Fountain Square of Lompoc

Allegation investigated: Staff do not respond to resident's calls for assistance in a timely manner.

At 8:00am on 08/20/2026, Licensing Program Analyst Jeffries arrived unannounced to the facility to issue final findings to all of the allegation to this complaint. LPA met with facility Business Office Manager (BOM) Veronica Guinea and announced who he is and the reason for the visit. Additionally, LPA was also at the facility to conduct a case management visit on a separate report. As to the allegation of, “Staff do not respond to residents’ calls for assistance in a timely manner.” It was alleged that, “Residents are being told to wait while caregiver continues to be on their cell phones, acknowledging residents’ pendants and walking away without asking them what they (residents) need.” It was discovered through documentation and interviews that on 05/05/2026 Licensing Program Analyst Jeffries (LPA) conducted an in-person interview with facility Administrator, Meshell Ramos who stated that, “there are not any problems with staffing, and I know some of the calls get turned off by the residents, but I don’t know why some of the calls go longer than 10 minutes.” On 05/05/2026, LPA interviewed Staff 1 – 5. (S1, S2, S3, S4, and S5) All staff interviewed said that they feel understaffed working at this facility. CONTINUED on LIC9099-C Substantiated All staff interviewed stated that they address the residents calls a quick as they can. All staff interviewed denied being on their cell phones when there was an outstanding call pending. On 05/05/2026 LPA observed two direct care staff in memory care using their cell phones and two direct care staff in assisted living using their cell phone while walking through the facility on 05/05/2026. On 05/05/2026 LPA conducted interviews with Residents 1 – 5 (R1, R2, R3, R4, and R5) all residents interviewed stated that the facility can use more staff. All residents interviewed stated that they have waited more than 10 minutes for staff to arrive when using the call button more than one time. All residents interviewed stated that they feel safe in the facility, but facility needs more staff on night and weekend shifts. On 06/15/2026 LPA conducted a data analysis of 5 random facility rooms from a form provided by the facility, titled Group Incident List, which shows all the call button calls each facility room had made for the month of April 2026. Sample Room 1 (SM1) had a total of 98 calls of which 21 calls were answered more than 10 minutes after the call button was pressed by the resident, which is 21% of the calls were answered past 10 minutes after call button was pressed by resident. SM2 showed 8 of 38 calls answered after 10 minutes, which is also 21% of calls answered past 10 minutes with at least one call taking more than 1 hour to answer. SM3 showed 61 of 226 calls being answered past 10 minutes, which is 27% of calls taking more than 10 minutes to answer. SM4 showed 6 of 25 calls being answered past 10 minutes, which is 24% of calls taking more than 10 minutes to answer. And SM5 showed 1 of 3 calls taking more than 10 minutes, which is 33% of calls taking more than 10 minutes to answer. The average call time for the facility according to the data provided by the facility for the month of April 2026 shows that on average at least 24% of the call buttons pressed by residents take more than 10 minutes to be answered by staff. Based on interviews, observations, and documentation there is enough evidence to support the allegation of, “Staff do not respond to residents’ calls for assistance in a timely manner.” And is substantiated at this time. Exit interview, report read, civil penalty issued for repeat violation, appeal rights and report provided. On 05/05/2026 LPA and Administrator reviewed facility training transcripts and noted that all staff have received at least 1 or more hours of Resident Rights training in the past 12 months including an all-staff meeting with mandated personal rights training in the past 4 months. At this time there is not enough evidence to support the allegations of, “Staff do not ensure residents’ basic needs are met.” and “Staff do not treat residents with dignity and respect. and both are unsubstantiated at this time Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Aug 20, 2026 · control 29-AS-20260501133657

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Sep 3, 2026

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. … This requirement was not met by the number of call response that resulting in call button times exceeding more than 10 minute response times as indicated in the complaint, which poses a potential danger to residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2026

Plan of correction: BOM and Administrator agrees to conduct training will all staff on addressing call button calls, how recognize and write a procedure for staff to recognize, address, and clear call button calls in the facility. To be completed by 09/03/2026 and email LPA documentation.

Type of visit: Case Management - Other

At 8:00am on 08/20/2026, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct a case management visit. LPA met with facility Business Office Manager (BOM) Veronica Guinea and announced who he is and the reason for the visit. Additionally, LPA was also at the facility to issued final findings to a separate complaint (29-AS-20260501133657) during this visit. On 07/03/2026 LPA Jeffries contacted the facility Administrator by phone and was informed that on this day (07/03/2026) it would be the last day of work for this Administrator (Shelly Ramos) with this facility. LPA requested that, due to the number of open complaints and past complaint currently associated to this facility, that they remind executive staff to update the new facility Administrator as soon as possible, as it was discussed that they had a qualified Administrator on staff who had been assigned as Administrator to this facility in the past. LPA made follow-up calls as instructed by Licensing Program Manager (LPM) as to the status of the new Administrator assigned to this facility. On 07/15/2026 LPA contacted facility by phone and was informed that Staff 1 (S1) was acting in the absence of an Administrator and would send the packet for the new assigned Administrator as soon as possible. On 08/05/2026 LPA requested that facility expedite new Administrator packet submission to Community Care Licensing. On 08/11/2026 LPA contacted S1 by phone as a follow up request for submission of new Administrator packet. Additionally, LPA follow up by sending an email with instructions for change of Administrator to S1 email. LPA contacted the facility on 08/12/2026 and S1 was not available (not currently in the facility) and on 08/19/2026 LPA was informed that S1 was on vacation. At the time of this visit on 08/20/2026 there is still no qualified or assigned Administrator to this facility and S1 acting in absence of Administrator has not been available by phone. On 08/20/2026 a citation for this facility not having a qualified and currently certified administrator (87405(a)) is issued supplemental to this report. Exit interview, report read, citation issued, appeal rights and report provided.the state’s words, verbatim · CDSS document, Aug 20, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Sep 3, 2026

87405Administrator - Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other administration of the facility as responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated specifiedsection.the state’s words, verbatim · CDSS document, Aug 20, 2026

Plan of correction: substitute who shall have qualifications adequate to be responsible and accountable for management and in this The Department may require that the administrator devote additional hours in the facility ... This requirment is not met be evidence of the lack of assigned Administrator and posess a potential risk to residents in care. BOM agrees to contact Parent Company (Tharon Lompoc, LLC) and provied weekly updates to the LPA as to the assingment of new Administrator, and cordinate all open Plan of Corrections with parent company untill all POC are cleared.

Allegation investigated: Facility is not sufficiently staffed to meet the needs of residents in care. Staff do not ensure medication is stored in originally received containers. Staff do not have the required training. Staff is not answering communications from residents’ representatives.

At 8:00am on 08/05/2026 Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to issue final findings to all of the allegations to this complaint. LPA met with Interm Executive Director, Sarah Kau, announced who he is and the reason for the visit. As to the allegation of, “Facility is not sufficiently staffed to meet the needs of residents in care.” It was alleged that on 04/21/2026 that “the facility appears to be critically understaffed.” It was discovered through documentation and interviews conducted by Licensing Program Analyst, Jeffries (LPA) that on 04/22/2026 LPA conducted an in-person interview with Administrator, Meshell Ramos, who stated that, “it is the staff responsibility to coordinated with other staff if they know they are going to call off on a shift. If they can’t get another staff to cover then the Administrator or designated admin will first request currently working staff to cover shift or call in a staff to cover that shift.” On 07/30/2026 LPA Jeffries reviewed facility work schedule (actual hours worked) for April 2026. CONTINUED on LIC9099-C Unsubstantiated LPA noted that the AM shift for that months shows a total of 6 staff call offs of which 3 of 6 were covered with additional staffing and of the 3 that were not covered with additional staffing, there were a total of 3 medtechs, 4 caregivers, and one administrator working. LPA noted that on the PM shift for April 2026, were 6 staff call offs. 4 of 6 call offs were covered with additional staffing, the other 2 of 6 shifts there were 2 medtechs and 5 caregivers working those pm shifts. LPA noted that overnight (NOC) shifts staff call offs. 2 of 2 additional staffing were noted to cover those call offs. At this time there is not sufficient evidence to support the allegation of, “Facility is not sufficiently staffed to meet the needs of residents in care.” and is unsubstantiated at this time. As to the allegation of, “Staff do not ensure medication is stored in originally received containers.” and “Staff do not have the required training.” It was alleged that, “staff do not ensure medication is stored in originally received container and staff do not have the required training.” It was discovered through inspection, observations, and interviews that on 04/22/2026 LPA Jeffries conducted a cursory medication audit and noted not “pre-pulled” medications during this medication audit and no medication stored improperly. On 06/15/2026 LPA observed medication cart and noted that medications that were prepared were for the current am medication pass on 06/15/2026. LPA noted that medications were properly stored and not pre-popped during both random medication audits and observations. On 04/22/2026 LPA conducted an in-person interview with medtech (S1). S1 stated that medications are never pulled until prior to medication pass, “at the most one-hour prep before that med pass.” S1 said that they have 4 years of experience as a medtech and the facility has mandatory annual medtech training. On 06/15/2026 LPA conducted in-person interviews with S2, and S3, both staff have current medtech training from facility, both S2 and S3 stated they only pull medications for the med pass they are doing next and never prepull medication. On 04/22/2026, LPA conducted an in-person interview with Administrator, Meshell Ramos, who stated that all medtechs have up to date training and additional medtech training is provided to direct care staff. LPA reviewed training documentation for the annual Medication Administration (medtech) Training and noted that 8 of 8 staff who are scheduled as medtechs have medication administration training within the last 12 months. At this time there is not enough evidence to support the allegation of, “Staff do not ensure medication is stored in originally received containers.” And is unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegation of, “Staff is not answering communications from residents’ representatives.” It was alleged that, “staff are not answering communications”, as the Administrator is not available and "Emails and phone calls never get returned.” It was discovered through interviews that on 04/22/2026 LPA conducted an in-person interview with Administrator, Meshell Ramos, who stated that they have not received any complaints about resident or responsible party communications in the past 30 days. Administrator stated that they either the Administrator or another staff member will respond to residents and residents’ responsible parties in a timely manner, typically the same day and the next day or Monday if its not an emergency and on the weekend. On 04/22/2026, LPA conducted in-person interviews with Residents 1-6 (R1, R2, R3, R4, R5 and R6) all residents stated that they or their responsible party have not had any communications issues with the facility. At this time there is not enough evidence to support the allegation of, ““Staff is not answering communications from residents’ representatives.” and is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Aug 5, 2026 · control 29-AS-20260422105446

Allegation investigated: Staff do not answer call buttons in a timely manner. Staff do not ensure the resident's medication is provided as needed.

At 8:15am on 06/15/2026, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct a continuing complaint investigation visit to the allegations to this complaint. LPA was also at the facility to conduct a second initial investigation visit to the allegations on a separate complaint (29-AS-20260609083723 and 29-AS-20260605145935), LAP was able to issue final findings to that second initial complaint on this visit. Additionally, LPA continued investigations on two additional and separate complaints (29-AS-20260501133657, and 29-AS-20260422105446), LPA also issued final findings on complaint 29-AS-20260316082212 and continued investigation to address the allegations to an additional two separate complaints (29-AS-20260422105446, and 29-AS-20260501133657). Today’s visit LPA was addressing two new complaints and three prior complaints, closing one older complaint and closing one new complaint on this visit for a total of five separate complaints addressed on this investigation visit.Final findings to the allegations to this complaint are as follows: As to the allegation of, “Staff do not answer call buttons in a timely manner.” It was alleged that on 03/14/2026, Substantiated Resident 1 (R1) had called for assistance with medication at 6:30am, and as of 8:30am the request for medication had not been satisfied. On 03/18/2026 Licensing Program Analyst (LPA) Jeffries conducted an in-person interview with R1. R1 stated that staff do not respond to the call button when pressed, and R1 has to wait up to 2 hours for staff to respond. On 03/18/2026 LPA conducted in-person interviews with Staff, S1, S2, and S3, all who stated that R1 would refuse to let staff clear call button, refuse showers, refuse incontinent assistance, and refuse medication often. On 04/15/2026 LPA conducted documentation audit of call button times for 6 rooms all in same hallway of R1’s room for the time period between 03/09/2026 and 03/17/2026.. Facility call button log for those 6 rooms during that time frame shows 16 calls for service took more than 1 hour to clear, 38 calls for service took more than 30 minutes to clear and 79 calls for service took more than 10 minutes to be cleared. Call button logs for R1’s room on 03/14/2026 show 36 calls for services, and 5 of 36 calls show longer than 20 minutes to respond. On 03/14/2026 R1 had pressed the call button at 5:17am and the call button log shows that that call was cleared 1 hour and 51 minutes (1:51) later, additionally R1 press button for call of service at 7:30am, the call button log shows that that call was cleared 1 hour and 45 minutes (1:45) later. There were no Facility Narrative Charting notes for the date of 03/14/2026, as not being able to clear call button logs. Based on interviews, observation and documentation, at this time there is enough evidence to support the allegation of, “Staff do not answer call buttons in a timely manner.” and is substantiated at this time. As to the allegation of, “Staff do not ensure the resident's medication is provided as needed.” It was alleged that, on 03/16/2026, Resident 1 (R1) had requested a PRN medication at 6:30am via the call button, R1 spoke with Staff (S2) and as of 8:30am on 03/16/2026 R1 still had not received their requested PRN medication. On 03/18/2026, Licensing Program Analyst (LPA) Jeffries conducted an in-person interview with R1 who stated that the facility is constantly late with all medication passes and take their time when a PRN is requested, R1 stated, the facility finally did provide the PRN on 03/16/2026, but was not sure of what time it eventually was provided that morning after 8:30am. On 04/15/2026, LPA reviewed R1’s Centrally Stored Medication Records (CSMR) and Medication Administration Records (MAR) for the month of March 2026. LPA noted that there were no PRN medications provide to R1 according to the MAR on March 15th or 16th of 2026. On 03/18/2026 LPA conducted interviews of Staff 1, S2 and S3, who stated they did not recall what time R1’s PRN was provided on 03/16/2026. Based on interviews, and facility records this is sufficient evidence at this time to support the allegation of, “Staff do not ensure resident’s medication is provide as needed.” and is substantiated at this time. Exit interview, report read, appeal rights and report provided. On 04/15/2026, LPA reviewed call button log for the morning of 03/14/2026 and noted that there were 4 call button logs starting at 6:39am, 7:37am, 8:21am and 8:24am. LPA noted that all calls exceeded 23 minutes due to R1’s refusal to allow staff to clear call button log. LPA also noted that the call button at 8:21am was cleared by staff in less than 1 minute. Based on interviews, documentation, and observation there is not enough evidence to support the allegation of, “Staff left resident in soiled bedding for an extended period of time.” and is unsubstantiated at this time. As to the allegations of, “Staff handle resident in a rough manner.” and “Staff do not treat resident with dignity and respect.” It was alleged that R1 had reported that when staff provide bed baths, they are rough, causing pain in privet areas. R1 also stated that staff speak in their own language (Spanish) around R1 and that they make fun of R1, laughing as they bathe or assist R1. On 03/18/2026 LPA conducted an in-person interview with R1 who stated that the staff intentionally speak Spanish and laugh when assisting R1 with bathing and transfers. R1 stated that they did not know what the staff were saying but would also laugh when speaking Spanish around R1. R1 denied understanding Spanish language. On 03/18/2026, LPA conducted interviews with S1, S2, and S3 who stated that their primary language is Spanish and it is only spoken to help them better assist R1 when providing care that require more than one staff. S1, S2, and S3 all deny laughing while providing care for R1. All deny making fun of R1 while providing care. On 04/15/2026 LPA conducted a documentation review of S1, S2, S3, S4, S5 and S6 who all have current regulation required training that includes but not limited to, Assisting with Proper Positioning, Residents Rights in Assisted Living, Cultural Awareness and Humanities, Transferring Safely, Urinary Incontinence, Residents Rights in Assisted Living, and Reporting Abuse. Based on interviews, and documentation, at this time there is not enough evidence to support the allegations of, “Staff handle resident in a rough manner.” and “Staff do not treat resident with dignity and respect.” Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Jun 15, 2026 · control 29-AS-20260316082212

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jun 29, 2026

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. … This requirement was not met by the number of call response that resulting in call button times exceeding more than 10 minute response times as indicated in the complaint, which poses a potential danger to residents in care.the state’s words, verbatim · CDSS document, Jun 15, 2026

Plan of correction: Administrator agrees to conduct a training will all staff on address call button calls, how recongnuze and write a procedue for staff to recognize, address, and clear call button calls in the facility. To be completed by 06/29/2025 and email LPA documentation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465((a)(6) · Plan of correction due date: Jun 29, 2026

(a) A plan for incidental medical .. each facility. The plan shall encourage routine medical …such care, by compliance with the following: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met by evidence of facility documentation failing to record dosage of medication provided on 03/16/2026 which poses a potential danger to residents in care.the state’s words, verbatim · CDSS document, Jun 15, 2026

Plan of correction: Administrator agrees to have all medication technitions to complete a 1 hour additional training on documentation of medication. To be completed by 06/29/2025 and email LPA documentation.

Allegation investigated: Facility is in disrepair. Staff do not ensure that the facility remains free of odors.

At 8:15am on 06/15/2026, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct an initial complaint investigation visit to the allegations to this complaint. LPA was also at the facility to conduct a second initial investigation visit to the allegations on a separate complaint (29-AS-20260605145935). Additionally, LPA continued investigations on three additional and separate complaints (29-AS-20260501133657, 29-AS-20260422105446, and 29-AS-20260316082212), LPA was able to issue final findings on complaint 29-AS-20260316082212 and continued investigation to address the allegations to an additional two separate complaints (29-AS-20260422105446, and 29-AS-20260501133657). Today’s visit LPA was addressing two new complaints and three prior complaints, closing one older complaint and able to issue final findings on this new complaint as follows: As to the allegations of, "Facility is in disrepair." and "Staff do not ensure that the facility remains free of odors." It was alleged that the facility has, "sewer gas leak throughout the north side of the building and in the kitchen and multiple leaks in the sewer system. Leaks include by the 3 compartment sink drain in kitchen. In the dishwashing area and CONTINUED on LIC9099-C Unsubstantiated an entire office room in the kitchen area full of gas from sewer due to grease trap improperly sealed. On 06/15/2026, LPA Jeffries conduced a physical tour and observation of the North side of the facility with focus on the kitchen area where "3 compartment sink drain" in the kitchen, kitchen office, and kitchen grease trap are located. LPA tested two separate faucets in the kitchen and did not note any smells imitating from either faucet in the kitchen and kitchen office area. LPA noted observation of new 1.5" plumbing pipe under the 3 compartment sink, draining into a internal floor drain with no apparent visual leaks and no evidence of abnormal smell imitating from new plumbing repair. LPA observed documentation of invoice from TNT Plumbing of Lompoc, CA dated 04/15/2026, to repair a leak on 03/18/2026. On 06/15/2026, LPA conducted an interview with maintenance director, staff 5 (S5) who stated that the repair was to fix a leak and was addressed as soon as the facility notice the leak, S5 stated that they never recalled any foul odor at the time 3 sink drain needed repair. On 06/15/2026 LPA conducted interviews of kitchen staff S6, and S7. S6 stated they knew of the repair but did not recall any bad smells in 12 months of working in the kitchen, S7 stated that they had never smelled sewer smell coming from the kitchen. On 06/15/2026, LPA conducted interviews of Residents (R1, R2, R3, and R4), R1, R2, R3, and R4 all reside on the north side of the facility in close proximity to the kitchen and did not recall a bad smell coming from the kitchen. LPA also reviewed facility invoices from Clay's Septic and Jetting, dating back 12 months of quarter grease trap cleaning and maintenance. At this time there is not enough evidence to support the allegations of, ""Facility is in disrepair." and "Staff do not ensure that the facility remains free of odors." and both allegations are unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Jun 15, 2026 · control 29-AS-20260609083723

Allegation investigated: Resident sustained a pressure wound due to staff neglect. Staff did not ensure resident received medical attention in a timely manner. Staff left resident soiled in feces for an extended period of time.

At 9:00am on 01/30/2026, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conduct the initial investigation visit. LPA met with Administrator, Meshell Ramos, announced who he is and the reason for the visit. LPA reviewed documentation, conducted interviews of Staff and Residents. LPA collected documentation and was able to determine and deliver final findings during the initial investigation visit. As to the allegations of, "Resident sustained a pressure wound due to staff neglect." and "Staff did not ensure resident received medical attention in a timely manner" It was alleged that, staff were unaware of foot wounds of Resident 1 (R1). On 01/30/2026, LPA Jeffries conducted an interview with R1. R1 stated that they had no issues with care at the facility and care provided by the staff. R1 stated that the facility addressees R1's foot wound in a timely manor and helped. R1 stated Home Health has been treating foot since its been hurting and has been seen by a Podiatrist. R1 stated that the wounds on the foot are "healing nicely and a nurse will be arriving to the facility today (01/30/2026) to look at R1's foot again." R1 stated that they had CONTINUED on LIC9099-C Unsubstantiated no issues at all with the care provided by the facility and its staff. On 01/30/2026 LPA Jeffries conducted interviews with multiple staff (S1, S2, S3, and S4). S1-4 all stated that they have continuous training by the facility. All stated that R1 would let facility staff know if R1 had any injury or illness, need for incontinence assistance and would routinely refuse showers weekly. On 01/30/2026, LPA Jeffries conducted interviews with multiple Residents (R2, R3, R4, and R5). R2-5 all stated they had no issues with assistive care that the facility provides, R1-4 all stated that they had no issues with showering or incontinence assistance the facility provides. R1-4 all stated they had no issues of concern with the facility in general. On 01/30/2026, LPA Jeffries reviewed documentation of incident report from the facility dated 01/21/2026 indicating that R1 was seen by Physician on 01/21/2026 who referred R1 to ER to determine stage of food wound. R1 returned to facility on 01/21/2026. R1's Podiatrist saw R1 on 01/26/2026 and Home Health wound care specialist saw R1 on 01/30/2026. LPA noted that the Home Health Care contract for R1 was to address R1's foot and began on or before December 23, 2025. which provided evidence of contestant licensed medical attention to R1's foot prior to R1's visit to the ER on 01/21/2026. Based on interviews, and documentation there is not enough evidence at this time to support the allegations of "Resident sustained a pressure wound due to staff neglect." and "Staff did not ensure resident received medical attention in a timely manner" and both are unsubstantiated at this time. As to the allegation of, "Staff left resident soiled in feces for an extended period of time." It was alleged that, facility staff are, "leaving residents in soaked diapers until they are dripping wet with urine or feces down their chairs." On 01/30/2026 LPA Jeffries conducted an interview with R1 who stated, R1 had no issues with care at the facility and care provided by the staff. R1 denied having any issues with incontinence care at the facility. On 01/30/2026, LPA Jeffries reviewed facility Shower Form & Skin Integrity Monitoring Form for R1 for the months of July 2025 through January 2026 which documents contestant showering assistance for the months of July through December 2025. The Shower Form & Skin Integrity Monitoring Form for R1 for the month of January shows that R1 refused 3 of 7 assisted showers (every other shower attempt) for the month of January 2026. LPA reviewed R1's Appraisals Needs and Assignments form and Care plan that state. "often Resident will only agree to one shower per week." On 01/30/2026 LPA Jeffries made observations during visit and noted no residents appearing to be uncomfortable or lacking needs being met by facility staff. Based on interviews documentation and observation there is not enough evidence at this time to support the allegation of,"Staff left resident soiled in feces for an extended period of time." and is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 29-AS-20260129095641

Allegation investigated: Staff do not respond to resident's calls for assistance in a timely manner.

At 9:00am on 11/06/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to issue final findings to the allegations to this complaint. LPA met with Community Relations Director, Sarah Kau, LPA announced who he is and the reason for this visit. Additionally, the facility annual inspection was conducted on a separate report on this date. The findings to the allegations of this complaint are as follows: As to the allegation of, “Staff do not respond to resident call for assistance in a timely manner” it was alleged that R1 was incontinent and when Resident 1 (R1) calls for assistance, staff do not respond in a timely manner. It was discovered through documentation and interviews that on 07/14/2025, LPA Jeffries conducted an interview with Family Member 1 (F1) who stated that R1 would press the call button for staff and “sometimes they just don’t show up”, then R1 calls F1 at home for assistance and F1 comes to the facility to help R1. F1 stated that R1 has called 911 because the staff fail to answer the call button sometimes. CONTINUED on LIC9099-C Substantiated On 08/13/2025, LPA Jeffries reviewed the facility provided call button response schedule for R1’s room from 06/24/2025 through 07/17/2025 (24 days) Tilted: Resident Incident Details Report: This report shows a total of 668 Resident Incident calls from R1’s room. Of those 668 calls, 221 calls took over 10 minutes for staff to respond to clear call button (33% of calls); of those 221 calls over 10 minutes, 86 (13% of calls) of the calls took over 20 minutes for staff to respond and clear. Serious Incident Report (SIR) from facility dated 06/24/2025 shows R1 calling 911 for chest pain at 9:50pm, on 06/24/2025 the last call button for R1 was pressed at 6:58pm and shows 42 minutes and 39 seconds to clear (42:39). SIR dated 06/29/2025 shows R1 calling 911 for chest pain at 12:30pm, the last call button press for R1 prior to time on this SIR was 12:16pm with staff clearing call 30 minutes and 14 seconds (30:14) later when Emergency Medical Technicians (EMT) arrived to the facility for R1’s 911 call, R1 refused transport at that time. SIR dated 06/30/2025 shows R1 called 911 for back pain at 7:30am. R1’s last button press to this SIR was 7:09am, 24 minutes and 23 seconds later (24:23) that call button press was cleared. SIR dated 07/03/2025 shows R1 calling 911 at 8:50am, R1’s last button press to this SIR was at 7:58am, call button was cleared 39 minutes and 26 seconds (39:23) later. SIR dated 07/04/2025 at 9:00pm showed R1 called 911 due to throat closing, the last call button press in relation to this SIR was 8:49pm, log shows this call button being cleared 32 minutes and 40 seconds (32:40) later. LPA noted that 5 SIR’s for calling 911 all show call response times by facility staff exceeding 24 minutes or more. LPA noted that on 04/03/2025 the facility was cited on a complaint for required signal system [87303(i)(1)(C)]. and as the plan of correction for that citation was to have all pendants (call buttons) reprogrammed by 04/17/2025. This POC was confirmed by email on 04/17/2025 that all pendants were working. Based on 33% of the button calls for incident for R1’s room took 10 minutes or more for staff to respond and 5 documented SIRs showing call times exceeding 24 minutes, and interviews, there is enough evidence to support the allegation of ““Staff do not respond to resident call for assistance in a timely manner” and is substantiated at this time. Exit interview, report read, citation issued, report and appeal rights provided. The next time R1’s call button was pressed was 3:50pm, approximately 7 hours in between calls and approximately 6 hours after R1 called F1 to alert for incontinence. According to F1’s interview, R1 had been changed by staff on or before 10:15am on 07/11/2025. However, there was no call button to summon staff for assistance from R1’s call button after 8:56am. On 07/14/2025, LPA interviewed Direct Care Staff (S1, S2, and S3), all stated that R1 required at least 2-person assist with incontinent care and showering but only wanted assistance from direct care staff who was not on duty during the day shift and refused direct care assistance for incontinence and showering. Based on interviews of F1 stating staff had difficulty helping R1, with cleaning and changing on 07/11/2025, and no indication of call button being pressed at time alleged in complaint, staff and R1’s interviews of R1’s right to refuse, and documentation there is not enough evidence at this time to support the allegation of, “Staff do not ensure that resident's toileting needs are met”, “Staff do not ensure resident's showering needs are met.” and are unsubstantiated at this time. As to the allegation of, “Staff handled residents in a rough manner.”, it was alleged that R1’s first day at the facility, 5 direct caregivers attempted to change R1 in a rough manner. It was discovered through interviews, and documentation that on 07/14/2025 LPA conducted an interview with F1 and R1, who stated that 4 staff members were trying to move R1 in ways that worked for them and not R1, and one staff member was just watching and not helping. On 07/11/2025 In interviews with S1, S2 who were working on 06/24/2025. S1 and S2 stated that R1’s behavior in the incontinent change that day made it difficult for staff to change R1 and they were attempting to work with R1 to make it work in light of the behavior to resist the assistance of staff. S1 and S2 stated, there was only room for 4 staff to help and they do not remember the 5th staff present on 06/24/2025. On 07/14/2025, LPA reviewed staff training on all facility direct care staff members, all staff are current and up to date on annual regulated training requirements which included training on resident transfers. On 08/13/2025 LPA reviewed R1’s Resident Assessment, which indicated that R1 required a 2 person assist with transfers, bathing, toileting, and dressing. Based on interviews indicating resisting staff care and documentation of regulated staff training, there is not enough evidence at this time to support the allegation of, “Staff handled residents in a rough manner.” and is unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegation of, “Staff so not provided adequate food service.” It was alleged that staff leave food for R1 across the room, where R1 could not reach food. It was discovered through interviews that on 07/14/2024 LPA conducted interviews with R1 who stated that they do not like the food at the facility. R1 stated,” a few days ago (did not remember specific date) dinner was delivered when I was sleeping and when I woke up it was cold. R1 stated that they had to call staff (via call button) in order to reach dinner.” On 07/11/2025, LPA interviewed S1, S2, and S3, all who stated that they had never seen meals being placed out of reach of R1’s bedside. On 08/13/2025, LPA reviewed facility’s call button report for R1’s room, which shows approximately 650 calls for service answered in a period of 22 days. On 07/14/2025, LPA reviewed R1’s Physicians Report (LIC602) singed and dated on 06/24/2025, which indicated that R1 is “able to feed self”. And Facility Resident assessment dated 06/27/2025 which indicated that R1 “Requires food cut chopped, pureed, or otherwise prepared.” With no other assessments pertaining to meals. Based on documentation, interviews, and staff observations, there is not enough evidence at this time to support the allegation of, “Staff do not provide adequate food service.” and is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 29-AS-20250711115229

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(14) · Plan of correction due date: Nov 7, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)… Personal Rights of Residents in All Facilities, residents… shall have all of the following personal rights: (14) To reasonable accommodation of their individual needs and preferences in all the health or aspects of life in the facility, except when accommodation would endanger safety of the individual resident or other residents. This requirement was not met by evidence of multipal prolonged times staff answering R1’s call buttons, which poses an imminent risk to residents in care.the state’s words, verbatim · CDSS document, Nov 6, 2025

Plan of correction: Community Relations Director (CRD), agreed to conduct Personal RIghts training for all staff on All Staff meeting. CRD will notifiy LPA of specific personal rights training course and date when all staff will complete training by 11/07/2025.

Type of visit: Required - 1 Year

At 9:00am on 11/06/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the facility annual inspection. Additionally, LPA issued final findings to the allegations to a separate complaint on a separate report. LPA met with Community Relations Director, Sarah Kau (CRD), LPA announced who he is and the reason for this visit. CRD made phone contact with Administrator Morgan Williams who was unavailable for annual inspection, who provided verbal authorization for CRD to sing for annual inspection report and compliant findings. This facility is approved for a maximum capacity of one hundred thirty (130) residents. All residents licensed and approved for non-ambulatory status, of which ten (10) may be bedridden. Facility is approved for delayed egress, with an approved hospice care waiver for twenty (20) residents. This facility has a main kitchen for all residents of the facility, and two (2) dining rooms. One (1) dining room is specifically for the Assisted Living residents of the facility, and the other dining room is for the Memory Care residents of the facility. CRD and LPA conducted physical inspection facility grounds outside, in-closed courtyards and building including resident rooms, storage, kitchen, dining rooms, medication room and offices. LPA observed at least 2 days of perishable food and at least 7 days of non-perishable food items maintained in the facility and sufficient emergency water supply located in the facility kitchen. LPA noted that resident rooms all have on suit bathroom. All resident rooms had required furniture and linins per regulations. LPA observed facility Maintenance Supervisor tested water in resident memory care bedroom that exceeded regulation standards of 120*(f), citation was issued [87303(e)(2)]. LPA observed chemicals stored in unlocked cabinet in memory care unit, citation issued [87309(a)]. LPA observed door to facility kitchen not operating properly and not closing as designed, and courtyard fountain in disrepair with loose rocks in the walkway surround fountain, citation issued [87303(a)]. No other citations or violations noted during the physical inspection of the facility. CONTINUED on LIC9099-C LPA observed fire extinguishers lactated throughout the facility all primed and in the green indicating working. LPA reviewed annual fire inspection dated 07/14/2025 from Securitas Fire Systems showing visual and functional test of sprinkler fire system with a grade of passing. LPA noted that there are complete first aide kits in memory care, kitchen and medication room. LPA noted that all hallways, sliding doors, doors and passageways were free and clear of debit. CRD and LPA conducted a full review of the annual care tools. LPA reviewed Emergency Disaster Plan, Infection Control Plan, Liability Insurance, and Centrally Stored Medication Records. LPA reviewed a sample of Staff and Resident files. LPA noted that there were no other violations or citations issued as a result of the document and file reviews. LPA noted no other citations or violations as a result of this annual facility inspection. Exit Interview, report read, report and appeal rights provided.the state’s words, verbatim · CDSS document, Nov 6, 2025

The state marks this report as 8 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Facility did not answer residents call button in a timely manner.

At 9:40 AM on 08/01/2025, LPA Jeffries arrived unannounced to issue final findings to the allegations to this complaint. LPA met with Resident Care Coordinator, Veronica Guinea (RCC), announced who he is and the reason for the visit was it issue final findings to the allegations to this complaint. As to the allegation of, “Facility did not answer residents call button in a timely manner.” It was alleged that the facility staff took 30 to 45 minutes to answer Resident 1 (R1’s) call button. It was discovered through documentation that, on 04/03/2025 there was a subsequent substantiated complaint pertinent to the facility call system being down from 03/28/2025 through 04/07/2025 that was filed. On 07/30/2025, LPA Jeffries reviewed the call button history for the room that R1 had resided. CONTINUED on LIC-9099-C . Substantiated The “Resident Incident Details Report” that was provided by facility, which shows 20 calls from R1’s room, dating from 04/13/2025 through 05/07/2025. 14 of 20 calls showed a response time ranging from approximately 11 minutes and 22 seconds (11:22) to 1 hour 49 minutes and 46 seconds (1:49:46) resulting in late responses average of approximately 41 minutes per late call, of the 14 late calls. And 1 minute and 35 seconds (1:35) average per the 6 acceptable call response times. At this time there is sufficient evidence to support the allegation of, “Facility did not answer residents call button in a timely manner.” and is substantiated at this time. Exit interview, report read, appeal rights and report provided. “Identified concerns and recommended actions take to resolve” entry to that form. LPA also noted that Outside Agency Service and Documentation form showed 52 prior visits without any additional concerns for R1 prior to the month of May 2025. Based on interviews, and documentation, there is not enough evidence to support the allegation of, “Facility did not ensure residents’ care needs were met.” and is unsubstantiated at this time. As to the allegation of, “Staff violated residents’ personal rights.” It was alleged that on 04/17/2025, R1 was not allowed to go to bedroom from the activity room. It was discovered through interviews and documentation that, on 06/26/2025, LPA Jeffries conducted an interview with S1, S2, and S3, all who stated that another Resident (R2) in Memory Care attempted to push R1 in their wheelchair into R1’s Room. All 3 staff stated that R1 and R2 were redirected back to the activity room for the safety of both residents. All 3 staff denied not allowing access to R1 to their room at any time other than R2 going into R1’s room for safety concerns. LPA Jeffries reviewed the staff schedule for 04/17/2025 and confirmed that S1, S2, and S3 were working in memory care on 04/17/2025. LPA Jeffries reviewed training for S1. S2, and S3 and all staff were current in the required staff training hours. R1 was no longer a resident at the facility and could not be interviewed. On 06/26/2025 LPA Jeffries attempted to interview R2, however R2 was not able to answer questions about 04/17/2025. At this time there is not enough evidence to support the allegation of, “Staff violated residents’ personal rights.” and is unsubstantiated at this time. As to the allegation of, “Facility was not maintained sanitary.” It was alleged that staff did not clean R1’s room or make R1’s bed, when wet with urine and floor had dried urine. It was discovered through interviews, documentation and observations that on 06/26/2025, LPA Jeffries conducted a physical inspection of the facility with focus on Memory Care Unit and room that R1 had resided over a month past. LPA noted that there were two housekeepers working in memory care unit and there were no overt smells and the facility and memory care appeared clean and in good repair. LPA noted that R1s former room was clean, floors were clean and discovered no issues in R1 former room. On 07/10/2025, 07/14/2025, and 07/22/2025, LPA conducted a physical walk through of the facility including memory care unit. LPA noted that the facility was clean and in good repair and noted at least two or more housekeeping staff working to clean rooms during these visits. LPA reviewed the facility schedule and noted that housekeepers were consistently scheduled during the months of April and May of 2025, additionally Care Staff was also consistently scheduled during April and May of 2025. Based on observations, and documentation there is not enough evidence to support the allegation of, “Facility was not maintained sanitary.” and is unsubstantiated at this time. Exit interview, report read, appeal rights and report provided.the state’s words, verbatim · CDSS document, Aug 1, 2025 · control 29-AS-20250624093140

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Aug 13, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. … This requirement was not met by the number of call response that resulting in call button times exceeding 41 minutes, which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2025

Plan of correction: PCC stated staff numbers are increased and all staff now has a walk-eTalke. PCC agrees to have a all staff training on call button response times, and clearing all calls in a timely manor. PCC will provide proof of training to LPA by 08/13/2025.

Type of visit: Case Management - Incident

At 10:45am on 07/22/2025, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conduct a case management visit pertaining to the serious incident report (SIR) on the date of 07/11/2025, of staff bringing loaded gun into the facility. On 07/14/2025, it was reported that on 07/11/2025, Staff 1 (S1) had brought a loaded gun into the facility, in the kitchen storage area, as reported by staff. Administrator Robin Murray and Community Relations Director (S4) inspected the kitchen where they discovered a gun in a drawer. Administrator immediately called Lompoc Police Department (LPD) who arrived and confirmed that the gun was loaded with 9 live rounds 9mm ammunition. According to LPD Police Report. S1 was taken into police custody along with all physical evidence. Administrator stated in the SIR that S1 was placed on administrative leave pending due process termination. At the time of visit Administrator stated that S1 had been terminated and presented paperwork indicating S1 had been terminated. As a result of S1 bringing a loaded gun with 9 rounds of live ammunition and leaving it in a accessible common drawer, the facility is issued a citation of 87309(a) Storage Space and Access. Exit interview, report read, citation, appeal rights and report provided.the state’s words, verbatim · CDSS document, Jul 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 22, 2025

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that ... knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met by evidence of: The licensee did not follow the section cited above when S1 brought a loaded gun into the facility and left it accessible, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 22, 2025

Plan of correction: Administrator agrees to conduct an all staff meeting to review employee handbook section that specificity address weapons at work. Administrator agreed to the all staff meeting that is taking place on 07/22/2025, and Administrator will send All Staff agenda signatures of staff in attendance to LPA.

Type of visit: Case Management - Other

At 9:15am on 07/10/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct a case management visit pertaining to Serious Incident Reports (SIR) from the facility, reviewed from March 2025 through June 2025. Upon arrive to the facility and entering at 9:15am there were no staff at the entrance, LPA singed in and walked into the facility. LPA walked down to the left side hallway and discovered the Med room unlocked and unattended. LPA called Administrator by phone and left a message on Administrators cell phone. LPA met with Resident Care Coordinator, Veronica Guinea (RCC),, announced who he is and the reason for the visit. LPA Jeffries took a short video of the unsecured medication room searched and found staff and asked staff to secure medication room. LPA noted that there were 5 residents in the dining room and 2 residents walking the hallway near the medication room when LPA discovered the unsecured and open medication room. LPA called Administrator on cell phone to request her presents at the facility at 9:30am. Facility will receive citation, 87465(h)(2) Incidental Medical and Dental Care, medications accessible to persons other than responsible employees. LPA Jeffries reviewed SIR's from the facility during the months of March 2025 through June 2025 and noted at least 18 SIR's with late and/or missing information as required by Community Care Licensing (CCL) Regulations 87211. LPA Jeffries noted that there were two verbal warning by LPA Jeffries to Administrator, Robin Murray about regulation reporting requirements of SIRs being submitted past the 7 days within the occurrence to report regulation requirements (87211(a)(1)), on 04/03/2025 and 04/30/2025. CONTINUED on LIC809-C LPA Jeffries followed up with an written warning of late SIRs in an email sent to Administrator on 06/18/2025, and followed up with an email to Administrator of copy of CCL 87211 reporting requirements sent to Administrator on 06/20/2025. In reviewing SIRs dated from March 2025 through June 2025 LPA noted that there were 105 SIRs submitted by the facility. 18 of 105 were submitted after the 7 day requirement. LPA also noted that 7 of 105 SIR's had no attending physician's name, findings, and treatment, if any; and disposition of the case when residents had returned from the Emergency Room (ER) visits. On 07/03/2025 LPA requested ER discharge paperwork for an incomplete SIR dated 06/24/2025. LPA noted that the ER discharge paper work was incomplete and contacted Administrator on 07/02/2025 by phone to reviewed CCL Regulations reporting requirements. Based on 18 of 105 SIRs in March 2025 through June 2025 being submitted past 7 days of the occurrence, and 7 of 105 SIRs review during that time not having attending physician's name, findings, and treatment, if any; and disposition of the case when residents returned from the Emergency Room, a citation is issued. Exit interview, report read, appeal rights and report provided.the state’s words, verbatim · CDSS document, Jul 10, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jul 24, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met by observation of LPA discovering open and unsecured medication room with no staff present. This poses an eminent danger to residents in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: Administrator agrees to reevalute and update medication securty policy and send update to LPA by 07/11/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(2) · Plan of correction due date: Jul 24, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence ...This report shall include...attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met was not met in 18 of 105 and 7 of 105 SIRs submitted in March through June of 2025, which poses a potential risk to Residents.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: Administrator agrees to contact hospital (ER) administrator and clarifiy discharge requiorments when a resieent is released back to the facility from the ER. Aministrator will request email of outcome and forward that email to LPA by 07/24/2025.

Allegation investigated: Due to staff neglect, residents sustained injuries while under the care and supervision of the facility. Staff are not properly documenting incidents Staff left residents soiled in bed for an extended period of time Staff are not meeting residents needs

On 5/30/2025 at 9:10am Licensing Program Analysts (LPAs) Haner-Tomasko and Jeffries conducted a subsequent complaint visit to deliver findings for the above allegations. LPAs met with Administrator Robin Murray and explained the reason for the visit. LPAs reviewed report with Resident Services Coordinator Veronica Guinea and Resident Services Supervisor Noemi Jimenez. On 12/16/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint regarding neglect/lack of care and supervision. The complaint alleged that multiple residents, Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4), sustained injuries while under the care and supervision of the facility. The complaint also included allegations of resident falls not being reported, staff left residents soiled in bed for extended periods of time, and staff not assisting residents during bedtime. (Continued on LIC9099-C) Substantiated The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Philippe Ryan Miles. On 12/17/2024, from 1:00pm to 3:45pm, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced initial complaint investigation visit to the facility. LPA Phillips met with Administrator Robin Murray and Community Relations Director Sarah Kau and explained the reason for the visit. During the visit, the LPA conducted in-person interviews at the facility pertaining to the complaint allegations, as well as requested and received facility documentation relevant to the investigation. The LPA determined further investigation was needed prior to issuing findings. On 12/23/2024, from approximately 1:04pm to 2:13pm, Investigator Miles and Investigator Heidy Bendana conducted interviews with Resident #1 (R1) and the resident representative for Resident #2 (R2); and on 04/13/2025, from approximately 11:54am to 2:04pm, with caregivers and med techs. The hospice residents (R2), Resident #3 (R3), and Resident #4 (R4) were not interviewed due to cognitive ability or being deceased. In addition, investigator Miles reviewed medical records from Assisted Home Health Hospice, Lompoc Valley Medical Center, Dignity Health Hospice, VNA Health Hospice, and facility file documents related to the investigation. On 5/30/2025 from approximately 10:10am to 10:50am, LPAs Haner-Tomasko and Jeffries interviewed additional staff and administrator. On the allegation: “Due to staff neglect, residents sustained injuries while under the care and supervision of the facility.” The investigation revealed that in October 2024, the facility increased the monthly rate for R2 due to the need of an “increase of the level of care and supervision,” however, R2 had an increase of witnessed and unwitnessed falls while sustaining multiple injuries. According to the Dignity Health Hospice medical records, it was noted R2 has had multiple falls. Caregivers stated R2 had multiple witnessed and unwitnessed falls, and behavioral episodes. Caregivers stated on one occasion, R2 went out a window, was found next door at Lompoc Skilled Nursing and Rehabilitation Center and therefore needed a higher level of care and supervision. (Continued on LIC 9099-C) According to the Assisted Home Health Hospice medical records, on 12/04/2024, the Licensed Vocational Nurse (LVN) visited R3 and found multiple bruises to R3’s left shoulder. During assessment, R3 “had significant swelling and bruising to left shoulder that extended to left bicep and a bruise to [the] left wrist. Facility med tech states that there were no falls reported in the last 24 hours. Facility Administrator Robin Murray reports that she was going to investigate and interview all staff that helped with R3’s care within the last 24 hours to see if anyone forgot to write an incident report…”. On 12/05/2024, R3 was taken to Lompoc Valley Medical Center, and it was discovered during X-rays that R3 suffered an “impacted fracture on the humeral neck and fracture of the outer aspect of the humeral head with partial subluxation.” Caregivers interviewed stated R3 needed a higher level of care and supervision. According to VNA Health Hospice medical records, it was noted that R4 was a fall-risk with having frequent multiple falls in the facility. The caregivers stated R4, who needed a higher level of care and supervision, had witnessed and unwitnessed falls in the facility in which R4 sustained injuries. Based on the interviews conducted and supporting documents, there is sufficient evidence the facility did not provide a proper level of care and supervision to R2, R3 and R4. Therefore, the allegation is deemed Substantiated at this time. On the allegation: “Staff are not properly documenting incidents.” During the Department’s investigation it was revealed that R1 sustained 4 falls. R1 was admitted to the facility in July 2024 with falls occurring August, October, November and December 2024, requiring medical attention; however only 1 incident report was submitted to Community Care Licensing (CCL). In addition, R4 had falls occurring February, April, and November 2024 requiring medical attention, with no incident reports submitted. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegations: “Staff left residents soiled in bed for extended periods of time and Staff are not meeting residents’ needs.” It was alleged staff left residents soiled in bed for extended periods of time, and staff were not assisting residents during bedtime, as some residents were observed in the early morning hours to still be in their wheelchairs and regular clothes. (Continued on LIC9099-C) According to the interview conducted on 12/17/2024, the Administrator stated to LPA Phillips that the facility has had a hard time retaining and hiring employees to work there due to the location as the facility is located in an isolated town comparatively in the County. The Administrator stated that during the months of October 2024 and November 2024, a number of staff (between 5-10) had left employment at the facility due to a number of reasons including financial and geographic. The staff interviewed by the LPA stated that the facility is always hiring employees to keep staffing at an appropriate level, but it is extremely difficult due to the location. Staff also stated to the LPA that there have been "a lot" of falls in the facility in the second half of 2024. The LPA was told that it was not unusual. The LPA was also told that there is a high turnover and low retention rate at the facility, but they are always trying to keep, retain, and hire staff. Multiple staff interviewed by IB investigators indicated the facility did not have enough staffing to meet residents’ needs. Staff indicated some assisted living and memory care residents required one-on-one staff, and the facility pulled facility staff from the floor to provide additional supervision, leaving the rest of the facility short-staffed. Additional interviews conducted with staff revealed there was not enough staffing to meet residents needs, residents were left soiled for extended period of time, and other needs such as assistance with dressing and bedtime routines were not met. Additionally, staff interviews revealed the facility call buttons were not functioning for a period of at least two weeks; this was addressed on complaint # 29-AS-20250403091059. Interviews revealed the ‘loaner’ call system was providing the incorrect room numbers. Staff also stated residents were given whistles to summon assistance, however staff could not tell which rooms the whistles were coming from, and therefore did not respond to residents. While conducting interviews with the caregivers, they disclosed that Resident #5 (R5) eloped from the facility multiple times. R5 was discovered at a staff’s house in the neighborhood and was found near the main roads in the city of Lompoc. The local police department brought him back to the facility. Incident reports submitted by the facility revealed that R5 eloped on 07/05/2024, 08/02/2024, and 10/13/2024. R2 also eloped from the facility and was found next door at the Lompoc Skilled Nursing and Rehabilitation Center. Based on the investigation, there is sufficient evidence to support the facility did not meet resident’s needs, including residents being left soiled for an extended period of time. Based on the information obtained, the allegations are deemed Substantiated at this time. (Continued on LIC9099-C) A $500 immediate civil penalty is assessed today. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D). Exit interview conducted, appeal rights and a copy of this report issued.the state’s words, verbatim · CDSS document, May 30, 2025 · control 29-AS-20241216152446

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: May 31, 2025

Basic Services (d)...if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal…and providing the other basic services…either directly or through outside resources. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Staff did not provide adequate care and supervision, residents sustaining falls resulting in injuries...the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: Licensee has hired additional staffing. Adminstrator will train staff on identifying changes in condition and communicating this to leadship to update resident appraisals. Administrator will email LPA the date of this training by 5/31/2025 and the completed training and signed roster after completed. which posed an immediate health and safety risk to residents in care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 31, 2025

Additional Personal Rights of Residents in Privately Operated Facilities (a) .., residents... shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers...to meet their needs. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when they did not provide adequate staffing which resulted in residents needs not being met, including residents being left soiled for an extended period of time.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: Licensee has hired additional staffing. Adminstrator will train staff on identifying changes in condition and communicating this to leadship to update resident appraisals. Administrator will email LPA the date of this training by 5/31/2025 and the completed training and signed roster after completed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Jun 13, 2025

Reporting Requirements(a) ... (1) A written report shall be submitted to the licensing agency…within seven days of the occurrence of any of the events specified in (A) through (D) below.... (B) Any serious injury as determined by the attending physician and occurring while... the resident is under facility supervision. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. The Licensee did not submit incident reports for numerous falls for R1 and R4,...the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: Administrator agrees to update their reporting protocol and conduct a staff training of the protocol. Administrator will email LPA documentation and a signed staff roster off all training participants on or before 6/13/2025. the resident is under facility supervision.

Allegation investigated: Staff did not prevent resident from being financially exploited. Staff did not safeguard resident's personal belongings.

At 8:20am on 05/30/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to issue final finding to the allegations to this complaint. LPA met with facility Resident Care Coordinator (RCC) Verinoca Guinea at 8:36am, announced he he is and reason for the visit. RCC called Administrator, Robin Murray and Administrator arrived at 8:50am. LPA Hanner-Tommasko arrived at 9:15am to address a seperate complaint and final findins on a sperate report. LPA deliverd the final findings to RCC and Resident Care Supervisor, Noemi Jimenez (RCS). As to the allegation of, “Staff did not prevent resident from being financially exploited.” and “Staff did not safeguard resident's personal belongings.” It was alleged that, sometime during the months October and November of 2024, Resident 1’s (R1) Medicare Card went missing from R1’s wallet, furthermore, R1’s hearing aids and cell phone went missing by the month of February 2025. Additionally, R1 was fraudulently charged for 12 unauthorized physical therapy sessions, charged from 12/09/2024 through 01/04/2025, that did not take place. CONTINUED on LIC9099-C Substantiated It was discovered in an interview with Facility Administrator, Robin Murray, on 04/30/2025, and email on 05/05/2025, that she had recalled, “Approximately in late November 2024, Mr. Grover, (Chris Grover, PT) came into the community and introduced stating that he worked next door (Lompoc Skilled Nursing & Rehabilitation [SNF]) and wanted to know if we (Fountain Square) had anyone who needed outpatient Therapy services. Administrator also stated that, Mr. Grover was introduced to the facility, Resident Care Coordinator (RCC), and was informed to always check in with the RCC as many family members are the Resident's decision makers. Administrator also stated, “one encounter, I was informed from my staff that he was only seen a couple of times, and for less than a five-minute period. One time I saw him walk in and looked for him and he had already left the community.” Administrator stated that they communicated with the Skilled Nursing Facility (SNF) next door as to PT being conducted by Chris Grover and it was determined that Mr. Grover was not an employee of the SNF, but a per Diem therapist. Administrator stated that they made a phone call to Chris Grover (date unknown, during the month of February 2025), telling him, “I told him we have no vendor contract with him, there is no solicitation in our community or generally in ALs as well, and that he is not allowed in the community.” On 05/02/2025 and again on 05/09/2025 Licensing Program Analyst Jeffries (LPA) reviewed all facility resident and visitor sign in logs dating from November 15, 2024, through January 20, 2025, provided by email on 05/05/2025 by Administrator, and noted that there were zero sign-ins by Chris Grover during that time period. LPA also noted that all visitor sign-ins to see R1 were all sign-ins by family members of R1 with no other noted visitors for R1 on the facility sign in logs during that time period. On 05/29/2025 LPA contacted Administrator by phone to confirm that all sign-in by the name “Chris” or “Christopher” were not Chris Grover, this was confirmed by email on same day. LPA Jeffries reviewed R1’s medical billing from December 9, 2024, though January 4, 2025, with 12 physical therapy visits billed to R1 resulting in a total of $5732.19; $2215.60 paid to Chris Grover; $2956.92 paid by insurance companies; and $559.67 paid as a co-pay fee. LPA noted that these invoices indicated that they were authorized by Doctor #1, who is R1 attending Physician. On 04/30/2025 LPA Jeffries conducted an interview with R1 Power of Attorney (W1) who stated that they had contacted Doctor #1’s office to determine if there was an authorization for Physical Therapy Services. W1 stated that Doctor #1’s office denied authorizing PT referral and had no documentation indicating those PT services were authorized through Doctor #1’s office. W1 state that they did not know who Chris Grover was, and as POA to R1 did not authorize him to conduct PT services at any time. CONTINUED on LIC9099-C W1 stated that they do not know how Chris Grover knew who R1’s Primary Care Physician was but suspected that the missing Medicare card, and Administrator stating to W1 that Chris Grover had been seen coming out of R1’s room. W1 stated that R1 receives PT through the Veterans Affairs Office (VA) outside of the facility. On 05/29/2025, LPA Jeffries conducted a phone interview with Resident 2 (R2) family member (W2) and POA of R2, who stated that, Chris Grover billed R2 for 13 sessions of PT that were unauthorized. W2 stated that they called R2’s primary care physician, Doctor #2, who was listed as the referring Physician, who stated they did not authorize any PT session to Chris Grover. W2 stated that the facility helped them dispute the charges but as of 05/29/2025 have not received any verification if those charges were refunded. W2 stated that they did know Chris Grover and did not authorize him to provided PT services to R2 at any time. W2 stated that they did not know Chris Grover and not know how he knew personal or medical information of R2. W2 stated that Chris Grover did speak with R2 briefly in the facility but did not know or recall what information was shared. LPA observed facility communication record to Doctor #2, dated 04/30/2025 requesting PT referral for R2, with a response of, “Do not have a record of this.” LPA noted that two residents (R1 and R2) both have a diagnosis of cognitive impairment and have different primary physicians. On 03/17/2025, at 4:00pm, 04/03/2025 at 12:15pm, and 04/30/2025 at 9:00am LPA Jeffries entered the facility unscreened by staff, and had to walk the halls of the facility to find staff in order to check into the facility. Based on, interviews, observations, documentation of facility log-in records that had no record of sign-in of Chris Glover, in which his presence at the facility was confirmed by Administrator statements and emails, observations of LPA on 3 facility visits of no staff to screen who is entering or exiting the facility, documentation of fraudulent bills for R1 and R2, and documentation of different residents detailed medical information in flatulent billing invoices. Due to lack of staff screening the entrance to the facility, reasonable efforts to safeguard resident property (and medical information) were not made and therefore, there is enough evidence at this time to support the allegations of “Staff did not prevent resident from being financially exploited.” and “Staff did not safeguard resident's personal belongings.” and are both substantiated at this time. Exit interview, report read, citations issued, appeal rights and report provided.the state’s words, verbatim · CDSS document, May 30, 2025 · control 29-AS-20250425142414

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a)(2) · Plan of correction due date: Jun 13, 2025

87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program...(2) A licensee who fails to make reasonable efforts to safeguard resident property,... The licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in Section 1569.153. This requirement was not met by evidence of lack of screening of uncleared staff and vendors, which puts residents in potential danger.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: Administrator will start the recruting and hiering process for a front desk receptionist to help with screening residents, vendors, and visitors.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(25) · Plan of correction due date: Jun 13, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (25) To protection of their property from theft or loss according to Health and Safety Code ... This requirement was not met by evidence of several missing property items of Resident 1, which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: Administrator argrees to have a one hour training for all staff on personal rights and safeguarding residents property and information.

Allegation investigated: Staff does not ensure residents call buttons are in good repair.

At 12:15pm on 04/03/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the initial investigation visit to the allegation to this complaint. LPA met with Administrator, Robin Murray announced who LPA is and the reason for the visit. LPA conducted interviews with staff and residents. LPA collected documentation relative to the allegation to this complaint and issued final findings. As to the allegation of, “Staff does not ensure resident call buttons are in good repair.” It was alleged that, "The pendant system has been down and not working for almost 2 weeks now (04/03/2025).” It was discovered by documentation and interviews that, on 04/03/2025, LPA Jeffries conducted an interview with facility Administrator, Robin Murray who stated that approximately two weeks ago (starting about 03/17/2025) the facilities pagers, used with the signal system had intermittent problems in identifying the wrong room number of residents. On 03/25/2025 the pendant system went down. On 03/26/2025 the facility maintenance supervisor, Sergio Herrera contacted Care Worx and an IT Tech regarding pendants registering/noting the specific caller accurately. CONTINUED on LIC9099-C Substantiated On 03/28/2025, Administrator Robin Murray contacted LPA Jeffries via email and noted that the system had been down and there is a loaner system in place on 03/26/2025, while the main system is being repaired and 1-hour checks were be conducted by facility staff. Administrator Robin Murray stated that the loaner system had also been alerting inaccurately reporting the wrong room numbers. Administrator Robin Murray noted that the pull strings in each room were also not working and reporting correctly. At this time there is enough evidence to support the allegation of, “Staff does not ensure resident call buttons are in good repair” and is substantiated at this time. Exit interview, report read, report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 29-AS-20250403091059

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(C) · Plan of correction due date: Apr 17, 2025

87303(i)(1)(C)Facilities shall have signal systems which shall meet the following criteria:(1)All facilities licensed for 16 ...shall have a signal system which shall:(C)Identify the specific resident living unit..This requirement was not met by evidence of Administrator admitting and reporting signal system malfunction. Which poses a potential risk to resident in carethe state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: Administrator and Maintenance Supervisor are currently programming each pendant on 04/03/2025. 8 of 32 pendants are programmed at time of investigation visit. Administrator is to check and assure all pendants are reporting accurately and report back to LPA by email on or before 04/17/2025.

Type of visit: Case Management - Incident

At 4:00pm on 03/17/2025, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct an Case Management Visit pertaining to the incident and subsequent reports on 03/09/2025 at approximately 9:15pm of Resident 1 (R1). LPA met with Community Relations Director, Sarah Kau (S1) announced who he is and the reason for the visit. LPA requested R1 full file including but not limited to R1’s LIC602 (Physicians Reports), Pre Admissions appraisal, Appraisals Needs and Services Plan, Resident contact information, and all resident file information. S1 and LPA conducted a physical tour of the facility and took photographs. There is no further information to report on this Case Management Visit. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Mar 17, 2025

Type of visit: Required - 1 Year

On 12/12/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility above to conduct an unannounced evaluation visit. When the LPA arrived, they were greeted by Administrator Robin Murray and Community Relations Director Sarah Kau. LPA informed facility representatives of the reason for the visit upon entry. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE). This facility is approved for a maximum capacity of one hundred thirty (130) residents. All residents licensed and approved for non-ambulatory status, of which ten (10) may be bedridden. Facility is approved for delayed egress, with an approved hospice care waiver for twenty (20) residents. The facility has a main kitchen for residents of the facility, and two (2) dining rooms. One (1) dining room is specifically for the Assisted Living residents of the facility, and the other dining room is for the Memory Care residents of the facility. The LPA inspected the food service areas in the facility and observed that items which could constitute a danger to residents are kept inaccessible to residents in the kitchen area. All appliances were in operable condition and looked clean/in good repair. Appliances such as microwaves, refrigerators, stoves, etc. are clean and operating properly. Food utensils, dishes, glasses, etc. are clean and in good repair with no cracks or chips. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. LPA observed an appropriate/adequate amount of perishable and non-perishable food items maintained in the facility. Furniture is room/resident appropriate, clean and in good repair. All rooms are appropriately furnished for their intended use such as bedrooms, common areas, etc. Hot water temperature is maintained as per Community Care Licensing (CCL) Title 22 regulations. Outdoor activity spaces have shaded areas and furnished for outdoor use. Each resident has an adult bed with a mattress, pad, bedsprings, and pillow, which are clean and in good repair. Each bed is fitted with sheets, pillowcase, blankets, and bedspread that are clean and in good repair. Continued on 809-C Each resident has adequate dresser and closet space for clothing and other belongings that includes at least two drawers or adequate dresser space. The facility has a sufficient supply of linens to permit weekly changing or more often to always ensure clean linens for residents. Equipment and supplies for resident personal hygiene is available and on site. Activity supplies are available for residents. As the facility has an approved fire clearance for a maximum 130 residents, a signal system was observed by LPA and required by the Licensing Agency. Refrigerators and freezers are maintained at an appropriate temperature Fahrenheit as per CCL regulations. Food storage and preparation areas are clean and appropriate for food preparation. The food service areas are clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. Central storage of resident medications was observed by LPA, inaccessible to residents. Cleaning supplies are kept in areas separate from where food supplies are stored. Walls, ceilings, floors, carpeting, window screens, and areas around the facility are clean, painted and/or in good repair. There are locked storage area(s) for poisons, toxic, cleaning solutions, disinfectants, etc. Fire extinguishers and smoke detectors operate properly. Doors and passageways are unobstructed. There are no pools/bodies of water on the physical plant of the facility as observed by LPA. During the inspection, LPA did not observe any firearms that would require trigger locks, locked and inaccessible, or firing pins removed. Facility physical plant includes enhanced supervision for resident wandering/elopement through delayed egress measures including installation of operational audio devices on doors to alert staff when doors are opened. The entrance to the facility has a main lobby with sign in materials. There is an assisted living dining room with an attached kitchenette. The facility contains resident bedrooms, assisted living common areas, and memory care common areas. Facility is appropriately furnished, with all furniture being in good condition. There are multiple fireplaces on the premises, which were all covered and inaccessible. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity supplies and equipment, including activity materials for the residents. All window screens were in good repair. There is appropriate lighting in the common areas of the facility. All passageways through the common areas of the facility were free of obstruction. Carbon monoxide detectors were operational at the time of the visit. The fire extinguishers were fully charged and serviced annually. The facility maintained a comfortable temperature in all areas inspected. LPA did not observe any noticeable outdoor hazards. Outdoor activity spaces in the facility are shaded and equipped with furniture for resident use. Facility has additional supplies/emergency supplies. Contd. 809-C The designated laundry area in the facility has appropriate storage of cleaning products, which are kept locked and inaccessible to residents. Emergency food and water in storage were observed to be in good condition by the LPA. Cleaning supplies, disinfectants, and other items that could pose a danger are kept in areas inaccessible to residents. Vehicles used to transport residents are in safe operating condition with appropriate insurance information. The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms in the facility were sufficiently stocked with soap, paper towels, required postings, and clean trashcans with closed lids. Towels and washcloths are not shared by residents in the facility. The hot water temperature was measured in the restrooms at the appropriate temperature per Title 22 regulations. There are an adequate number of toilets per residents in the facility. Nightlights are installed as observed by LPA. All toilets and hand washing areas are maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences are available accommodate any physically handicapped residents who need such items. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The facility has provisioned to each resident of furniture, equipment and supplies necessary for assistance in personal care and maintenance of personal hygiene. An emergency exiting plan and emergency phone numbers are posted in an appropriate place. First-aid supplies, which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual, are maintained. Administrator’s records, employees and resident records are maintained at the facility and available for review by the LPA as employees are hired and residents accepted into the facility. The facility complies with CCL standards for health screening, staff training, criminal background clearance and transfer requests. LPA observed one (1) employee missing a health screening/TB test results in their personnel file. Admission agreements and needs and services (ANS) plan are maintained for each resident and/or their authorized representative. Resident records are maintained on the facility premises in a secured area. Centrally stored medications are locked inaccessible to residents. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. The facility administrator meets the qualifications as specified in Title 22 regulations with a pending renewal RCFE administrator certificate. Provider Information Notices are available and able to be presented to Staff, residents, visitors, and accessible to LPA upon request during the inspection process. Exit interview conducted by LPA. Copy of this report provided to the facility.the state’s words, verbatim · CDSS document, Dec 12, 2024

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: Due to lack of supervision, resident hit resident

On 11/07/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent complaint investigation visit to deliver final findings for the above allegation. During this visit, LPA met with Administrator Robin Murray and explained the reason for the visit. On the allegation: Due to lack of supervision, resident hit resident. It is alleged that when R1’s responsible party visited them in care at the facility they were not properly supervised. It is also alleged that the responsible party of Resident #1 (R1) was contacted by the facility to inform them that R1 had been hit by another resident in care. When R1’s responsible party visited the facility after receiving this information, they observed R1 with a bruised and swollen face, allegedly from being hit by another resident. Continued on 9099-C Substantiated LPA confirmed through interview and record review that R1 was admitted to the facility above on 08/29/2024 and discharged by their responsible party on 09/19/2024. LPA requested and received Documented Narrative Charting by the facility for R1 while in care. On 09/19/2024, staff documented that R1 was involved in an altercation with another resident. According to facility staff, R1 was struck by another resident in the face which caused R1 to begin bleeding. Facility staff documented that an incident report was completed, but the Licensing Agency has not received any unusual incident/injury report (UIR) regarding R1 while in care. Through interview with LPA, it was stated that the responsible party of R1 visited the facility in September 2024 and observed R1 outside in the courtyard area of the facility wearing little clothing and shivering due to the cold. Staff documented in facility narrative charting that upon admission on 08/29/2024 R1 was an elopement/wandering risk. The Needs and Services Plan for R1 states the need for standby assistance from staff due to R1 being a falling risk and that R1 needs secure memory care due to a history of wandering and exit seeking behavior. Staff found R1 sleeping in another resident’s room on multiple occasions including 08/29/2024 and 08/31/2024. Staff also stated that on 09/10/2024, R1 needed to be redirected multiple times to leave another resident’s room after staff were notified by another resident that R1 was in their room. According to facility staff and narrative charting, on 09/16/2024, R1 had an unwitnessed fall while attempting to use the restroom alone. The Licensing Agency did not receive any unusual incident/injury report (UIR) for R1 while in care including the unwitnessed fall incident on 09/16/2024, nor the physical assault by another resident on 09/19/2024. Facility documentation states the need for R1 to have enhanced supervision due to being a falling risk as well as an elopement/wandering risk. However, multiple incidents involving R1 occurred in the facility which would not have happened with appropriate supervision by staff. Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated. Exit interview conducted. Copy of this report provided to facility. R1's responsible party stated that when they bathed R1 after discharge, there was dried feces all over the backside of R1. Documented Narrative Charting by the facility for R1 stated that on 09/18/2024, R1 was observed by staff to have soiled themselves in bed, which soaked through their mattress. R1’s resident assessment and R1’s needs and services plan both indicated that R1 required stand by assistance while bathing/showering 7 times per week. The resident assessment also stated that R1 bathes themselves with standby assistance daily in the afternoon. All staff interviewed by LPA indicated that resident assessments are followed, and all residents are bathed/showered regularly. All residents interviewed by LPA indicated they are bathed appropriately at the facility. LPA observed residents in the facility during complaint investigation visits on 10/11/2024 and 11/07/2024. During both visits, LPA did not observe any residents with dirty clothing, unwashed/greasy hair, and did not smell any noticeably unpleasant odors on any resident. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. On the allegation: Staff overmedicated resident. It is alleged that relatives of R1 felt they were overmedicated by the facility while in care due R1’s observed physical and mental state. LPA requested and received medical information for R1 while in care at the facility including the current medication record for R1 maintained by their primary care physician (PCP). LPA also received the medication orders and instructions provided by R1’s PCP with the listed medications prescribed dosage, symptom/reason, and quantity. LPA conducted record review of the individual narcotic record for R1 while in care at the facility. The individual narcotic record provides the name and directions for the medication, date and time provided, dosage, staff signatures, and amount remaining. LPA additionally reviewed the centrally stored medication and destruction record for R1 while in care at the facility as well as the medication release documentation for overnight visits and respite discharges. Record review of all medication information provided by both the facility and the PCP of R1 showed no evidence of any overmedication occurring by the facility to R1. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. Continued on 9099-C On the allegation: Staff did not safeguard resident’s belongings. It is alleged that when R1’s responsible party visited the facility in September 2024, R1’s shoes were missing and R1 was allegedly wearing other residents’ clothes. It is also alleged that R1’s responsible party brought a lot of clothing and belongings to have in the facility prior to admission. However, when R1 was discharged, the facility could not find any of R1's belongings and they were never returned. LPA requested and received the contents of R1’s facility file/record. However, there was no documented LIC 621 form Resident Personal Property and Valuables. LPA interviews with facility staff stated that R1 and/or their responsible party declined to provide a documented inventory upon entry into the facility. All staff interviewed by LPA stated that R1 had the items/belongings in their bedroom returned to them upon discharge from the facility on 09/19/2024, and that any item which could not be found was replaced promptly by the facility. LPA found no evidence through all interviews in the facility and record review of facility documentation that staff did not return R1’s belongings or replace R1's belongings upon discharge from the facility. Facility staff stated to LPA that a pair of R1's shoes were unable to be located, but stated that staff purchased a replacement pair of shoes for R1. LPA was provided evidence that R1 had their shoes replaced by the facility in an appropriate time frame. LPA additionally interviewed facility staff about R1 wearing other residents’ clothes while in the facility, but all staff interviewed stated that they did not witness R1 wearing other residents’ clothes. Facility narrative charting did document that R1 occasionally slept in other residents’ rooms and would have to be redirected to leave other residents rooms on multiple occasions, but there is no documentation of R1 wearing other residents clothing. Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated. Exit interview conducted. Copy of this report provided to the facility.the state’s words, verbatim · CDSS document, Nov 7, 2024 · control 29-AS-20241007151923

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 8, 2024

87468.2(a)(4) Add’tl Personal Rights of Residents…(a) …residents in...RCFE shall have all following personal rights: (4) To care, supervision, and services that meet individual needs delivered by staff sufficient in numbers, qualifications, and competency to meet needs. This requirement is not met based on interviews and record review, licensee did not comply with the section cited above when staff failed to provide appropriate supervision to Resident #1 resulting in multiple incidents which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: The licensee will take appropriate measures to maintain and increase staffing in the facility. Licensee will also provide training to all staff on resident personal rights including supervision and neglect.

Type of visit: Case Management - Deficiencies

On 11/07/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced Case Management-Deficiencies visit. LPA arrived at the facility, met with Administrator Robin Murray, and announced the purpose of the visit. On 09/16/2024, Resident #1 (R1) sustained an unwitnessed fall while attempting to use the restroom, causing back and leg trauma. R1 stated to facility staff that they slipped and fell hurting their leg. R1 denied any pain medication and any medical treatment. The facility contacted the primary care physician for R1 who documented for the resident to continue their current plan of care. On 09/19/2024, staff documented that R1 was involved in an altercation with another resident. According to facility staff, R1 was struck by another resident in the face which caused R1 to begin bleeding. Facility staff documented that an incident report was completed, but the Licensing Agency has not received any unusual incident/injury report (UIR) regarding R1 while in care. On 11/07/2024/2024, LPA interviewed Staff about the lack of received Incident Reports to the licensing agency regarding either the incident on 09/16/2024 or 09/19/2024 occurring in the facility. The facility above has previously been cited for deficiencies regarding reporting requirements to the licensing agency on 07/11/2024. The facility will be cited for deficiencies regarding Reporting Requirements to the licensing agency. Exit interview conducted, a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 7, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Dec 5, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report submitted to licensing agency…within seven days...(D) Any incident that threatens welfare, safety or health of any resident This requirement was not met based on interviews and record review; licensee did not comply with section cited above when Licensing Department did not receive incident reports regarding a resident fall and physical altercation which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: Licensee agrees to submit Incident Reports to the Licensing Agency regarding any incident that threatens the welfare, safety, or health of any resident. The licensee will submit a plan describing how the facility will ensure reporting requirements are followed.

Allegation investigated: Facility staff did not meet resident's needs Facility has insufficient staffing Facility did not contact responsible party about a change in condition Facility is not reporting incidents

Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent case management-incident investigation visit to deliver final findings for the above allegations. During today’s visit, LPA Phillips met with Administrator Robin Murray and explained the reason for the visit. On the allegation: Facility staff did not meet resident’s needs. It is alleged that a visitor to the facility observed a long stream of water running down the hallway coming from the shower door in the facility. Allegedly there was no response when the visitor knocked on the shower door, and facility staff could not be located. When staff were finally located, Resident #1 (R1) was on a shower chair, with two (2) inches of water on floor. R1’s washcloth had fallen on the drain. Allegedly facility staff stated R1 was fine, and very independent. It is alleged that if R1 passed out and fallen they would have drowned. Staff stated R1 was there for approximately five (5) minutes, but other accounts allegedly said 20-25 minutes is how long it would have taken to flood that much. Continued on 9099-C Substantiated On 04/12/2024, LPA conducted an initial facility site visit for a complaint investigation into the allegations above. LPA interviewed residents, staff, and conducted record review of relevant documentation to the allegations. According to staff interviewed by LPA, on 03/28/2024, R1 had asked staff to get blankets because they were in cold water for a while. Staff interviewed by LPA stated they couldn’t tell how long R1 was in the shower. The staff stated to LPA that R1 was not unconscious or slumped over, but just was in cold water for a brief period. Staff interviewed by LPA stated that R1 should not have been in that shower location because it’s supposed to be closed as the drain clogs. The administrator of the facility stated R1 wasn’t supposed to be in that location, and that R1 has been told not to use that shower before, because it’s broken. The administrator additionally said R1 was taking a shower and dropped the washcloth. Staff stated to LPA that after the shower incident R1 was in their room with numerous blankets on, shivering. Staff interviewed by LPA stated that R1 had been in the shower, freezing cold, trying to warm up. Staff stated to LPA that R1 should never have ambulated from their room to the shower, with no walker present. LPA requested and received relevant facility documentation pertinent to the allegation. Through record review, the Physician’s Report for R1 dated 01/30/2024 states that R1 has the capacity for self-care including bathing and dressing/grooming. R1 has a secondary diagnosis of unspecified visual loss as well as a history of falls documented in the Physician’s Report. The mental condition of R1 is listed as confused/disoriented, but R1 has no documented wandering, aggressive, sundowning, or inappropriate behavior according to the Physician’s Report. Additionally, R1 has a documented physical health status of motor impairment/paralysis with an unsteady gate and refusal to use a walker. The Resident Appraisal of R1 dated 02/03/2024 states that R1 can care for themselves physically with the ability to understand and communicate their needs. The 02/03/2024 Resident Appraisal of R1 does state that R1 has had a decline in mental condition and cognitive changes. R1 is also documented to need required grab bars in the bathroom for safety but does not need help with bathing. However, the Resident Appraisal states that R1 does need help setting up a new environment when bathing. The 03/09/2024 Needs and Services Plan for R1 indicates that R1 has independent bathing during the morning (AM) everyday Monday-Friday. R1 is listed as able to shower on their own. Staff do need to set up the shower to ensure safety in a new environment. Staff will monitor R1’s hygiene for changes and staff should notify the home health agency representative if R1 requires assistance. R1 moved into the facility on 02/04/2024 due to anticipated decline related to a diagnosis of cancer and hospice needs. The Assisted Living Advantage Resident Assessment for R1 dated 01/25/2024 states that R1 bathes independently and showers on their own without reminders, stand-by assistance from staff, or total assistance from staff. Continued on 9099-C Documented Narrative Charting by the facility indicates that on 03/25/2024, R1 stated to staff that they fell out of their bed but denied any pain. The narrative charting states that R1 needs to be checked on more often. On 03/28/2024, R1 received a hospital bed and requires full assistance including the changing of briefs. Also, on 03/28/2024 narrative charting stated R1 was found on the ground in the bathroom, looked “out of it” and very pale. Home health agency services were requested. On 03/29/2024, R1 was found on the floor by the kitchen area of the facility and helped back to their bed by staff. Additionally, on 03/29/2024, R1 was found multiple times trying to walk around their room with an unsteady gait and lacking balance. A bedside commode had been ordered for R1 a week prior to the 03/28/2024 incident in the shower. According to interviews by LPA, the facility had installed the commode on top of the toilet without the basket. Eventually the basket was found, and staff were educated it should be bedside. R1 received a hospital bed and staff were informed to make sure the bedrails were up. On 03/29/2024, R1 fell out of the hospital bed, and staff were again informed the bedrail needs to be up on the bed. Staff were educated by home health agency representative on how to keep bedrail up, check on R1, and turn R1. Home health agency also provided a bed alarm for R1. On 04/04/2024, R1 had another fall from the bed with the bedrail not up as instructed and no alarm. The facility administrator stated that the bed alarm is not working anymore for R1, and they must have taken the battery out themselves. On 04/10/2024, Witness #1 (W1) visited the facility and observed R1 uncovered by their blanket, with a bruise on their hip. W2 stated to LPA that when asked about the bruise, R1 stated that they had fallen again. W1 stated to LPA that the bed alarm is supposed to be attached to R1’s bed, but it was under bed with the battery cover open and battery gone. Staff were unable to find batteries or cover piece for bed alarm. W1 stated to LPA that they were told by the administrator that R1’s home health agency needed to provide another alarm. W1 stated to LPA that they observed the bedrails on R1’s hospital bed not in the highest position and were crooked. W1 stated that R1 would not be able to move the bedrails on their own. Based on the information obtained, there is sufficient evidence that facility staff did not meet resident’s needs. Therefore, the allegation is deemed Substantiated at this time. On the allegation: Facility has insufficient staffing. It is alleged that the facility is understaffed which is detrimental to the care of residents. The allegation states that if the facility feels that they do not have enough staff to provide the care R1 needs, they need to alert outside agencies. It is alleged that there are not enough staff in the facility, and it was not a good idea for R1 to have moved in. Continued on 9099-C On 04/12/2024, LPA conducted an initial complaint investigation visit to the facility above. During this visit, LPA requested and received relevant facility documentation pertinent to the allegation. Through record review of the facility staff roster and the facility staff schedule, as well as LPA interviews with current staff, LPA was informed that the facility has been in the process of a staffing hire for multiple positions throughout 2024. The facility staffing hire was stated to LPA to be in response to vacant employment positions in the facility. On 08/29/2024, LPA conducted a subsequent complaint investigation visit and observed facility postings advertising hiring positions. Staff interviewed stated that many new positions have been hired in the facility in June and July of 2024. This was corroborated through record review of the current staff roster and schedule during the 08/29/2024 visit by LPA. Through staff interview by LPA, the facility is aware of the disadvantages of being potentially understaffed and have been actively trying to correct this through hiring multiple new employees. No resident interviewed by LPA in either the Assisted Living or Memory Care portion of the facility indicated that any of their Activity of Daily Living (ADL) needs are not being met by facility staff due to a lack in staffing. Based on the information obtained, there is sufficient evidence that the facility has insufficient staffing. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Facility did not contact responsible party about a change in condition. It is alleged that the facility did not inform the Power of Attorney (POA) for Resident #1 (R1) about a change in condition. The allegation states that R1 was independent when admitted into the facility, but is no longer independent. Through record review, LPA learned through the Physician’s Report for R1 dated 01/30/2024 that R1 has the capacity for self-care including bathing and dressing/grooming. On 03/28/2024, R1 experienced an incident regarding lethargy and disorientation while bathing/showering. R1 then agreed to a home health agency evaluation and a change in postural supports as well as medication. Through interview and record review by LPA, on 04/03/2024 the POA for R1 was contacted by Witness #2 (W2) regarding a change in condition for R1. The POA for R1 was unaware of the incident regarding R1 on 03/28/2024 or R1’s change in condition. Staff indicated R1 was lethargic due to home health agency hospice care. On 03/31/2024, W2 visited the facility and observed R1 in bed and lethargic. Through interview with staff, LPA was told that R1 was declining and needed an evaluation by a home health agency. W2 tried to confirm the POA of R1 would be aware of the change in condition. Through interview by LPA, it was stated the home health agency representative let the POA of R1 know about the change in condition. Continued on 9099-C W2 informed the facility that the POA needs to be informed of a change of condition by the facility as well. Based on LPA interviews with staff and records review, facility staff seemed unaware on the need for the facility to inform the responsible party of R1 about a change in condition. Based on the information obtained, there is sufficient evidence that the facility did not contact responsible party about a change in condition. Therefore, the allegation is deemed Substantiated at this time. On the allegation: Facility is not reporting incidents. It is alleged that multiple service providers from agencies collaborating with the facility believe the facility does not appear to be reporting incidents to Community Care Licensing Division (CCLD). Through interview with facility staff and home health agency service providers, LPA learned that Resident #1 (R1) had multiple falls on 03/29/2024, and a fall on 04/04/2024. CCLD has not received any Unusual Incident/Injury Reports (UIR) for any alleged falls in care since R1 was admitted into the facility above on 02/04/2024. On 02/09/2024, the Department received a self-reported Unusual Incident/Injury Report (UIR) regarding R1, but it did not concern any fall or injury in care at the facility. On 07/11/2024, LPA conducted a case management-deficiencies visit to the facility above. During the complaint investigation of complaint # 29-AS-20240627081510, the following deficiencies were observed: There were no incident reports submitted for Resident #2 (R2’s) hospitalizations on 06/02/2024 and 06/11/2024 due to non-epileptic seizures caused by oral medications prescribed to R2 for cancer treatment in combination with radiation chemotherapy. There was no UIR submitted to the Department on 06/12/2024 due to R2 being observed unresponsive and with no pulse by facility staff. There was no death report submitted for R2’s Death on 06/13/2024 while in the Critical Care Unit (CCU) of the hospital. Based on interviews and records review, licensee did not submit incident reports for R1’s falls while in care, R2's hospitalizations, or death report for R2. Based on the information obtained, there is sufficient evidence that the facility is not reporting incidents. Therefore, the allegation is deemed Substantiated at this time. Exit interview conducted. A copy of this report has been provided to the facility. No resident interviewed by LPA stated that facility staff members do not respond to call buttons timely. All residents interviewed stated that when a call button is pressed a staff member will respond to their needs. Residents stated to LPA that waiting times can vary depending on the time of day a call button is pressed, but there are not any delays that have inconvenienced the residents. During the 04/12/2024 initial complaint investigation visit to the facility above LPA attempted to request a documented call log from the facility listing date, time, wait length of call button responses by Staff. LPA was told that the facility did not have a documented log of call button responses for the facility. All staff members of the facility interviewed by LPA stated they make every attempt to answer call buttons in a prompt manner with no delays. Based on the information obtained, there is insufficient evidence that facility staff do not respond to call buttons timely. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of this report provided to the facility.the state’s words, verbatim · CDSS document, Sep 3, 2024 · control 29-AS-20240410083709

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 1, 2024

87411(a) Personnel Requirements-General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... to ensure provision of personal assistance and care This requirement is not met as evidenced by: Based on interviews and records review, licensee did not comply with section cited above by failing to have sufficient staff to meet the needs of residents, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2024

Plan of correction: The licensee has shown LPA appropriate measures to maintain and increase staffing in the facility, including job advertisements observed by the LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 1, 2024

87211(a)(1)(D) Reporting Reqs. Licensee shall furnish to licensing agency...including...(1) Written report submitted to licensing agency and to person responsible for resident within 7 days… (D) Any incident which threatens the welfare, safety or health of any resident… This requirement is not met as evidenced by: Based on interviews and records review, licensee did not comply with section cited above by failing to report an incident and change of condition in R1 to licensing and responsible pary, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2024

Plan of correction: The licensee has submittted a plan describing how the facility will ensure reporting requirements are followed. Submit proof to Community Care Licensing Division (CCLD).

Allegation investigated: Staff handle resident in a rough manner Staff are not providing resident with adequate drinking water Staff are not providing resident with adequate food service

On 08/23/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent complaint investigation visit to the facility above to deliver final findings for the above allegations. During today’s visit, LPA Phillips met with Community Relations Director Sarah Kau as the administrator was not available, and explained the reason for the visit. On the allegation: Staff handle resident in a rough manner. It is alleged that Resident #1 (R1) does not like to take showers because facility staff throw R1 in the shower and scrub the wounds on R1’s left lower leg that are provided treatment by an outside Agency on a regular basis. LPA conducted record review of facility documentation relevant to the allegation above. On 03/25/2024, a Physician Communication sent by the facility indicated that the facility staff were requesting specific Home Health Agency orders regarding the cleaning of R1’s lower left leg as R1 has cellulitis and is very combative when bathing and taking antibiotics. Continued on 9099-C Unsubstantiated On 04/17/2024, another Physician communication sent by the facility indicated that R1 had aggressive behaviors toward staff including trying to hit Staff with their cane and attempted to slam doors into staff members. There are frequent communications between the primary physician of R1 and facility staff during March 2024 and April 2024. The primary basis for these communications is the fact that R1 is extremely physically combative and aggressive with staff as well as refusing antibiotic medications for the lower left leg injury/wound. The facility has documentation asking the primary physician of R1 for home health agency orders regarding these issues and requesting guidance. The Skilled Nursing Facility (SNF) transfer orders for R1 into the facility above on 01/12/2024 indicated that R1 has a primary diagnosis of dementia with agitation and psychosis. R1 needed supervision and assistance with Showering/Bathing Activities of Daily Living (ADL) including staff providing physical steadying assistance, lifting, holding, supporting, and providing partial/moderate assistance. Narrative charting from the facility indicated that on 03/29/2024, R1 had a staff assisted shower and stated that staff members “dunked them in chemicals.” Staff members documented that R1 had the wounds on their lower left leg cleaned and had antibiotic cream applied by staff as well as bandages. On 03/23/2024, narrative charting by the facility stated that R1 was aided in the shower and R1 stated staff “intentionally put soap in their eyes and only used cold water.” Facility narrative charting from January 2024 through March/April 2024 indicates that R1 is very disruptive and combative to both staff and other residents while eating in the dining room and in the bathroom during grooming/bathing. All staff interviewed by LPA indicated that they provided antibiotic cream to the affected wounds on R1’s lower leg and cleaned/bandaged the area but did not scrub or touch the area in a rough manner. All residents interviewed by LPA stated that they have not had any issues with staff supervision and/or assistance during ADLs including bathing and/or grooming. Based on the information obtained, there was insufficient evidence that staff do not maintain a comfortable room temperature for resident(s). Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff are not providing resident with adequate drinking water. It is alleged that staff do not give R1 any water so R1 drinks water out of the faucet and if the faucet water were to get turned off, R1 would have to drink the toilet water. On 05/01/2024, LPA conducted an initial 10-day complaint investigation visit to the facility above. During this visit, the 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. LPA visually observed the dining/food service area as well as the kitchen area of the facility. Continued on 809-C The LPA inspected the kitchen/food service area and observed alternating choices for breakfast, lunch and dinner daily as well as an alternate menu choice form which does not change but has a number of choices including multiple options for drinks including water, milk, juice, coffee, soda, etc. and additional requests if the facility can accommodate the request. LPA observed the dining area for residents and noticed residents being served water and juice while LPA was at the facility. All residents interviewed by LPA indicated that they receive water and/or a specific drink during each meal and have never observed any resident being refused a drink. Staff interviewed by LPA stated that residents served meals at the facility have dietary requirements which are followed. Staff stated that residents are required to complete a facility form called the Dietary Order Clarification form which lists the resident name, room number, effective date of the dietary order, the resident requirements such as regular diet, controlled carbohydrates (NCS), Approximate levels of sodium (NAS), Finger foods, meals to be cut up prior to serving, mechanical soft, Pureed food, and/or thickened liquids. The Dietary order clarification form also lists what the resident is allergic to and/or if the resident is diabetic. The form has a space to list the Special needs of the resident and is signed by the Resident Care Director, Dining Services Director of the facility, and the Primary Physician of the resident. According to all staff interviewed by LPA, the facility follows dietary guidelines by the primary physician of the resident. Staff interviewed by LPA stated the facility provides a weekly menu to residents with daily changes, as well as a set menu that is not altered. Staff stated to LPA that whenever a resident has a change of condition regarding meals, the facility will document a Dietary Order Clarification to specify what the resident's primary care physician is changing in the resident's diet. The Skilled Nursing Facility (SNF) transfer orders for R1 into the facility above on 01/12/2024 indicated that R1 has a primary diagnosis of dementia with agitation and psychosis. Narrative charting by the facility from January 2024 through March/April 2024 indicated R1 was frequently verbally aggressive to both staff and other residents including shouting accusatory remarks. Based on the information obtained, there was insufficient evidence that staff do not maintain a comfortable room temperature for resident(s). Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff are not providing resident with adequate food service. It is alleged that staff only give Resident #1 (R1) vegetable soup to eat for every meal and R1 is tired of it. It is also alleged that staff only give R1 vegetable soup to eat because of R1’s teeth and dentures. On 05/01/2024, LPA conducted an initial 10 day complaint investigation visit to the facility above. During this visit, the 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. LPA visually observed the dining/food service area as well as the kitchen area of the facility. Continued on 9099-C The LPA inspected the kitchen/food service area and observed perishable food items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which was observed by LPA in the kitchen area of the facility. The freezer and refrigerator were both the appropriate temperate Fahrenheit for the storage of food and prevention of spoiling. Staff interviewed by LPA stated that residents served meals at the facility have dietary requirements which are followed. Staff stated that residents are required to complete a facility form called the Dietary Order Clarification form which lists the resident name, room number, effective date of the dietary order, the resident requirements such as regular diet, controlled carbohydrates (NCS), Approximate levels of sodium (NAS), Finger foods, meals to be cut up prior to serving, mechanical soft, Pureed food, and/or thickened liquids. The Dietary order clarification form also lists what the resident is allergic to and/or if the resident is diabetic. The form has a space to list the Special needs of the resident and is signed by the Resident Care Director, Dining Services Director of the facility, and the Primary Physician of the resident. According to all staff interviewed by LPA, the facility follows dietary guidelines by the primary physician of the resident. Staff interviewed by LPA stated the facility provides a weekly menu to residents with daily changes, as well as a set menu that is not altered. Staff stated to LPA that whenever a resident has a change of condition regarding meals, the facility will document a Dietary Order Clarification to specify what the resident's primary care physician is changing in the resident's diet. According to Staff and verified by LPA during facility record review on 05/01/2024, the Dietary Order Clarification dated 01/12/2024 for Resident #1 (R1) stated that according to the physician of R1, the resident requires all meals to be Pureed. This form was signed off on by the physician for R1 and facility staff. Staff stated to LPA that regarding meals for residents, there is a weekly menu which has alternating choices for breakfast, lunch and dinner daily as well as an alternate menu choice form which does not change, but has a number of choices including salads, items from the grill, items from the deli section, and additional requests such as yogurt or ice cream. Staff interviewed by LPA stated that R1 had recently seemed upset about the choices of food and had told staff that they preferred vegetarian choices. Staff stated to LPA that there is no record of R1 being a vegetarian by any physician orders, but that R1 was accommodated with vegetarian options of meals. LPA corroborated this accommodation to vegetarian options through record review of R1’s Dietary Order Clarification form and weekly menu guidelines. Based on the information obtained, there was insufficient evidence that staff do not maintain a comfortable room temperature for resident(s). Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of report provided.the state’s words, verbatim · CDSS document, Aug 23, 2024 · control 29-AS-20240423144138

Allegation investigated: Facility staff did not meet residents' needs

On 07/11/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Phillips met with Community Relations Director Sarah Kau as the Executive Director/Administrator of the facility was unavailable at the time, and explained the reason for the visit. On the allegation: Facility staff did not meet residents' needs. It is alleged that during a hospital visit, Resident #1 (R1) was observed to have feces on their backside, under their untrimmed nails, and on their arms. The allegation stated that neglect on the part of the facility staff was not believed to be happening purposefully, but rather due to the level of care needed by R1 and R1’s current living situation within the facility. Continued on 9099-C Unsubstantiated On 07/03/2024, Licensing Program Analyst (LPA) conducted a complaint investigation visit to the facility above. R1 was assessed by the facility in the preplacement appraisal on 02/26/2024 as in the process of beginning cancer treatment for Glioblastoma. In March 2024, R1 began concurrent treatment with chemotherapy radiation as well as oral medication for the cancer Gliobastoma multiforme/tumor. R1 and the facility were also informed that R1 needed to take the oral medications for the cancerous tumor on an empty stomach and that these medications had serious side effects. Physician notes for R1 from the oncology department of the hospital as well as R1’s primary care physician indicate on 05/03/2024 that R1 needed to modify and/or decrease certain oral chemotherapy medications due to having serious side effects which were warned about previously by the prescribing physician. LPA reviewed physician communications with the facility on 06/02/2024, R1 had been found lying in bed having a seizure and 911 was called. R1 was taken to the hospital and returned the next day with a diagnosis of a non-epileptic seizure caused by certain medicines taken by R1 for cancer or R1’s cancerous brain tumor. On 06/08/2024, R1 had continuous diarrhea which was very runny and had a horrible smell which was attributed to the side effect of the oral medications for cancer. On 06/11/2024, R1 was again taken to the hospital for a non-epileptic seizure in the facility which was attributed to a reaction from oral chemotherapy medications and/or R1’s cancerous brain tumor. Narrative Charting from the facility stated that on 06/12/2024 R1 was found unresponsive and with no pulse at night in the facility. CPR was started immediately and 911 was called. R1 was taken to the hospital and admitted into the Critical Care Unit (CCU). The family of R1 was notified and R1 passed away the next day on 6/13/2024. Staff interviewed by LPA stated that when R1 passed away, a physician was waiting for brain scan results to complete a pending Hospice Care admission. Through record review, LPA learned that on 05/31/2024 R1 was evaluated by Home Health Agency for Hospice Admission, but this process was pending at the time of R1’s death due a physician ordered MRI on R1’s brain being needed to complete the hospice admission process. Through interview with Staff and record review, LPA learned that severe diarrhea was one of the side effects of the oral medications R1 was taking for cancer treatment. LPA interviews with Staff also revealed that R1 was being seen weekly for radiation oncology at the time of death and had multiple seizures attributed to either a reaction to the oral chemotherapy medications or due to the brain tumor in R1. The non-epileptic seizures also caused R1 to have loss of bladder and bowel control. Through record review of Staff roster/schedule and interview, LPA was informed that the facility has been in the process of a staffing hire for multiple positions in June and July of 2024. Continued on 9099-C The facility is aware of the disadvantages of being potentially understaffed and have been actively trying to correct this through hiring multiple new employees. No resident interviewed by LPA in either the Assisted Living or Memory Care portion of the facility indicated that any of their Activity of Daily Living (ADL) needs are not being met by facility staff. Through Staff interview, LPA was told that R1 would have severe diarrhea and continuous runny bowel movements sporadically among other serious side effects as a result of the oral chemotherapy medication and that Staff monitored R1 to assist with hygiene, but the diarrhea could happen very suddenly and may have occurred while R1 was being transported to the hospital or while in the hospital which could not have been cleaned or assisted to by facility staff. Physician Reports for R1 on 06/02/2024 and 06/11/2024 stated that a symptom of R1’s non-epileptic seizures due to the cancerous tumor was loss of bladder and bowel control. As R1 was hospitalized on 06/11/2024 due to a non-epileptic seizure in the facility, a symptom of this would be loss of bowel control while being transported to the hospital or while in the hospital after 911 was called by the facility and paramedics arrived. Based on the information obtained, there was insufficient evidence that facility staff did not meet residents’ needs. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of this report provided to the facility.the state’s words, verbatim · CDSS document, Jul 11, 2024 · control 29-AS-20240627081510

Type of visit: Case Management - Deficiencies

On 07/11/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a case management-deficiencies visit to the facility above. During the visit, LPA Phillips met with Community Relations Director Sarah Kau as the Executive Director/Administrator of the facility was unavailable at the time, and explained the reason for the visit. During the complaint investigation of complaint # 29-AS-20240627081510, the following deficiencies were observed: There were no incident reports submitted for Resident #1 (R1’s) hospitalizations on 06/02/2024 and 06/11/2024 due to non-epileptic seizures caused by oral medications prescribed to R1 for cancer treatment in combination with radiation chemotherapy. There was no incident report submitted to Licensing on 06/12/2024 due to R1 being observed unresponsive and with no pulse by facility staff. There was no death report submitted for R1’s Death on 06/13/2024 while in the Critical Care Unit (CCU) of the hospital. R1’s representative was notified of R1’s hospitalizations and subsequent death. The facility acted appropriately in each instance to provide R1 appropriate medical attention. However, the licensee did not notify Licensing of the incidents or the death of R1. Exit interview, deficiencies cited, report given, appeal rights given.the state’s words, verbatim · CDSS document, Jul 11, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A),(B) · Plan of correction due date: Aug 8, 2024

87211a(1)(A),(B) Reporting Reqs. Licensee shall furnish to licensing agency...including...(1) Written report to licensing agency…within 7 days…(A) Death of resident...regardless where death occurred...(B) Any serious injury determined by attending physician..occurring to resident under facility supervision This requirement is not met as evidenced by: Based on interviews and records review, licensee did not comply with the section cited above. Licensee did not submit incident reports for R1's hospitalizations or death report for R1, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 11, 2024

Plan of correction: The licensee will submit a plan describing how the facility will ensure reporting requirements are followed. Submit proof to Community Care Licensing Division (CCLD) by 08/08/2024

Type of visit: Prelicensing

On 11/28/2023 Licensing Program Analyst (LPA) Brian Phillips arrived at the facility announced for a scheduled visit to conduct a required Pre-licensing facility site inspection visit at the Fountain Square of Lompoc facility due to a change of ownership. When the LPA arrived, they were greeted by Administrator Robin Murray, and informed them of the reason for the visit. At the time of arrival for the scheduled Pre-Licensing Inspection, there were 62 residents currently in care. This is a Pre-Licensing inspection visit to a currently operating facility due to a change in ownership. The 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. This facility is a Residential Care for the Elderly (RCFE) that consists of assisted living and memory care portions of the facility. The facility has an age range of 60 years and older for all residents in care. The facility fire clearance is approved for one hundred thirty (130) total residents, one hundred and twenty (120) of which are non-ambulatory and ten (10) of which are bedridden. The pending license is requesting twenty (20) residents for hospice waivers, ten more than the approved hospice waiver for the current license. The facility is approved for delayed egress in the memory care unit section of the facility. KITCHEN(S): The facility has a main kitchen for residents of the facility, and two (2) dining rooms. One (1) dining room is specifically for the Assisted Living residents of the facility, and the other dining room is for the Memory Care residents of the facility. The individual dining room areas in the memory care segment of the facility and the assisted living segment of the facility are closest to the resident bedrooms that section serves. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in the kitchen are inaccessible to residents. Kitchen appliances were in operable condition and looked clean/in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last 7 days. Additional perishable food items were maintained on a shelf and/or an extra freezer. The hot water temperature was measured at an appropriate temperature as per the regulation. Heating devices such as stoves are inaccessible to residents as are potentially dangerous items. Continued on 809-C The kitchen was clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The freezer and refrigerator were both in the appropriate temperate Fahrenheit. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. The facility also has a kitchenette area off the main assisted living dining room area. This kitchenette is inaccessible to residents by locked door, but there is a viewing window in which residents can approach to receive food. COMMON AREAS: At the time of the visit, the main lounge(s) and dining room(s) were observed to be appropriately furnished, with all furniture in good condition. The entrance to the facility has a main lobby with sign in materials as well as COVID screening procedures. There is an assisted living dining room with an attached kitchenette. The facility itself is shaped in an enclosed square like design with resident rooms making up the borders while the assisted living common areas, and memory care common areas/courtyard make up the interior. There is a lounge area for residents off the main dining room and main lounge that is appropriately furnished, with all furniture being in good condition. There are multiple fireplaces on the premises, which were all covered and inaccessible. There are activity materials in the common areas of the facility in good repair and operating condition. The facility maintains a grand piano, popcorn machine, and multiple rooms for resident activity. These rooms include a lounge room, salon room, and sensory room. The facility maintained a comfortable temperature in all areas inspected. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit in each of the buildings inspected. The fire extinguishers in all buildings inspected were fully charged and were last serviced in 2023. The LPA observed required postings throughout all common spaces including Resident Personal Rights and Resident Council Rights. There are activity supplies and equipment, including reading materials for the residents in all common areas inspected. All window screens were in good repair in all the areas comprising the facility. There is appropriate lighting in all the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all ramps are well-lit with sturdy hand railings/stair chair accessibility devices. This facility is one (1) story throughout and therefore there are no stairways for residents to utilize. As the facility has more than 16 residents and is multiple stories, there is a signal system in place which was functional at the time of the inspection by the LPA. OUTSIDE/LAUNDRY/MISCELLANEOUS: The facility is completely enclosed with auditory delayed egress exits into and out of the memory care segment of the facility. Continued on 809-C There is a main entrance road into the facility and an administrative entrance area for visitors. The facility has walls surrounding the courtyard area of the memory care portion of the facility, with electronic combination delayed egress entrances/exits. The facility has outdoor activity spaces and is enclosed by a fence with self-closing latches and/or gates or walls. There are 2 side gates from the facility which are delayed egress self-closing. Auditory devices are in place to monitor exits, if exiting presents a hazard to any resident. The facility has an outdoor patio area for residents outside of the memory care dining room area. There are no bodies of water on the facility premises aside from a shallow fountain in the outdoor courtyard. Outdoor activity spaces and the dining patio for residents are equipped with furniture for resident use. Electronic devices are in place to monitor exits of the memory care building in the facility, if exiting presents a hazard to any resident. All outdoor areas with stairs, inclines, ramps, or open porches have accessibility ramps for residents, are well-lit, and have hand railings/grab bars. This is a facility with over 16 residents, therefore there is a designated laundry room where cleaning products are stored, which are kept locked. The laundry room is accessible through the main hallway of the facility which wraps around the memory care and assisted living areas of the facility. There was emergency food and water in a storage room/area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to residents are kept in areas inaccessible to residents. There are multiple first aid kits that include sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport residents are in safe operating condition with appropriate insurance information. BEDROOMS: The facility has resident bedrooms in the memory care and assisted living segments of the facility. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are 65 bedrooms that can be designated for 2 residents per bedroom to equal a total capacity of 130 residents. LPA inspected multiple rooms in both the assisted living segment and the memory care segment that houses residents. The bedroom for residents consists of a closet area for storage, a bed, and room for a couch and/or television with furniture. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assistive device such as a wheelchair or a walker. Each room has at the least a chair, nightstand, chest of drawers, and sufficient lighting. Each resident bedroom in the independent living segment of the facility is furnished with a smoke alarm/fire alarm system, emergency call system, and appliances for the residents. RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. Continued on 809-C There are non-private restrooms in the common areas of the facility that include showers for resident bathing needs. All restrooms inspected by the LPA had assisting equipment for residents including grab bars and/or non-skid surfaces. The bathrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees Fahrenheit. There are an adequate number of toilets and showers per resident in the facility. Nightlights are installed in the hallways outside of the common area restrooms. INFECTION CONTROL: Upon entry to each building, the facility has a central entry point for symptom screening and a sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate isolation rooms if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. The facility maintains a COVID-19 Health Care System Mitigation Playbook from the California Department of Public Health as well as an Emergency Preparedness Informational Form and Interim Guidance for Outbreak Management in Long-Term Care and Post-Acute Care Facilities. The facility maintains an Infection Control Plan as well as an Emergency Operations Program and Plan Manual with aspects pertaining to infection control. As of 09/21/2023, this facility had an infectious disease outbreak relating to numerous cases of positive COVID-19. Residents who tested positive were isolated according to the facility’s infection control plan, and enhanced cleaning procedures were implemented in 2023. RECORDS: The facility keeps confidential storage of personnel records and resident records on-site at the facility. Personnel records reviews were reviewed for, but not limited to LIC 501 personnel records, LIC 503 health assessments with Tuberculosis (TB) test results, Personnel Action Notice, Job Description with date of employment, LIC 9052 Employee Rights, LIC 508 criminal record Statements, criminal record clearances, first aid/CPR certification that is not expired, and the appropriate training. All staff member personnel records had the appropriate documentation with no expiration of any training. Resident records were reviewed for LIC 603 Pre-Admission/Placement appraisals, LIC 602 Physicians Reports, Consent Forms, Personal Rights for Residents, LIC 601 Emergency Information, LIC605A Release of Medical Information, PRN Authorization, Needs and Services Plan (ANS), Resident Assessments, Mini-Mental State Exam (MMSE) for residents with dementia, Self-management of medications if applicable, Medication Orders/Logs, Advance Directives, Conservatorship Documentation, and Physician Orders for Life-Sustaining Treatment. Contd. 809-C MEDICATIONS: The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. This facility maintains two (2) separate areas for centralized medication storage. The centralized medication storage area for the assisted living area of the facility is located in a locked room along the hallway in the assisted living area. This locked room contains the centralized storage of medications in a locked trolley, with an additional lock for the narcotic medication storage. This system is identical on the memory care portion of the facility, with the locked centralized storage of medications being a room off of the memory care dining area, with a locked trolley identical to the assisted living segment. Centrally stored medications are inaccessible to members and kept in a locked cabinet in two (2) separate Staff member offices in both sections of the facility. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. LPA audited the medications for members and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no additional or prohibited markings by the facility. The facility maintains a Medication Binder that contains the facility Medication Policy, Medication Administration Records (MARS), Checklist for logging/accepting medications and prescriptions, Medication Self-Administration Support, Medication Terminology, and Medication Notes/Physician Notes/Pharmacy Notes for each member. FACILITY DOCUMENTATION: There are required postings throughout the facility, including emergency exiting plans with necessary telephone numbers. The facility keeps copies of the LIC 200 Application for an RCFE, LIC 215 Applicant Information LIC 308, LIC 400 Affidavit Regarding Client/Resident Cash Resources, LIC 401 Monthly Operating Statement, LIC 402 Surety Bond, LIC 401(a) Supplemental Financial Information, LIC 403 Balance Sheet, LIC 404 Financial Information Release and Verification, LIC 500 Personnel Report, LIC 501 Personnel Record, LIC 503 Health Screening Report, LIC 610E Emergency Disaster Plan for Residential Care Facilities For the Elderly, LIC 9282 Residential Infection Control Plan, and LIC 999 Facility Sketch. The facility additionally has a Plan of Operation, Control of Property, The Job Description for Each Staff Position, Personnel Policy, In-Service Training for Staff, Facility Program Description, Rules of Discipline/Personal Rights, Admission Agreement for Residents, Sample Food Menu, Theft & Loss Policy, Neighborhood Complaint Policy, Hazard Assessment, and Job Description for the Administrator. The facility has on file a Dementia Care Plan document as well as Hospice Care Waiver. The facility had an approved inspection/test from the fire department most recently on 10/19/2023. No deficiencies cited. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 28, 2023

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for Elderly (RCFE) Application Type: Change in Ownership (CHOW) Capacity: 130 Census (if any clients in care): 60 COMP II Participants: Steven Aron, Applicant Robin Murray, Administrator Interview Method: Telephone interview On November 2, 2023 at 9:00 AM, applicant and administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview conducted with Applicant and Administrator. Copy of report sent via email and informed to return sign copy by end of business day today.the state’s words, verbatim · CDSS document, Nov 2, 2023