Garden Creek

Allegation investigated: Staff are not dispensing medication as prescribed

At 9:30am, on 10/7/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to deliver final findings to the allegation of this complaint. LPA met with Administrator Audie Sherberg, announced who he was and the reason for the visit. On the allegation, staff are not dispensing medication as prescribed. It was alleged that facility staff failed to bring a resident their medication timely, and when the medication was later brought, the staff also left a cup of another resident’s medications in the room, which was returned to staff. LPA record review and interviews revealed that 49 of 60 residents at the facility receive assistance with medication management from the facility staff and multiple residents who receive this assistance take the medication carbidopa-levodopa for Parkinson’s disease, including Resident #1 (R1). (Continued on LIC9099-C) Substantiated Staff interviews revealed the facility has a policy to provide residents with their medications as timely as possible but with a window of one hour before and one hour after the scheduled time. Staff stated it is known that medications for Parkinson’s disease should be given on time per the physician’s order to avoid worsening symptoms. The physician order for R1’s carbidopa-levodopa states it is to be administered at 2:00am, 5:00am, 7:30am, 11:30am and 3:30pm. Interviews revealed on one occasion staff did not bring R1 their morning medications. R1 notified staff to remind them and when staff brought R1 their medications, staff also left a cup of medications in R1’s room intended for another resident. R1 returned this medication to facility staff. Other residents interviewed stated they have not had medications left in their room intended for another resident, and staff interviewed are not aware of a time medications intended for one resident were left in another resident’s room. Interviews and record review revealed there was a day in July 2025 when R1 used their pendant to remind the medication technician on duty, Staff #1 (S1), for their carbidopa-levodopa scheduled at 5:00am. R1 went looking for S1 and found S1 sleeping on a couch outside the medication room on the second floor. After R1 woke up S1, S1 provided R1 their medications. A verbal warning given to S1 was documented by the Administrator and after additional disciplinary actions for other reasons S1’s employment was terminated by the facility. During staff interviews one other staff member admitted they administered R1’s medication scheduled at 2:00am approximately 75 minutes after 2:00am, and an additional interview confirmed this. Resident interviews revealed there have been times when they did not receive their medications timely and they needed to alert staff to remind them they had not received their medications at the scheduled time. Record review revealed the facility medication technicians are not current on the required medication training per California Health and Safety Code. This was addressed during the facility annual inspection conducted by the LPA during the same visit. (Continued on LIC9099-C) Based on all interviews conducted and documents obtained, at this time the above allegation was found to be substantiated, due to staff delaying the administration of time sensitive medication with specific hours of administration scheduled by the resident’s physician. Exit interview conducted, deficiency cited on LIC9099-D page, report signed, and report provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 29-AS-20250911081035

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 21, 2025

Incidental Medical and Dental Care (a) A plan for incidental medical... care shall be developed by each facility. The plan shall... provide for assistance in obtaining such care, by compliance with the following: (4)The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not dispense medications as prescribed delaying the administration of time sensitive medication with specific hours of administration scheduled by the resident'sthe state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: Administrator states they will create a policy that ensures time sensitive medications are passed in a way not to cause delay. All staff that handle medications will be trained in this policy. The policy, training and signed staff roster will be emailed to the LPA on or before 10/21/2025. physician which poses a potential Health, Safety, and Personal Rights risk to persons in care.

Type of visit: Case Management - Annual Continuation

At 9:30am, on 10/7/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct a Case Management - Annual Continuation to continue the annual inspection started on 9/16/2025. LPA met with Administrator Audie Sherberg, announced who he was and the reason for the visit. LPA and the Administrator in Training Erika Consebida and the Maintenance Supervisor conducted a full tour of all three floors of the facility. The first floor contains the main lobby, staff room, administrative office spaces, kitchen, dining room (with communal, private and outdoor dining areas), an activities room, seventeen resident bedrooms, and an outdoor courtyard in the middle with seating and shade for residents and visitors. The second floor has a beauty salon, medication room, a common area with seating and a full kitchen for cooking activities, twenty-six resident bedrooms, the laundry room through a locked door for resident safety and an outdoor patio space overlooking the central courtyard with seating and shade. The third floor includes, an activity room, twenty-one resident bedrooms, and an outdoor terrace overlooking the east side of the surrounding area with seating areas. All resident bedrooms have an on-suite bathroom and a kitchenette. LPA tested facility hot water in several bedrooms throughout the facility ranging from 109.5 - 115.6*(f), within regulation temperatures 105*-120* (f). The main kitchen faucets are not used by residents and deliver water hotter than 125*(f) and the faucets are marked with signage indicating the hot water per regulation. LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods in the main kitchen. Each floor has community use restrooms. The facility has two elevators, serviced on 6/27/2025 and emergency evacuation chairs at the top of the two stairwells. LPA noted that the facility is in good repair with no obstructions in hallways, doorways or exits. (Continued on LIC9099-C) The facility offers activities to all residents in care. Daily activities are displayed on a white board next to the reception desk and a monthly activity schedule is provided in print to the residents. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records (CSMR), finding eleven medications of the five resident CSMRs reviewed not documented. Staff stated if the LPA audited all the resident CSMRs who receive medication administration assistance from the facility the LPA would find more medications not documented per regulation. The facility employs approximately 67 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed a sample number of staff files for current 1st Aid/CPR, Health screening with TB results, training and fingerprint clearance. Administrator has current certification. While reviewing medication technician training required by the California Health and Safety Code (HSC) the facility could not provide the required annual training documentation for any of the medication technicians and the Vice President of Operations Lisa Hulse stated they do not have their current required training. Lisa stated the facility is currently working with a new training company to provide all required initial and annual staff training. The facility keeps separate files on each resident confidentially. LPA reviewed a sample number of resident files for signed Admission Agreements and Appraisals/Reappraisals. LPA and Administrator conducted a review of the annual care tool modules. Citations issued at this time. Exit interview conducted, deficiencies cited on the LIC809-D page, report signed, and report provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 7, 2025

The state marks this report as 10 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At 8:45am, on 9/16/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Administrator Audie Sherberg, announced who he was and the reason for the visit. This is a three story facility with 64 resident rooms. LPA noted a large lobby space when entering the front door with a grand piano for residents and visitors to play, an area to sit near a self-contained fireplace, a set of stairs leading to the second floor, fresh fruit and snacks for residents to enjoy freely across from the reception desk and an area with board games, puzzles, books and a computer for resident use. Next to the game area are administration offices. The facility has wired smoke detectors in each room that were tested by Alpha Fire & Security Alarm on 11/13/2024. There is a battery operated carbon monoxide detector next to the fireplace in the lobby that is functioning normally. LPA observed fire extinguishers throughout the facility tagged current and in the green compression range, serviced on 4/3/2025. Medications are locked in a med room on the second floor in medication carts. LPA was not able to complete the annual inspection and may return at a later time to finish. There were no deficiencies cited at this time. Exit interview conducted, report signed, and report provided to Administrator Audie Sherberg.the state’s words, verbatim · CDSS document, Sep 16, 2025

Allegation investigated: Facility staff are not meeting resident’s care needs.

On 6/10/2025 at 08:50am Licensing Program Analyst (LPA) Haner-Tomasko conducted a 10-day complaint visit to the facility above. LPA met with Administrator Liza Hix and explained the purpose of the visit. LPA requested the following records: Resident Roster, Staff Roster, and Resident 1's (R1's) preadmission appraisal, current physician report and care plan. From 09:34am to 11:54am LPA conducted interviews with staff and R1. On allegation: Facility staff are not meeting resident’s care needs. It was alleged R1 requires more care than staff thought and staff are unable to provide R1 water or check on R1 overnight and therefore R1 frequently wakes up dehydrated, and was recently sent to the hospital, but later released because of dehydration. (Continued on LIC9099-C) Unsubstantiated LPA interviews with staff revealed many of the residents are relatively independent and do not require much hands-on assistance. Staff stated R1 requires the most assistance out of all residents currently and resists staff assistance at times. Staff stated, R1's family hired an outside caregiver just after their admission to the facility to assist facility staff due to increased care needs. Staff stated R1 prefers to stay in bed, but it does take 2 care staff to provide some care to R1. When the outside caregiver is not there staff stated they can radio for help from medication technicians or another available care staff and they receive support form the other staff. Staff stated they are able to meet the residents needs, but feel R1's level of care is too high to reside in the facility. Staff interviews revealed R1 uses a pendant to call staff regularly for assists inlcuding to drink fluids. Staff interviews also revealed that facility caregivers (Personal Care Attendants) do not have a way to review each residents care needs. Staff stated care needs are relayed at shift change meetings, but only medication technicians have access to care plans and resident appraisals. During LPA interview with R1, R1 stated they prefer to stay in bed, the staff provide assistance when needed, including providing R1 fluids. R1 stated they just want to sleep and not get out of bed. LPA interview with Lisa Hulse, Vice President of Operations, and resident file review revealed the facility contacted R1's primary care physician regarding R1's change in condition on 5/9/2025, the day after admission, and the physician visited R1 on 5/13/2025. Lisa stated R1 received additional assistance upon admission through home health care agency Central Coast Home Health and after R1's first hospitalization was transitioned to palliative care through the same agency. LPA record review revealed R1 has been to the hospital two times since in care at the facility and neither visit had a discharge diagnosis of dehydration. Record review revealed three appraisals of R1 were completed prior to R1's admission, a reappraisal due to updated care needs for R1 has not been completed as of today's visit. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, no citation was given at this time and report was provided.the state’s words, verbatim · CDSS document, Jun 10, 2025 · control 29-AS-20250609084320

Allegation investigated: Staff did not seek medical attention in a timely manner for resident after a fall Facility failed to report incident to Residents responsible party and Licensing Facility failed to report resident death to Licensing

Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above. LPA met with Liza Hix, Administrator and explained the purpose of the visit. LPA requested the following records: Resident Roster, Staff Roster, All incident reports on R1, Death report for R1, Procedure or policy for Reports, falls, discharge and extra care after discharge of residents at the facility, admission agreement for R1, refund of rent paid and refunded for R1, disciplinary report for staff, hospital discharge paperwork, and notes or charting for R1. The facility was able to provide resident roster, staff roster, staff schedules for December 2023, R1's admission agreement, Refund of rent paid and refund issued, staff email to supervisor/managers reporting R1 going to Hospital. Facility was not able to provide any other records requested. LPA De Leon conducted interviews with staff at 10:15am, 10:45am, 11:04am, 12:40pm, 12:50pm, 1:28pm, 2:06pm, 2:14pm, and 2:45pm, Substantiated On the allegation: Staff did not seek medical attention in a timely manner for resident after a fall. LPA conducted interviews with staff and witness that revealed Resident 1 (R1) did have a fall in the early morning, R1 was not wearing R1's pendant to call for help, R1 was on the floor calling for help for an unknown amount of time, and the facility did not call 911 or seek medical attention for R1. R1 had another fall that afternoon and 911 was called to transport R1 to the ER. Based on the evidence this allegation is Substantiated at this time. On the allegation: Facility failed to report incident to Residents responsible party and Licensing. LPA conducted interviews with staff which revealed no 911 or medical visit was made for R1 after the 1st fall, R1's 2nd fall was reported immediately to R1's family. Incident report for either of R1's falls on12/30/2024 were not reported to Community Care Licensing (CCL). Witness 1(W1) interviewed revealed a call was made to W1 in the late morning 12/30/2024 regarding a fall for R1, R1 was fine, got cleaned up and taken down to breakfast. W1 stated later that afternoon W1 was immediately called about R1 having another fall and was being transported to the hospital. Based on the evidence and lack of facility records provided this allegation is Substantiated at this time. On the allegation: Facility failed to report resident death to Licensing. LPA conducted interviews with staff and requested records of death report for R1. The facility was unable to provide a copy of the death report. W1 stated the facility staff was told about R1's death in the hospital within the days proceeding the death of R1, W1 cleaned out R1's room and gave away some of R1's belongings so certain staff knew of R1's death at that time. W1 stated R1's death was reported to management within the week of R1's passing. Based on the lack of records provided and CCL not having a death report on file this allegation is deemed Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for administrator. On the allegation: Facility denied care and supervision services after resident was discharged from the hospital. LPA interviewed staff which revealed no staff denied care or supervision services after a residents discharge, Staff stated they would provide the services immediately and let business staff know to up date care services on resident 1 (R1). Staff stated they understand the procedure to provide care immediately and business office sends a letter to resident and responsible parties of care fee increase. Witness 1 stated after discharge a staff told W1 they could not provide additional care services to R1 until the next business working day W1 would have to sign up for additional care services at that time. LPA reviewed R1's Admission Agreement and in Appendix A there is a clause that states Additional "Round the Clock" care the facility would provide the service for a fee of $25.00, the fee would be billed to the family on a weekly basis and will be expected to be paid within three days of receipt. Based on the lack of evidence this allegation is Unsubstantiated at this time. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 29-AS-20241107133319

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Nov 21, 2024

(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need... This requirement was not met as evidenced by: Based on records review and interviews the Licensee did not comply with the regulation above, Staff did not seek medical attnetion for R1's fall which posses a potential Health, saefty and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: Administrator agreed to train all care staff and med-techs on facilities policies for falls and calling 911, regulation 87465 and provide proof of training with staff signatures and an up to date LIC 500 for staff to CCL 11/21/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Nov 21, 2024

(a) Each licensee shall furnish to the licensing agency such reports...:(1)...(B)Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirment was not met as evidenced by: Based on record review the Licensee did not comply with the regulation above, the facility did not report R1's falls on an incident report to CCL and did not report the first fall timely to R1's family which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: Administrator agreed to train all staff in reporting procedures/policy and regulation 87211 and provide proof of training with staff signatures and an up to date LIC 500 for staff to CCL 11/21/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Nov 21, 2024

(a) Each licensee shall furnish to the licensing agency such reports...:(1)...(A)Death of any resident from any cause regardless of where the death occurred,...This requirement was not met as evidneced by: Based on record review the Licensee did not comply with the regulation above, CCL did not receive a death report for R1 which poses a potential Health, safety and personal rights risk to reisdents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: Administrtor agreed to train all staff in reporting procedures/policy and regulation 87211, reporting time/date for deaths and provide proof of trianing with staff signatures and an up to date LIC 500 for staff to CCL 11/21/2024.

Type of visit: Required - 1 Year

At 9:45am on 10/28/2024, Licensing Program Analyst (LPA) De Leon arrived at the facility unannounced to conduct the annual inspection. LPA met with Administrator Liza Hix and explained the purpose of the visit. This facility has 64 bedrooms/bathroom. This facility is 3 stories, the first floor there is a large waiting and entrance way with front desk. There is an enclosed center courtyard, there is a kitchen and dining room, resident rooms, mail room, storage rooms and facility offices. The second floor has a beauty salon, storage rooms, central medication room, activities room and resident suites. The 3rd floor has resident rooms, locked storage closets, and an activities/library room. The grounds also have independent living facilities located next door and plenty of outside seating and walking ways for residents. There is a designated smoking area in the back parking lot of the grounds. Administrator and LPA conducted a tour of the facility, LPA observed, all floors, kitchen, dining room, all activities rooms, medication room and 10 residents rooms. LPA noted that there are fire extinguishers placed throughout the facility all in the green and currently tagged for service. LPA noted that the facilities walkways and exits were free and clear of debris or obstructions. LPA noted that the food supply met regulations for 2 days of perishables and 7 days of non-perishables for more than 46 residents. LPA conducted an audit of medications, medications was stored in original container, no medications were expired and no labels were altered. LPA reviewed 5 staff files, all required forms were present. LPA reviewed 5 resident files, all required forms were present. No other violations, or citations were discovered during this annual inspection. LPA interviewed 3 staff and 2 residents. Exit interview, copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Oct 28, 2024

Type of visit: Required - 1 Year

At 9:50am on 11/17/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct the annual inspection. LPA signed in at the front desk and had Maintenance Staff (S1) contact the Administrator. Administrator Kirk Klotthor arrived at 10:10am, LPA announced who he is and the reason for the visit. This facility has 64 bedrooms/bathroom suites, currently the rooms occupied are all single occupancy at this time. This facility is 3 stories, the first floor there is a large waiting and entrance way with front desk. There is an enclosed center courtyard, there is a kitchen and dining room, resident rooms, mail room, storage rooms and facility offices. The second floor has a beauty salon, storage rooms, central medication room, activities room and resident suites. The 3rd floor has resident rooms, locked storage closets, and an activities/library room. The grounds also have independent living facilities located next door and plenty of outside seating and walking ways for residents. There is a designated smoking area in the back parking lot of the grounds. Administrator and LPA conducted a tour of the facility, LPA observed, all floors, kitchen, dining room, all activities rooms, medication room and a sample of residents rooms. LPA noted that there are fire extinguishers placed throughout the facility all in the green and currently tagged for service. LPA noted that the facilities walkways and exits, were free and clear of debris and obstruction. LPA noted that Alpha Fire conducted a comprehensive 5 year evaluation of the facilities sprinkler system on 11/14/2023 with no issues. LPA noted that the food supply met regulations for 2 days of perishables and 7 days of non-perishables for more than 51 residents. LPA noted that there were no special diets. LPA conducted a sample medication audit and reviewed Centrally Stored Medication Records and found no issues. LPA reviewed sample staff files and found no issues. LPA reviewed sample amount of resident fils and found no issues. LPA conducted full care tools review. LPA noted one technical violation, of liability insurance pertaining to amount of aggregate, Administrator will address before 12/01/2023. No other violations, or citations were discovered during this annual inspection. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Nov 17, 2023

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.