Fredericka Manor

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Assistant Jolene Hall. CCL received a SOC 341 report regarding missing jewelry belonging to Resident 1 (R1). On June 2, 2026, Staff 1 (S1) visited R1’s cottage to introduce new staff, and R1 reported that several pieces of their jewelry were missing. R1 stated they had been staying at their other home during the week of May 18 due to a water shutoff and returned on May 22. On May 23 or 24, R1 noticed their jewelry box felt lighter and discovered multiple items missing. R1 did not report the loss earlier because they believed their former housekeeper was still employed, but the housekeeper had already resigned. The facility began an internal investigation and notified Chula Vista Police Department, which issued incident number 054024. R1 reported several pieces of gold jewelry missing, including rings, bracelets, a bangle, necklaces, pendants, and earrings, with an estimated total value of $22,223. R1 has insurance coverage for three of the missing items, totaling $6,933. R1 was off campus and unable to be interviewed at the time of LPA visit. LPA interacted with staff and obtained facility records. No deficiencies were cited or observed on this date. An exit interview was conducted with Jolene Hall, who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documentsthe state’s words, verbatim · CDSS document, Jun 15, 2026

Allegation investigated: Lack of supervision resulted in resident self-neglect

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Resident Services Director Corinna Norton and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of records review, interviews with facility staff and resident. LPA reviewed R1’s facility records, which show R1 has hereditary motor and sensory neuropathy and alcoholic liver disease. According to their care plan dated 2/17/26, R1 is fully oriented, participates in activities, and has supportive family and community connections. The care plan states they are independent in all daily living tasks including bathing, grooming, dressing, toileting, eating, and mobility. They use a walker or cane but require no physical assistance. They self manage their own medications, do not need wellness checks, do not receive outside provider services, and have no identified special needs. Unsubstantiated Facility charting documented several incidents involving R1’s alcohol use, falls, and smoking indoors. On 2/17/26, a med tech checked on R1, who denied falling but smelled strongly of liquor. Later that day, the med tech found R1 sitting on the floor by the toilet; R1 stated their legs gave out and they intentionally sat down. Staff also found an empty liquor bottle next to R1’s recliner and a lit cigar in the room. On 2/18/26, staff found R1 smoking a cigar in their room, reminded them of the no smoking policy, and offered to escort them to the patio, which R1 refused. On 2/20/26 at 1:36 a.m., R1 paged staff and was found stuck between the toilet. They smelled of alcohol, and staff called 911 for hospital transport. Further documented incidents occurred on 3/3/26, 3/4/26, and 3/5/26. On 3/3/26, during dinner delivery, R1 was smoking and drinking liquor, prompting staff to notify security and the campus nurse. On 3/4/26 at 11:10 p.m., R1 paged staff and was found sitting on their living room floor, denying a fall. Earlier that morning, staff noticed cigar smoke in the hallway and notified security. On 3/5/26, R1 paged staff again and was found on the floor near their bed, stating they drank four ounces of vodka and could not recall if they hit their head. Staff called 911 for transport. Incident reports submitted to CCL reflect similar events on 10/28/25, 3/5/26, and 3/13/26, where R1 was found on the floor, smelled of alcohol, and was transported to the hospital. LPA interviewed R1 in their room. LPA observed multiple tobacco pipes, several ashtrays, loose tobacco scattered on the floor, an unopened bottle of beer, and a strong odor of smoke. R1 stated they are being evicted due to smoking violations. R1 told LPA that staff are “wonderful,” check on them frequently, and help whenever they ask. R1 also stated they have had their medical condition since birth and that it contributes to their tendency to fall. LPA interviewed several staff who assist R1. Staff 1, who oversees R1’s floor, stated they regularly offer R1 help with bathing, laundry, and escorting, but R1 consistently refuses, saying they will do it on their own later. Staff 1 stated they check on R1 at least every two hours because they are aware R1 drinks and smokes in their room. Staff 2 stated they work with R1 daily and that R1 smokes in their room one to two times a day, drinks liquor every day, and becomes intoxicated roughly once every two weeks. Staff 2 stated they check on R1 six to seven times a day to ensure they are safe. Staff 3 reported R1 is polite with them and often compliments them. Staff 3 also confirmed R1 regularly drinks and smokes in their room and stated they check on R1 about five times per shift due to R1 declining offered services. All staff interviewed stated that R1 consistently refuses assistance but that staff continue offering support and frequently monitor R1. The Resident Services Director stated the facility has been working closely with R1 and their family for an extended period in an effort to provide the support R1 needs. They stated staff have offered R1 medication management, shower assistance, weekly housekeeping, laundry services, and escorting to the patio smoking area. R1 repeatedly declines these services, including refusing housekeeping that is included in their contract. The director stated the building has a strict no open flames policy, but R1 continues to smoke indoors, leaving ashes scattered throughout the unit. They also stated that R1 openly identifies as an alcoholic and has experienced multiple falls related to alcohol use. The director expressed concern that R1 could fall asleep or pass out while smoking, creating a fire hazard. Due to ongoing safety violations and repeated refusal to comply with the no smoking policy, the director stated R1 was issued a 30 day notice to vacate on 3/3/26, with a required move out date of 4/2/26. Based on interviews, documentation, and observations, there is insufficient evidence showing the facility failed to supervise R1. R1 is assessed as fully independent, repeatedly refuses services, and continues unsafe behaviors due to personal choice rather than lack of staff involvement. Staff monitor R1 far more frequently than required, respond promptly to call pendant activations, redirect when possible, notify security, and call 911 when necessary. The incidents appear related to R1’s medical condition and their alcohol and tobacco use rather than any lack of supervision. Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is unsubstantiated. An exit interview was conducted with Corinna Norton. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Corinna Norton whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 08-AS-20260306143759

Allegation investigated: Staff did not meet a resident's bathing needs Staff did not provide adequate food service to a resident Staff left a resident unattended for an extended period Staff did not provide a resident privacy

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Resident Services Director Corinna Norton and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff and residents. It was alleged that facility staff did not meet Resident 1's (R1) bathing needs, staff did not provide adequate food service to R1, staff left R1 unattended for an extended period and staff did not provide R1 with privacy. LPA interviewed R1 on July 29, 2025. R1 stated that the facility hired many new workers, and they feel some of their care has declined because of this. R1 reported that on July 13, 2025, no staff checked in all day to see whether they had eaten. R1 said they missed breakfast, lunch, and dinner. Unsubstantiated R1 stated they receive meal delivery and expect meals to be brought to the room daily. R1 also told LPA that they purposely did not press their call button that day to “prove a point,” believing staff should notice when they have not eaten. R1 stated meal delivery usually takes 45 minutes to an hour. R1 reported that staff have told them they sometimes avoid entering the room if R1 is sleeping because R1 becomes upset when awakened. R1 also stated that earlier in the year, workers were in their room fixing bathroom plumbing. R1 said workers walked in and out without concern for privacy and that R1 was never offered a temporary room. R1 stated the bathroom repairs lasted 21 days. R1’s bathing schedule is Thursday and Sunday. R1 stated they did not receive three Sunday baths in a row but did receive their Thursday baths. LPA interviewed several other residents on July 29,2025 and December 1, 2025. Residents interviewed reside on the same floor as R1. All residents reported no issues with food service, privacy, or care. LPA interviewed Staff 1 (S1) on December 1, 2025. S1 stated that R1 is very particular about how things should be done. S1 said R1’s mood can vary, especially after returning from medical visits. S1 confirmed R1 is scheduled for two baths per week and stated that if a bath is missed, it is usually because R1 refused. S1 explained that staff go to R1’s room when R1 calls but avoid unannounced entry because R1 becomes upset. LPA interviewed Staff 2 (S2) on December 1, 2025. S2 stated R1 likes tasks done in specific ways and becomes frustrated when they are not done exactly as requested. S2 confirmed R1’s bathing schedule. S2 stated that if R1 dislikes a certain staff member, R1 refuses a bath from that person, and staff must rearrange schedules to accommodate this. S2 recalled workers being in R1’s bathroom months ago but stated the work lasted only one or two days, not several weeks. S2 said staff only enter R1’s room if called because R1 becomes upset when staff enter without notice. Regarding food service, S2 said they deliver meals to multiple residents and delays may occur because they are also assisting with care tasks. S2 said they do not believe R1 ever missed a meal because one time when the kitchen did not receive R1’s order, R1 insisted S2 retrieve the meal immediately, and S2 did so. Manager of Maintenance (MM) stated R1 was offered a guest room during the bathroom repair period, but R1 refused the offer. MM stated R1 told them they do not use the bathroom at all. MM stated outside vendors were escorted and did not have a way to enter R1’s room freely. The bathroom had only one access point, and workers had to pass the pony wall to reach the repair area. A nearby light fixture was removed and later reinstalled after patching and painting. On December 1, 2025 the Director of Heath Services (DHS) stated that R1 does not receive wellness checks as part of their service plan. Staff check on R1 only during scheduled services or when R1 requests assistance. R1 has showers scheduled twice each week, but the schedule sometimes changes when R1 refuses a shower or prefers to wait for specific staff to return to work. LPA reviewed meal delivery procedures and logs. Records showed: Residents who want room delivery fill out a room-service meal form. Residents on regular delivery can fill out a form each time or have a standing order. For residents requiring escort service (including R1):A room service order form is completed by the resident, nursing staff, or by standing order. The meals-to-go server prepares the meal. Meals are placed on the bistro counter. Nursing staff pick up the meal, sign the delivery slip, and deliver it. Scheduled meal times are: Breakfast: 8:45 a.m. Lunch: 11:45 a.m. Dinner: 4:45 p.m. Based on the documented meal times and meal delivery process, R1’s reported 45-minute to one hour wait time falls within the documented delivery window. In regards to Bathing Needs: R1 reported missed Sunday baths, but staff and records showed baths were offered, and refusals and scheduling adjustments were involved. In regards to Food Service: R1 stated they missed meals but also reported they purposely did not call for help. Meal procedures and records show R1 was provided meals within the expected time frame. In regards to R1 being left attended: No evidence showed R1 was ignored. Staff check in during scheduled services or when R1 calls. In regards to R1's privacy rights being violated. No evidence showed that anyone violated R1’s privacy, and maintenance staff reported workers were escorted and did not have direct access to R1’s room. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are unsubstantiated. An exit interview was conducted with Corinna Norton. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Corinna Norton whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Dec 1, 2025 · control 08-AS-20250724114829

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Director of Resident Services Corinna Norton, to discuss the purpose of the visit. Today's visit is in response to the self reported incident involving Resident 1 (R1- see LIC811 Confidential Names List) who had an unwitnessed fall resulting in a closed fracture. LPA conducted a health and safety check, interacted with staff and obtained facility records. No deficiencies were cited or observed on this date. An exit interview was conducted with Corinna Norton who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Dec 1, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose De La Cruz made an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Director of Resident Services (DRS) Corina Norton. The facility's license shows a maximum capacity of five hundred and sixty (560) residents age 60 and above. One hundred and nineteen (119) might be non-ambulatory residents and five (5) might be bedridden. During today’s inspection there were two hundred and eighty-four (284) residents in care, four bedridden and twenty-one non ambulatory. LPA arrived at 8:20 am, facility looks clean and in good repair and decorated for the Holidays. At 8:35 am LPA requested residents and staff files, at 9:16 am LPA reviewed residents’ files and at 10:21 am LPA reviewed staff files. At 12:10 pm, LPA and DRS toured the facility, toured the interior and exterior and inspected four residents’ rooms, two cottages, two of the four clinics and two activity rooms as well as a physical inspection of four of the seven floors. During the inspection, LPA measured the water temperature and found that the main building had approved readings of 115 degrees Fahrenheit, but a cottage and one of the dementia care facilities had readings of 128.1 and 126.3 Fahrenheit degrees. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linen and hygiene supplies were present at the laundry room, as well as Personal Protective Equipment. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC809] The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days of non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. A pond exists on the premises surrounded by a five foot tall fence. Per DRS, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. One deficiency was cited per California Code of Regulations, Title 22 (refer to the LIC809-D page). No Civil Penalty was assessed. Plan of Correction was jointly developed with the staff responsible. An exit interview was conducted with DRS Corinna Norton, to whom a copy of this report, the LIC 809-D pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.the state’s words, verbatim · CDSS document, Oct 29, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Director of Resident Services Corinna Norton, to discuss the purpose of the visit. Today's visit is in response to the self reported incident involving Resident 1 and Resident 2 (R1-R2 - see LIC811 Confidential Names List) who had delayed assistance after pressing their pendant button. LPA interviewed staff and residents and obtained facility records. No deficiencies were cited or observed on this date. An exit interview was conducted with Corinna Norton, who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 9, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Director of Resident Services Corinna Norton, to discuss the purpose of the visit. Today's visit is in response to the self reported incident of Resident 1 (R1 - see LIC811 Confidential Names List) received by Community Care Licensing on 02/10/2025. According to the LIC624, R1's POA reported that they withdrew $800 dollars from the bank on 12/17/24. On 1/18/25 they both noticed that all of the cash was missing. POA further stated that anywhere from $200 to $300 was spent by R1, which meant $500 to $600 dollars was missing. The facility conducted an internal investigation and filed a police report with Chula Vista Police Department, incident #12894. LPA interviewed R1 and obtained facility records. No deficiencies were cited or observed on this date. An exit interview was conducted with Corinna Norton, who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documentsthe state’s words, verbatim · CDSS document, Feb 13, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was allowed entry and discussed the purpose of the visit with Director of Resident Services (DRS) Corinna Norton. According to the facility’s license, the facility has a maximum capacity of Five hundred and sixty (560) residents. Of whom one hundred nineteen (119) may be non-ambulatory. Hospice waiver approved for fifteen (15) residents. Five (5)residents may be bedridden. LPA, accompanied by DRS toured the interior and exterior of the facility, and inspected several rooms in both the assisted living and the memory care unit. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. Hot water temperature was measured in the facility at 114 degrees F. The ambient temperature inside the facility was measured at 75 degrees F. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. Their are no pools/bodies of water on the premises. Per DRS, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C] LPA reviewed multiple staff and resident records/files. Records review did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Corinna Norton whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Oct 10, 2024

Allegation investigated: Resident's room passageways are obstructed Staff is not following resident's special diet

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Director of Resident Services Corinna Norton and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of LPA observation, records review and interviews with facility staff. It was alleged that Resident 1's (R1) (an LIC 811 Confidential Names List was provided to the facility representative to identify the resident) room passageways were obstructed. It was reported that R1 had recently moved into a room in the assisted living section and R1's "move-in" boxes were still stacked throughout the room. LPA reviewed internal facility notes dated May 28, 2021. Facility contact notes indicate R1 hired a professional moving company to assist with delivery and unpacking on June 23, 2021. Unsubstantiated On June 22, 2021 the moving company received an email from R1 indicating that R1 wanted to remove the "unpacking" from their service. The moving company confirmed with R1 that R1 wanted to remove the "unpacking" service since the facility did not provide any unpacking services. Facility contact notes reveal that R1 was in regular communication with facility staff and outside vendor regarding R1's move to the assisted living section of the facility as well as R1's room accommodations. It should be noted that the R1 expressed a desire for facility staff to unpack R1's boxes. However, upon review of the admission agreement, it was confirmed that there was no explicit provision for staff unpacking boxes and personal belongings as part of the facility's services. This aspect was clarified through ongoing communication with R1 during the move-in process. It was alleged that staff were not following R1's special diet. It was reported that R1 had a "low carb diet" but staff continued to give R1 foods high in carbohydrates which caused R1's blood sugar levels to rise. LPA reviewed R1's meal order forms dated June 28, 2021 through August 22, 2021. R1's meal order forms revealed that R1 had the option of ordering "low carb" meals. Further review of the forms revealed an example of what R1 ordered for lunch; beef barley soup and crackers, ham and provolone and carrot and jicama sticks. An example of what R1 ordered for dinner; tossed salad, Salisbury steak and mixed vegetables. Review of dietary records and internal emails dated May 2021 through August 2021 revealed the Director of Dining Services was in regular communication with R1 regarding R1's special diet and R1's food options. Records review revealed R1's special diet was generally followed as prescribed, although R1 could select any items from the menu R1 desired, including carbohydrates. LPA Interviewed Director of Resident Services (DRS) who stated that R1 was at the facility less then six months. DRS stated that R1 was offered moving and unpacking services from a vendor that the facility utilized but R1 refused. DRS stated that R1 was unhappy with the facility meals and as a result the Director of Dining Services would sit down with R1 on a regular basis and R1 would select food items that met her dietary needs. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. An exit interview was conducted with Corinna Norton. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Corinna Norton whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Jul 25, 2024 · control 08-AS-20210706135019

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Director of Resident Services Corinna Norton, to discuss the purpose of the visit. Today's visit is in response to the self reported incident of Resident 1 (R1 - see LIC811 Confidential Names List) who suffered a fall and fracture. LPA interviewed staff and obtained facility records. R1 was discharged back to the facility on June 8, 2024. No deficiencies were cited or observed on this date. An exit interview was conducted with Corinna Norton, who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jun 12, 2024

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Dang Nguyen and Amy Rodgers conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Director of Resident Services Corinna Norton. Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 12/28/2023). According to the LIC624: on 12/27/2023, Resident #1 (R1) left the facility and was unable to find their way back home. [See LIC 811 Confidential Names List for a description of R1.] Local police were called; later that same evening police brought R1 back to the facility unharmed. During today’s visit, LPAs performed a brief facility tour and welfare check on R1, verifying that they were unharmed. LPAs also collected copies of pertinent records and interviewed relevant staff and R1’s responsible person. According to R1’s latest LIC602 Physician’s Report (dated 11/17/2023), their doctor determined that although R1 had Mild Cognitive Impairment, they were still able to safely leave the facility unassisted. The doctor wrote that R1 was not confused/disoriented, had no wandering behavior, was able to follow instructions, was able to communicate needs, and was independent in all Activities of Daily Living (ADLs). Licensee’s own care appraisals on R1 (dated 11/22/2023 and 11/29/2023, respectively) corroborated that R1 was “active” and independent in all ADLs. Interviews and records showed: Licensee had a written Absentee Notification Plan, and that staff followed this plan during the incident. Licensee also notified R1’s physician of the incident and performed a timely reappraisal of R1’s care needs, as was required. Following the reappraisal, Licensee relocated R1 to its secured memory care section. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] No deficiencies were cited during today's visit. LPAs issued Technical Assistance (TA) regarding the facility’s Absentee Notification Plan. An exit interview was conducted with Norton, to whom a copy of this report, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jan 17, 2024

Type of visit: Collateral

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Collateral visit. The LPA introduced himself and discussed the purpose of the visit with Director of Health Services Cha Cha Doles. During the visit, the LPA conducted interviews with staff. No deficiencies were cited on today's date. An exit interview was conducted with Doles, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Jan 3, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Executive Director, Ben Geske, after identifying themselves and stating the purpose of the inspection. This facility serves five hundred and sixty (560) elderly residents; age 60 and above; one hundred and nineteen (119) may be non-ambulatory and five (5) may be bedridden. Hospice care waiver for fifteen (15). Facility is equipped with delayed egress. This is a muti-unit property, with marked entry and exit door on first floor. Elevators are available for residents to use to access all floors. LPA was accompanied by the Campus Director, Lujan during a tour of the facility. A tour of the facility was conducted in the Summer House, Timken wing and Towers area in the community and included a sample of resident units, the dining area, recreation rooms, and food storage areas. Signal systems are in place and operational. The last disaster drill was conducted in October 2023. PPE supplies are onsite. The is a large body of water, however it is enclosed with a locked gate.. Passageways were free from obstructions. According to Executive Director, Geske, there are no weapons and/or ammunition stored on the premises. All doors and elevators were operational. Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are all accessible in rooms or in locked facility store room. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room. Centrally stored medications were properly stored and locked on medication carts. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions. Staff records review verified that all staff records are complete and compliant. All direct care staff have First Aid certificates and First Aide/CPR certificates, and staff training. Resident records reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPAs conducted a thorough review of In-service training procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted, this report was discussed with Executive Director, Geske. The report along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to Executive Director, Geske.the state’s words, verbatim · CDSS document, Nov 2, 2023