LIC 501 so that we can determine if the Administrator meets the education / experience requirement. In addition, at this meeting the notified Licensee/Administrator was advised future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and further potential administrative action. Community Care Licensing Department (CCLD) will do the following: · Increase Monitoring to quarterly visits. · TSP 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. Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited during this visit. An exit interview was conducted and copy of this report was provided via email and an electronic email receipt confirms receiving these documents.the state’s words, verbatim · CDSS document, May 12, 2026

Type of visit: Case Management - Deficiencies

On 8/29/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom visited the facility unannounced to conduct a case management visit regarding the fire that occurred at the facility the morning of 8/26/2025. LPA Lindstrom met with Administrator Jacob Harryman (S1), introduced herself, and explained the purpose of the visit. LPA Lindstrom interviewed S1, S2, and S3. S1 stated that on 8/26/2025, a fire broke out in the living room of a resident’s apartment (R1). R1 was in the apartment at the time of the fire. Staff (S2) rescued R1 within moments of the smoke alarm sounding in their apartment and staff evacuated all residents and staff from the facility within ten minutes. S2 stated that they determined that the alarm was sounding in R1’s apartment, entered R1’s room, and saw R1 sitting in a chair on their balcony. S2 observed smoke and flames about a foot high in the corner of the living room near an outlet located on the back of a kitchen counter. S2 stated that they observed R1’s oxygen concentrator in this corner near the outlet and that the oxygen concentrator tubing that stretched from the machine, across the living room, and beneath the balcony door was on fire. S2 went onto the balcony, removed the oxygen tubing canula from R1’s nose, lifted R1 up, and carried them out of the apartment to safety. S2 stated that they called 911 at 7:07 AM and that the fire department arrived approximately ten minutes later. S2 stated that R1 uses an oxygen concentrator at all times. S2 stated that staff did not supply oxygen to R1 from the time she was evacuated from her apartment until the fire department arrived on scene. S1 stated that R1 was transported to the local hospital for smoke inhalation. (Continued on 809-C) The LPA inspected R1’s apartment. LPA Lindstrom observed the outlet in the living room where the fire started. The counter wall with the outlet had black scorch marks on it, as did the adjacent carpeting and wall. LPA Lindstrom observed a thin, blackened line that ran from the outlet area, across the living room carpet, under the balcony door, and across the balcony floor, to within approximately ten inches of the chair R1 had been sitting in. LPA Lindstrom observed charred remains of oxygen concentrator tubing on the balcony floor. The LPA also observed the uncharred remains of tubing, including the cannula, and approximately two and half feet of line coming from it. LPA Lindstrom observed a photograph of damaged items removed from R1’s room. The damaged items included a rectangular device approximately 3 feet wide by 2 feet deep. S1 stated that they had never noticed the electric fireplace in R1's apartment. S2 stated that the electric fireplace had been in the resident’s room since Fall 2023 when the resident moved in. S3 stated that she had observed the electric fireplace in R1’s room since early 2024. On the day of the fire, the electric fireplace and the oxygen concentrator had been plugged into a non-surge protected outlet extender located at the outlet where the fire started. LPA Lindstrom reviewed the facility’s Admission Agreement, titled “Foothill Village California Residency Agreement.” R1 signed this agreement on 9/20/2023. This admission agreement was written by Integral Senior Living, which was the previous management company for the facility. In May 2025, Red Bench Living assumed management of Foothill Village. The LPA observed that on page 6 of the admission agreement that R1 signed, there is a section titled “Explosives, Firearms, and Flammables.” This section says: “No explosives, flammable materials, or firearms may be brought into any area of the community. This includes weapons, barbecue equipment, gasoline, motor oil, space heaters, and candles.” LPA Lindstrom reviewed the facility’s LIC610E Emergency and Disaster Plan for Residential Care Facilities for the Elderly. The LPA reviewed Section C of page 6, which lists procedures that address, “Operating assistive medical devices that need electric power for operation, including but, not limited to oxygen equipment…” The facility made no mention of plans for assistive oxygen equipment on the form. S2 stated that facility staff did not administer oxygen to R1 between the time of evacuation from their apartment and arrival of the fire department. (Continued on 809-C) California Code of Regulations (CCR), Title 22, Section 87468.1(a)(2) states that residents shall have the personal right “to be accorded safe, healthful and comfortable accommodations, furnishings and equipment.” California Code of Regulations (CCR), Title 22, Section 87405(b) states that the facility administrator “shall have the responsibility and authority to carry out the policies of the licensee.” California Code of Regulations (CCR) Title 22, Section 87212(b)(2)(A) states that “each facility shall have a disaster and mass casualty plan of action…” that includes a fire safety plan. This facility is hereby cited per 22 CCR Section 87468.1(a)(2), Section 87405(b), and Section 87212(b)(2)(A). Due to a violation involving administrator qualifications and duties, an immediate civil penalty of five hundred dollars ($500) was hereby assessed. The immediate civil penalty was assessed using the LIC412IM paper form. The Administrator and Licensee were informed that a civil penalty assessment based on Health and Safety Code Section 1569.49(f) is currently under review and may be assessed at a later date. Once this has been determined, CCLD personnel will return to assess the civil penalty, if necessary. An exit interview was held with the Administrator. Appeal rights and a copy of this report were left with the Administrator.the state’s words, verbatim · CDSS document, Aug 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 5, 2025

Personal Rights of Residents (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights (2) To be accorded safe, healthful and comfortable accomodations, furnishings and equipment. This requirement was not met as evidenced by:: The facility failed to remove the non-surge protector multi-plug outlet extender that caught on fire.the state’s words, verbatim · CDSS document, Aug 29, 2025

Plan of correction: Licensee will conduct inspections of all resident rooms to ensure all non-surge protected multi-plut outlet extenders are removed from resident rooms.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(b) · Plan of correction due date: Sep 5, 2025

Administrator-Qualifications and Duties (b) The administrator of a facility shall have the responsibility and authority to carry out the policies of the licensee. This requirement is not met as evidenced by: Based on the admissions agreement stating that space heaters are not allowed and the facility allowed resident to have a fireplace space heater.the state’s words, verbatim · CDSS document, Aug 29, 2025

Plan of correction: Licensee will conduct inspections of all resident rooms to ensure all space heaters are removed from resident rooms.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87212(b)(2)(A) · Plan of correction due date: Sep 5, 2025

Emergency Disaster Plan (b)...The plan...include (2) Plan for evacuation including: (A) Fire safety plan. This requirement was not met as evidenced by: Section C on page 6 of LIC610 did not include mention of oxygen equipment.the state’s words, verbatim · CDSS document, Aug 29, 2025

Plan of correction: Licensee will develop an emergency disaster plan that includes procedures for assistive medical devices for oxygen equipment.

Allegation investigated: Licensee does not ensure staff are in good health and capable of performing duties and assigned tasks Staff do not ensure residents rooms are kept in clean sanitary conditions Staff do not ensure facility is kept free of mal odors Staff do not ensure residents are provided with clean linens Licensee does not ensure residents personal belongings are kept safely secured Staff do not ensure medications are dispensed as prescribed

On 05/07/2025, Licensing Program Analysts (LPAs) Arielle Pascua and Triel Lindstrom arrived unannounced to this facility to conduct a complaint visit. LPAs met with Facility Designated Administrator (FDA), Jacob Harryman and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current census was 50. A brief interview with FDA Harryman was conducted. Allegation: Licensee does not ensure staff are in good health and capable of performing duties and assigned tasks It was alleged that the licensee does not ensure staff are in good health and capable of performing duties and assigned tasks. During the course of this investigation, LPA reviewed facility files and conducted staff interviews. Based on interviews conducted with 7 staff members, 7 out 7 staff members state that they believe that they are in good health and are able to conduct their job duties as expected. 7 out 7 staff members deny that other staff members are unable to perform their job duties. Unsubstantiated A review of 7 staff records show that each staff member was given a health screening as well as a TB test. All records show that 7 out 7 staff members reviewed were provided clearance to work at the facility based on their health screening. In addition, LPA conducted observations and found no indication that the facility staff could not conduct their job duties. Based on the information gathered, there is not sufficient information that the licensee does not ensure that facility staff are in good health and capable of performing duties and assigned tasks. Allegation: Staff do not ensure residents rooms are kept in clean sanitary conditions It was alleged that facility staff do not ensure resident rooms are kept clean and sanitary conditions. During the course of this investigation, LPA conducted observations and conducted resident staff interviews. Based on interviews conducted with 7 staff members, 7 out 7 staff members deny that they do not ensure residents rooms are kept clean and sanitary. 7 out 7 staff members state that some residents can be messy but ensure to communicate this with management to ensure that their needs are being including keeping the resident rooms in a clean and sanitary manner. An interview with 7 residents were conducted. 7 out 7 residents state that the facility ensure that their rooms are kept tidy and clean. 7 out 7 resident deny that they do not get their rooms cleaned on a weekly basis. In addition, LPA conducted a tour of several resident bedrooms and found that all rooms were kept clean and sanitary. Based on the information gathered, there is not sufficient evident to prove that the staff do not ensure resident rooms are kept in clean and sanitary conditions. Allegation: Staff do not ensure facility is kept free of mal odors It was alleged that facility staff do not ensure facility is kept free of mal orders. During the course of this investigation, LPA conducted tours of the facility on 02/05/2025 and 05/07/2025 including but not limited to the main areas, dining area, living areas, resident bedrooms, and bathrooms. LPA was not able to smell any type of odors throughout the facility that was considered as malodorous. Based on the information gathered, there is not sufficient evidence to prove that the facility staff do not ensure facility is kept free of mal odors. Allegation: Staff do not ensure residents are provided with clean linens It was alleged that facility staff do not ensure that residents are provided with clean linens. During the course of this investigation, LPA conducted resident and staff interviews and conducted tours of resident bedrooms. Based on interviews with 7 staff members and 7 residents, 7 out 7 staff members deny that they do not provide residents with clean linens. It was stated that cleans are cleaned once a week as part of their admissions agreements or as needed through their care plan. 7 out 7 residents state that they are able to obtain clean linens if requested but prefer to have their own. LPA conducted a tour of several resident bedrooms and observed that all resident bedrooms had clean linens. Based on the information gathered, there is not sufficient evidence to prove that the facility does not ensure that residents have clean bed linens. Allegation: Licensee does not ensure residents personal belongings are kept safely secured It was alleged that the licensee does not ensure residents personal belongings are kept securely. During the course of this investigation, LPA reviewed facility records and conducted resident interviews. Based on interviews conducted, 7 out of 7 residents deny that their belongings are not kept safe. 4 out 7 residents have been living at this facility for up to 4 years and have no issues. 3 out 7 residents have lived at the facility for up to 1 year and report no issues regarding their personal belongings. A review of the facilities theft and policy was also conducted. This facility has a locked and secured space for the resident's belongings in resident rooms and may provide a lock for the dresser at the residents bedside as requested. Based on the information gathered, there is not sufficient evidence to prove that the facility does not ensure resident personal belongings are kept safely secured. Allegation: Staff do not ensure medications are dispensed as prescribed It was alleged that the staff do not ensure medication are dispensed as prescribed. During the course of this investigation, LPA reviewed facility records and conducted staff interviews. Based on interviews conducted 5 out 5 staff members deny that medications are not being provided as prescribed. It was stated by most residents obtain medication through a bubble pack system and are changed according to the doctor’s orders. An interview with 5 residents were attempted however, due to medication conditions, 2 out 2 residents did not know what medications were taken throughout the day. 3 out 5 residents reported no issues regarding their medication. A review of the Medication Administrator Record and compared to current medication. There was nothing to indicate that staff was not providing medication as prescribed. Based on the information gathered, there is not sufficient evidence to prove that the staff do not ensure medications are dispensed as prescribed. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, May 7, 2025 · control 27-AS-20250131132652

Type of visit: Required - 1 Year

On 05/07/2025, Licensing Program Analysts (LPA) Triel Lindstrom and Arielle Pascua arrived at the facility to conduct an unannounced annual inspection. LPAs Lindstrom and Pascua identified themselves, explained the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). DFA Jacob Harryman (Administrator Certificate # 6071704740, expiration date 07/30/2026) was on-site and a brief interview followed. DFA Harryman led LPAs Lindstrom and Pascua on a tour of the facility and accompanied LPAs on their inspection of interior and exterior areas of the facility. This facility is a four-story apartment building that is licensed to serve 78 residents, including 59 nonambulatory and 19 ambulatory individuals. The facility offers licensed care on the first through third floors, including memory care on the first floor and assisted living on the second and third floors. The fourth floor is independent living. It has a hospice waiver for 6. Its fire clearance was issued by Angels Camp Fire Department on 02/08/2021. The current census is 50 residents in licensed care. The annual inspection began with a records review. LPA Lindstrom requested and reviewed three resident files and five staff files. Each staff file contained the required documentation, including First Aid/CPR certification, criminal background clearance, and TB test results. Each resident file contained the required documentation, including ofpre-appraisals, admission agreements, and physician reports. LPAs Lindstrom and Pascua then inspected the physical plant including but not limited to the dining area, kitchen, storage rooms, common areas, resident bedrooms and bathrooms, laundry rooms, and outside patios to ensure compliance with Title 22 regulations. The Administrator Certificate, Facility License, Complaint Hotline Poster, Ombudsman information, menus, activity calendars, and resident personal rights are publicly posted. LPAs Lindstrom and Pascua toured the kitchen and observed a two-day supply of perishable food and seven-day supply of non-perishable food, located in a storage room, walk-in freezer, and walk-in refrigerator. Food is properly stored. Appliances are in working order, except for the AC unit in the walk-in freezer. DFA Harryman stated that repairs are scheduled for tomorrow. The range hood was recently cleaned. LPAs Lindstrom and Pascua observed food debris and grease on the sides of appliances, walls, lower shelves of counter units, slip mats, and floors of the kitchens and walk-ins. Additionally, LPAs Lindstrom and Pascua observed that the linoleoum floor tiles in the kitchen and the carpet in the passage way leading into the kitchen is discolored over a large portion of it. LPAs Lindstrom and Pascua then toured common areas intended for resident use. These were clean and odor-free. These areas have adequate furnishing, lamps, and lighting, as well as decorations on the wall. Several residents were observed sitting in these areas, talking to each other and guests. The outside patios on both the assisted living and memory care floors have outdoor chairs and tables in good repair, with views of the surrounding trees and hills. LPAs Lindstrom and Pascua toured resident living quarters. These are clean and odor-free. Apartment units have updated appliances and fixtures, operable and intact windows and doors, and flooring in good repair. The water fixtures work, toilets flush, grab bars are present and sturdy, and non-slip mats are in good condition. LPA Pascua measured the temperature of the hot water in one resident bathroom sink. Hot water temperature was measured at 118.4 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit. LPAs Lindstrom and Pascua then toured the locked central medication storage area. All medication is in a locked medication cart. Along with staff, LPA Lindstrom reviewed and compared medication to medication administration records. Inside temperature was within the required regulatory range. LPA Lindstrom tested two smoke and carbon monoxide detectors and found them in working condition. There were evacuation chairs in the stairwells on each floor. The elevators were inspected on 04/12/2025. LPA Lindstrom requested that updated copies of these documents be emailed to her by 5:00 PM on May 14, 2025: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (4) LIC 610 Current Emergency Disaster Plan (5) Proof of Current Liability Insurance (6) LIC 500 Current Personnel Report (7) LIC 309 Administrator Organization A technical violation was issued for Section 87303(a). As a result of this annual visit, the facility is in compliance with Title 22 Regulation. There are no deficiencies at this time. An exit interview was conducted with DFA Jacob Harryman, and a copy of this LIC 809 report was provided to the facility.the state’s words, verbatim · CDSS document, May 7, 2025

Type of visit: Case Management - Incident

On 9/19/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management in relation to an incident report that was received. LPA Jensen met with Executive Director Jacob Harryman and Memory Care Director Angelica White. LPA Jensen received an incident report wherein an assisted living resident (R1) reported vomiting black blood. LPA Jensen reviewed R1's Physician's Report (LIC 602), Pre-Admission Appraisal, Medication Administration Record (MAR), Needs and Service Plan, Progress Notes and incidents reports from 2024. LPA Jensen observed an LIC 602 that indicates R1 requires a mechanical soft diet. LPA Jensen also observed that the Needs and Service Plan did not indicate any kind of special diet requirements. As a result of record reviews and interviews conducted with the Executive Director and Memory Care Director it was learned that R1's LIC 602 was completed when R1 left a skilled nursing facility and mechanical soft diet was no longer required after he returned to the facility. A physcian's order for regular diet is now on file. It was also learned that the incident reported was unrelated to R1's dietary needs. LPA Jensen provided technical assistance and recommended that all LIC 602's are checked for accuracy, updated as needed and that facility staff should ensure that Needs and Service Plans reflect the physician report indicators. No citations were issued as a result of this visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 19, 2024

Type of visit: Required - 1 Year

THIS IS A CONTINUATION OF THE REQUIRED 1 YEAR ANNUAL COMMENCED ON 5/15/24 On 5/16/24 Licensing Program Analyst Maja Jensen arrived at facility unannounced to continue a required 1 year annual inspection. LPA Jensen met with Executive Director Mary McClure and explained the purpose of today's visit. On 5/15/24 LPA Jensen toured the grounds and physical plant. All paths on the grounds were observed to be free of obstruction. There are shaded areas and patio furniture for the residents to enjoy outdoor activities. There are no bodies of water on the property. LPA Jensen observed a broken hand rail on an exterior patio that was marked with caution tape. LPA Jensen confirmed with the Maintenance Director and the Executive Director that the rail has been broken for approximately one week and repairs are currently in process. LPA Jensen also reviewed documentation confirming a contractor is scheduled for repairs as of 5/17/24. LPA Jensen toured the physical plant. The facility was observed to have adequate furnishings and lighting. There are night lights available in the hallways. The facility maintains an adequate supply of linens. All medications and toxins are inaccessible to residents in care. The first aid supplies were observed to be complete. There is an evacuation chair located in the stairwell. The elevator in the main hall was determined to be in working order. The fire extinguishers were last serviced in January of 2024 and are in compliance. The carbon monoxide detectors were tested and in good working order. The facility is equipped with an interior fire sprinkler system. LPA Jensen toured the kitchen. A two day supply of perishable food was observed and a 7 day supply of non-perishable food was observed. On 6/16/24 the lunch menu consisted of Grilled Ruben on Rye with beet salad and jello. Various snacks, desserts and fresh fruits were also available. The menu is posted in a variety of places and a menu is also printed for the individual rooms. LPA Jensen toured the memory care section of the building while accompanied by staff 1 (S1).The facility has two designated sections for memory care. LPA Jensen pointed out to S1 that 1 of 2 memory care sections has a distinct smell and is not being kept free of incontinence odor. LPA Jensen interviewed 2 staff members that state the incontinence odor in the memory care section have been an ongoing issue. LPA Jensen interviewed the Executive Director who confirmed that the carpet in the memory care unit is scheduled to be replaced. LPA Jensen reviewed and obtained a copy of the invoice for carpet replacement in this section of the building. All required postings were placed in easily viewable locations. LPA Jensen requested and received updated copies of the LIC 500, LIC 308 and liability insurance. LPA Jensen reviewed 5 staff files and determined them to be compliant. LPA Jensen reviewed 10 resident files and determined them to be well organized, current and compliant. The inspection tool was used during the course of this annual inspection. Deficiencies are being cited pursuant to the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 16, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87265(b)(3) · Plan of correction due date: May 23, 2024

Managed Incontinence ...the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by: Based on LPA Jensen's ability to smell incontinence odors in the facility. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 16, 2024

Plan of correction: The Licensee is replacing the carpet and offering new incontinence care products that help to eliminate odors. An in-service training will also be conducted by POC due date with proof of correction to be sent to Department.

Type of visit: Required - 1 Year

On 5/15/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual visit. LPA Jensen met with Mary McClure and explained the purpose of today's visit. The facility has 4 floors. The 4th floor is used for independent living. The 2nd and 3rd floors are for assisted living and the first floor is for dementia care. During the course of the visit LPA Jensen toured floors 1 through 3. LPA Jensen also toured the grounds. Due to time constraints this annual will require a continuation. An exit interview was conducted a copy of this report was provided.the state’s words, verbatim · CDSS document, May 15, 2024

Allegation investigated: Facility is odiferous Facility is dirty

On 4/15/24 at approximately 11:45am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open an investigation in to the above listed allegations. LPA Jensen met with Angelica White, Resident Care Director, and explained the purpose of today's visit. During the course of the visit, LPA Jensen took the elevator down to the unit of the facility known as "Transitions". LPA Jensen detected an odor from the elevator. Once LPA Jensen arrived at the lower floor at Transitions, the odor was stronger. There was a definite discernable difference between the main lobby and the Transitions unit in terms of detectable odor. LPA Jensen interviewed the Resident Care Coordinator and the Maintenance Director who both confirmed that there is an odor on occassion likely eminating from a sewer pipe that connects with a bathroom on the lower level. LPA Jensen inspected the carpets and observed and photographed in excess of 15 significantly sized stains in the carpeting on the lower level dining room and main level lobby dining room. Substantiated Based on LPA Jensen's observation of the dining room carpeting on the lower and main level, the allegation of "facility is dirty" is SUBSTANTIATED. Based on LPA Jensen's inspection of the facility lower level, and interviews conducted with facility staff, the allegation of "Facility is odiferous" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies for the stained carpets and for the malodorous nature of the facility are both being cited under the same regulatory section. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 15, 2024 · control 27-AS-20240408161123

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 22, 2024

Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met based on LPA Jensen's observation of stained carpeting and observation that facility is malodorous. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2024

Plan of correction: The Licensee or Administrator will send a plan that addresses all areas of the stained carpeting and odor from the sewer line emanating in the lower level of the facility by 4/22/24 and will commence the work required to come in to compliance by 5/13/24.

Allegation investigated: Staff are retaining a resident that requires a higher level of care Staff are billing resident for services not provided

On 1/3/24 at approximately 9:50am, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with Resident Care Director Angelica White and explained the purpose of today's visit. During the course of the investigation LPA Jensen conducted interviews with care staff, the Executive Director, and the Resident Care Director. LPA Jensen reviewed records that included Resident 1's (R1's) Admission Agreement, Service Plan, Service Agreement, Memory Care Assessment, Progress Notes, R1's medical records, physician communications, LIC 602's, medication prescription orders, Medication Administration Records, billing invoices, emails between the facility and R1's responsible parties and emails from R1's responsible parties to LPA Jensen. Allegation 1-Staff are retaining a resident that requires a higher level of care: LPA Jensen reviewed the records listed above. Continued on LIC 9099C... Unfounded There are no records that would indicate R1 requires a higher level of care then what the facility is able to provide. There are no medical records stating the resident requires a nursing facility or is inappropriately placed. During the course of interviews conducted, both the Resident Care Director and Executive Director indicated that they discussed with R1's responsible parties that in their opinion, R1 would benefit from having access to a larger, more secure outdoor area due to exit seeking behaviors. There was no evidence found to support that the facility staff was prohibiting R1's responsible parties from relocating R1 if they felt a higher level of care was warranted. Based on the records reviewed and the interviews conducted the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, or is without a reasonable basis. Allegation 2 - Staff are billing resident for services not provided: LPA Jensen reviewed the most recent Service Plan, Service Agreement and Memory Care Assessment. The Service Agreement specifies various services including but not limited to extreme weather monitoring, elopement risk and behaviors. The Service Agreement indicates how many providers are needed during which shifts and the frequency of the service needed. While each individual service is listed as having an estimated monthly cost of zero, there is a section that provides for the level of care and pricing information which is derived by multiplying the point value of an assessment conducted by a given dollar amount. This Service Agreement was signed by the responsible party on 9/1/23. The Service Agreement is directly correlated to the Service Plan which lists services that will be provided and adds specific notes as to what those services entail. The Memory Care Assessment lists various activities of daily living, functional capabilities, cognitive capabilities and psycho/social capabilities with each category being assigned a point value. R1 was charged for additional services based on the needs outlined in the Service Agreement, Service Plan and Memory Care Assessment collectively. LPA Jensen conducted interviews with care staff and reviewed progress notes which confirm that R1 was receiving services related to exit seeking behaviors and declining cognitive function. LPA Jensen compared R1's physician report from the time of admission to current and confirmed that R1 has had a deterioration of condition thus warranting a new service plan arrangement. While the service plan and service agreement may be perceived as convoluted and unnecessarily difficult to understand they appear to be in compliance therefore the allegation is UNFOUNDED. A finding means that the allegation is false, could not have happened, or is without a reasonable basis. An exit interview was conducted and a copy of this report, appeal rights and the LIC 811 was provided. A finding of UNSUBSTANTIATED means that although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report, appeal rights and an LIC 811 was provided.the state’s words, verbatim · CDSS document, Jan 3, 2024 · control 27-AS-20231122163414

Type of visit: Case Management - Deficiencies

On 1/3/24 LPA Jensen conducted an unannounced visit to continue a complaint investigation in to complaint control number 27-AS-20231122163414. LPA Jensen observed a deficiency while conducting the complaint investigation and conducted a case management to address the concern. LPA Jensen met with Resident Care Director Angelica White and explained the purpose of the visit. While reviewing records for complaint control number 27-AS-20231122163414 LPA Jensen reviewed an admission agreement for Resident 1 (R1). The admission agreement states that under Part C - Change of Service Plan, on page 13: ...We will preform regular Resident Assessments of your needs. If we determine , in consultation with you, your family and/or your physician, that you need a modification of the service plan that you are currently receiving at Foothill Village, and we provide this service, you agree to change to a level of service that is appropriate to your needs. The rates for services, as set forth in Appendix A, shall apply immediately. LPA Jensen reviewed Appendix A and observed no rates to be set forth. Section II - Schedule of Care Fees is crossed out and no monetary values are listed. Deficiencies are being cited pursuant to the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies may result in the assessment of Civil Penalties. An exit interview was conducted and a copy of this report and appeal rights were giventhe state’s words, verbatim · CDSS document, Jan 3, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(B)(1) · Plan of correction due date: Jan 10, 2024

Admission Agreements Rate for additional items and services, including: A comprehensive description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services shall be listed. This requirement was not met as evidenced by LPA Jensen's review of an admission agreement for R1 that references a fee schedule in Appendix A that was missing or non-existent. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 3, 2024

Plan of correction: The Licensee or facility staff shall submit a plan for approval by the POC due date, to LPA Jensen, that describes actions that will be taken to audit admission agreements and bring them in to compliance.

Type of visit: Case Management - Incident

On 11/27/23 at approximately 3:15pm, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management for an incident report received. LPA Jensen met with business manager Kim Gerhmann and explained the purpose of the visit. LPA Jensen reviewed an incident report that was sent on 11/25/23 for an incident wherein Resident 2 (R2) was feeling ill and vomiting on 11/23/23. R2 was transported to the hospital and had not been discharged by the time the report was sent. LPA Jensen asked if R2 has returned to the community and was advised he has not. LPA Jensen inquired as to whether the facility staff is aware of his diagnosis and it was confirmed through interview they are not aware of R2's diagnosis. LPA asked staff to follow up for the purposes of ruling out infectious disease or taking the necessary precautions if needed for infectious disease. Facility staff followed up with the discharge nurse and determined R2 was not diagnosed with infectious disease and will return to the community shortly. No deficiencies were observed. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 27, 2023

Allegation investigated: The full-time employee is not qualified by formal training or experience for the operation of the food service. The person in the kitchen lead or chef is not a nutritionist, a dietitian, or a home economist and they are not regularly consulting with the facility Food temperatures are not right

On 11/16/23 at approximately 1pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue an investigation in to the above listed allegations. LPA Jensen met with Mary McClure and explained the purpose of today's visit. LPA Jensen reviewed the training records for 4 of 4 kitchen staff and determined them to be in compliance. Based on LPA Jensen's kitchen staff file reviews the allegation of "the full-time employee is not qualified by formal training or experience for the operation of the food service" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. LPA Jensen reviewed documentation related to the facility Registered Dietician Nutritionist (RDN). The facility contract with the RDN is quarterly and she conducts a review of a 4-6 week menu cycle. In addition the RDN is available "as needed" in an on call capacity. Continued on LIC 9099C... Unsubstantiated Continued from LIC 9099A... -What nutrients you should be most concerned with as a senior -Special diets Based on LPA Jensen's review of RDN consultation documentation, the allegation of "there are no records of the consultation from a nutritionist, a dietitian, or a home economist" are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided. LPA Jensen reviewed a copy of the menu posted for September 2023. Meals listed for breakfast lunch and dinner appeared to meet the recommended dietary allowances of the Food and Nutrition Board of the National Research Council. Meals included a variety of grains, fruits, vegetables and proteins. Based on LPA Jensen's review of RDN consultation documentation and the facility food service menus the allegation of "The person in the kitchen lead or chef is not a nutritionist, a dietitian, or a home economist and they are not regularly consulting with the facility." is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. LPA Jensen conducted site visits and inspected the facility kitchen on 9/27/23 and 11/16/23. During the course of the kitchen inspection on both occasions LPA Jensen observed the refrigerator and freezer temperatures to be in compliance therefore the allegation of "food temperatures are not right" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 16, 2023 · control 27-AS-20230918151004

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 23, 2023

Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on LPA Jensen's observation of debris in various locations in the kitchen. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2023

Plan of correction: The Licensee agrees to conduct a deep cleaning of the kitchen and send photos to LPA Jensen by 11/23/23.