Gardens at Escondido

Type of visit: Required - 1 Year

On 02/06/2026, Licensing Program Analyst (LPA), Jacqueline Shaw-Ross arrived at the facility unannounced to conduct a required annual inspection and met with Executive Director, Monica Flores. The facility file review was conducted at the Regional Office and additional forms were requested and reviewed on site. The facility is licensed for 101 elderly residents; ages 60 and above; all of whom may be non-ambulatory, ten (10) of which may be bedridden. A hospice waiver is approved for 18 residents; and approved for delayed egress. LPA Shaw-Ross toured the facility, and inspected the facility inside and outside. There were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. The facility consist of three levels for assisted living and one level for memory care. Physical Plant: The facility phone number is (760) 480-8155 and is operable. LPA Shaw-Ross observed a sample the residents’ living units, and each was equipped with required furniture as per Title 22. LPA Shaw-Ross inspected a sample of the facility restrooms on the first floor as well as bathrooms in residents living units, and the hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately, and there was liquid soap and paper towels currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. LPA Shaw-Ross reviewed the facility's fire extinguisher logs, emergency fire drill log, and all are being serviced regularly. First aid kit(s) were complete and readily accessible. LPA Shaw-Ross observed required postings such as "If you See Something, Say Something" the "Personal Rights," along with the Ombudsman in common areas throughout the facility. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There is designated storage space for residents and staff files, that are inaccessible to residents in care currently at the time of this visit. Medications: Were locked and inaccessible to residents in care, and there is a sufficient supply of medication for each resident. LPA reviewed a sample of resident medications to ensure medications are dispensed accordingly. No medication errors were observed at the time of visit. The facility cooling system and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. Care & Supervision: Facility has sufficient staff on site at the time of this visit. Receptionist at the front desk, maintenance team, and house keeping teams were observed on each floor. Nurses and other care staff were in sufficient numbers for this facility type. Records Review: LPA Shaw-Ross reviewed a sample of seven (7) resident and six (6) staff files, conducted resident and staff interviews,and reviewed previous Community Care Licensing forms. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit. An exit interview was conducted, and a copy of this report was discussed and provided to Executive Director, Monica Flores.the state’s words, verbatim · CDSS document, Feb 6, 2026

Allegation investigated: Due to staff neglect, resident sustained a burn requiring hospitalization.

On 09/22/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation noted above. LPA met with Monica Flores, Executive Director and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, and the investigation consisted of observations, interviews and records review. On 07/13/2023 Community Care Licensing received a complaint alleging due to staff neglect, resident sustained a burn requiring hospitalization. Resident #1 (R1) was admitted to the facility on 06/15/2023. On 07/13/2023 during medication pass, R1 was found inside their bedroom in a frog-like position facing downward at the foot of their bed. Staff #1 (S1) checked R1’s vitals and observed R1 to have redness around their calf of their legs, but no blistering. Emergency Services were activated and R1 was sent out and admitted to a local hospital from 07/13/2023 to 08/02/2023. Unfounded A review of the relevant medical records related to R1’s hospitalization were reviewed. The medical records indicated R1 was not diagnosed with a burn. R1 was diagnosed with injuries related to R1’s health conditions. The investigation did not provide sufficient evidence that staff neglect caused the injuries R1 was diagnosed with. The investigation further revealed staff obtained timely medical attention for R1’s observed injuries. Therefore, based on interviews and records review the allegation is unfounded. A finding that the complaint is unfounded means the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted where a copy of this report was reviewed and provided to Monica Flores, Executive Director.the state’s words, verbatim · CDSS document, Sep 22, 2025 · control 18-AS-20230713151454

Allegation investigated: Licensee did not allow resident access to telephone. Licensee did not allow resident to leave facility.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Monica Flores. On 05/16/2025 it was alleged that Licensee did not allow Resident 1 (R1) access to a telephone and did not allow R1 to leave the facility. The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, residents, outside sources, and records review. Staff interviews consistently revealed that R1 was allowed to receive phone calls from outside parties and family and that the facility assisted with the communication. Additionally staff informed that R1 had a personal cell phone in their possession that they used, and sometimes misplaced around the facility. Outside source interviews did not corroborate the allegation, as outside sources informed that they had directly observed the facility assisting R1 with phone calls. (Continued on LIC9099 p.2) Unsubstantiated (Continued from LIC9099 p.1) Outside sources informed that R1 no longer had the mental capacity to sign an updated Power of Attorney document that would have restricted communication. R1 was interviewed during the facility visit. R1 informed that they enjoyed living at the facility and that they were able to communicate with their family and friends freely. R1 did not express any concerns about living at the facility. No records were found to show that R1 was restricted from communicating with family, friends, practitioners, or any other outside person. Regarding the allegation, "Licensee did not allow resident to leave facility", staff interviews revealed that R1 was not able to leave the facility unassisted due to cognition, however R1 was able to leave with an escort, which had been done many times. Staff informed that a family member typically arranged for R1 to be picked up from the facility and brought back. During interview R1 informed that they remained at the facility most of the time, but their family came to visit them. R1 did not express concern regarding the facility allowing them to leave the facility. An outside source (OS1) familiar with R1 informed that R1 suffered from diminished capacity but was able to leave the facility with someone. OS1 informed that the facility had not prevented R1 from leaving the facility with an escort. A second outside source, OS2, corroborated staff statements that R1 was not allowed to leave the facility by themselves due to cognition. Review of facility and outside source records showed inconsistent determinations regarding R1's mental capacity, however, R1's Physician's Report specifically indicated that R1 was not allowed to leave the facility unassisted due to cognition. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Monica Flores, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 20, 2025 · control 08-AS-20250516142641

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Monica Flores, to discuss the purpose of the visit. Today's visit is in response to the facility's self report of a fire in a resident's room. The investigation revealed that the personal lamp owned by the resident involved tipped over and malfunctioned, starting the fire. The resident attempted to put the fire out with a blanket. Staff responded immediately to the fire alarm and extinguished the fire with a fire extinguisher. Fire department and paramedics responded to the scene. Residents were assessed and no injuries were identified. No resident was transported to the hospital during the event. The investigation revealed that the staff members involved assisted the residents to safety. LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Monica Flores, Executive Director, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 14, 2025

Allegation investigated: Uncleared staff caring for residents.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to initiate and deliver findings for a complaint investigation regarding the above-mentioned allegation. LPA identified themselves and met with Executive Director Monica Flores, to discuss the purpose of the visit and elements of the complaint. During the visit LPA collected facility records, and interviewed staff. On 03/28/2025 it was alleged that an uncleared staff was caring for residents due to being underage. Staff interviews revealed that the staff in question had a valid work permit, approved by their school, to work at the facility during the summer of 2024. Review of facility records corroborated staff statements, showing that the staff member had the legal background check documents and records in their file. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Monica Flores, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 4, 2025 · control 08-AS-20250328163548

Allegation investigated: Staff yells at residents.

On March 30, 2025, the California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent visit to gather information regarding the above allegation. LPA met with Philip Green, the Food Services Director, and explained the purpose of the visit. LPA contacted Monica Flores, Executive Director, and informed Flores of the intention of the visit. The investigation consisted of Interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1 to #7 (S1-S7) and resident members #1 to #9 (R1-R9). List of documents reviewed/obtained Resident Roster (dated 09/28/23 & 03/29/25), Staff Roster (dated 10/11/23 & 03/29/25), (R1)'s Physicians Report LIC 602 (dated 06/01/22 and 11/02/22), Residence and Care Agreement (dated 06/06/22), Resident Assessment (dated 06/03/22), Identification and Emergency Information LIC 601 (dated 06/02/22), and other pertinent documents associated with this complaint. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff yells at residents. The complaint states that the facility staff yelled at Resident #1 (R1). On October 5, 2023, during a meeting with residents about the facility's updated policies, Staff #1 (S1) reprimanded (R1) after (R1) asked a few questions regarding the new mileage radius of the facility van. Following the meeting, (S1) approached (R1) and criticized (R1) for asking questions in front of other residents in the meeting. (R1) felt humiliated as a result of this confrontation. On October 11, 2023, between 10:00 AM and 11:30 AM, the Department interviewed a staff member identified as Staff #1. (S1) denied having yelled at Resident #1 (R1) and stated that this accusation was false. (S1) explained after the Meet and Greet meeting held on October 5, 2023, (R1) approached (S1) while leaving the meeting. (R1) stated to (S1), “Why are you being so mean to me?” (S1) reported stating to (R1) that (S1) has not been mean to (R1) and that the new transportation policy would only affect new residents that are placed at the facility after the facility’s attorneys revise the admission agreement. (S1) firmly denied raising (S1)'s voice at (R1). On October 11, 2023, between 10:00 AM and 11:30 AM, the Department interviewed a staff member referred to as Staff #2 (S2). During the interview, S2 recounted an incident from the Meet and Greet meeting held on October 5, 2023, where (R1) asked several questions and who advocated for other residents facing cognitive impairment challenges. Due to (R1)'s persistent questioning during the meeting, Staff #1 (S1) appeared to be "annoyed" and dismissed (R1)'s inquiries, stating, "No, not right now, give me a second." (R1) continued addressing sensitive issues related to facility turnover, visibly upset (S1). (S2) reported that (R1) felt upset over the negative interaction after the meeting and apologized for the encounter with (S1). Furthermore, (S2) mentioned, according to (R1), that (S1) reprimanded (R1) and yelled, "Don't you ever speak to me like that again!" in front of the residents. This confrontation left (R1) feeling humiliated. On March 29, 2025, between 11:50 AM and 12:30 AM, the Department interviewed staff members identified as Staff #3 through Staff #5. Three (3) of the three (3) staff members were unable to recount any incident between Resident #1(R1) and Staff #1(S1) on October 5, 2023. Not all staff members were able to confirm this accusation. Both (S3) and (S4) noted that (S1) and (R1) displayed inconsistent behavior but did not witness the incident themselves or hear from others if it had occurred. (Evaluation Report continue LIC 9099-C) On March 29, 2025, between 09:25 AM and 11:45 AM, the Department interviewed resident members identified as Resident #2 through Resident #8 (R2-R8). Seven (7) out of the seven (7) resident members confirmed are unable to validate this accusation. (R2-R8) commended all facility staff, noting that their interactions with Staff #1 (S1) were cordial and professional. They also stated that they had never witnessed inappropriate behavior from (S1). The Department attempted to interview Resident #1 (R1) several times by telephone, but these attempts were unsuccessful because the contact number was no longer valid. Additionally, (R1) is no longer a resident at the facility and did not provide a forwarding contact address. The Department reviewed Resident #1 (R1)’s Residence and Care Agreement California (dated June 06, 2022). It revealed outlined on page 26 subsection (I), title “Personal Right,” indicated in part, "Consistent with California Law, you shall have the rights set forth in the Statement of Residents’ Personal Rights. A review (R1)’s Physician's Report LIC 602 (dated 06/01/22 and 11/02/22) revealed (R1) had no mental health challenges. Further review of (R1)’s prescribed medication (dated 11/02/22) revealed that all nine medications had side effects affecting psychological condition, including anxiety, headaches, dizziness, confusion, and trouble concentrating (ref: National Institutes of Health - NIH). An additional review of staff training records verified staff had completed Workplace Sensitivity Training Courses, including Resident Rights, Elder Abuse, Sexual Harassment Prevention, Cultural Competency, Standard Precautions, and Customer Service. During the visit on March 29 and 30, 2025, the Department identified that the facility promotes the rights of its residents. To improve the environment, posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. This helps ensure that residents are well-informed about their rights, contributing to their well-being. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is determined Unsubstantiated. An exit interview was conducted with Philip Green, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Mar 30, 2025 · control 18-AS-20231006100625

Allegation investigated: Staff are not assisting resident with transportation. Staff are not adhering to the admission agreement.

On March 29, 2025, the California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent visit to gather information regarding the above allegations. LPA met with Monica Flores, Executive Director, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of Interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1 to #7 (S1-S7) and resident members #1 to #9 (R1-R9). List of documents reviewed/obtained Resident Roster (dated 09/28/23 & 03/29/25), Staff Roster (dated 10/11/23 & 03/29/25), (R1)'s Physicians Report LIC 602 (dated 06/01/22 and 11/02/22), Residence and Care Agreement (dated 06/06/22), Resident Assessment (dated 06/03/22), Identification and Emergency Information LIC 601 (dated 06/02/22), and other pertinent documents associated with this complaint. (Evaluation Report continues LIC 9099-C) This report serves as an amendment to clarify the finding. It does not supersede the complaint investigation findings reflected in the report created 03/29/25. Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff are not assisting resident with transportation. The complaint alleges that the facility staff are not assisting Resident #1 (R1) with transportation. (R1) is not receiving adequate transportation support for medical appointments, requiring (R1) to find alternative transportation independently. On September 28, 2023, between 10:10 AM and 1:15 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Four (4) out of the five (5) staff members reported that transportation for residents had been unavailable for approximately four months due to mechanical issues or a lack of proper documentation for the facility’s Mercedes-Benz Sprinter van. On September 28, 2023, between 10:10 AM and 01:15 PM, the Department interviewed resident members identified as Resident #1 through Resident #3 (R1-R3). Three (3) out of the (3) resident members reported that staff informed them the facility van was out of commission for repairs and didn't have a current vehicle registration card. The resident must arrange alternative transportation using taxis or Uber rides, which are out-of-pocket costs for the resident and are non-reimbursable. On March 29, 2025, between 09:25 AM and 11:45 AM, the Department interviewed resident members identified as Resident #4 through Resident #9 (R1-R9). Five (5) out of the six (6) resident members confirmed that the facility van was out of commission for several months in 2023 and had arrangements with family members to provide transportation services. On March 29, 2025, between 11:50 AM and 12:30 PM, the Department interviewed staff members identified as Staff #6 and Staff #7. One (1) of the two (2) staff members recounted an incident from 2023 when the transportation van was rendered out of commission, impacting the daily routines and facilities operations. This unexpected breakdown had implications that extended inconvenience, affecting the staff's ability to transport individuals as needed efficiently. The Department reviewed Resident #1 (R1)’s Residence and Care Agreement California (dated June 06, 2022). It outlined on page 9 subsection (G), title “Transportation,” indicated in part, "We will make available to residents, or otherwise assure the provision of, scheduled transportation to the nearest appropriate health facilities for medical and dental appointments, social services agencies, shopping, and recreational facilities within a 12-mile radius. (Evaluation Report continues LIC 9099-C) This report serves as an amendment to clarify the finding. It does not supersede the complaint investigation findings reflected in the report created 03/29/25. As a result, residents are entitled to scheduled transportation to medical and dental appointments within a 12-mile radius of the facility. Further review of the facility’s van temporary California Registration Care (dated September 12, 2023) and invoice for wheelchair lift replacement (dated September 11, 2023) validated the information provided by staff and resident statements. The Department reviewed the facility’s transportation request forms from April 2023 to September 2023. It found that transportation for medical and dental appointments was not provided between May 12, 2023, through September 19, 2023. According to the facility's transportation log, transportation for Resident #2's medical appointment scheduled for May 16, 2023, was canceled. Additionally, the concierge was instructed not to make any transportation reservations until further notice. On March 29, 2025, between 12:37 PM and 1:26 PM, the Department inspected the facility's Mercedes-Benz Sprinter van and confirmed that the van and the wheelchair lift were fully operational. However, the vehicle's registration tags from the Department of Motor Vehicles had expired in September 2024, demonstrating that the van is currently being operated with outdated registration. Based on the gathered information, sufficient evidence is demonstrated to substantiate the validity of this allegation. Allegation #2: Staff are not adhering to the admission agreement. The complaint details alleged that the staff does not adhere to the admission agreement. It is reported that staff do not follow the admission agreement guidelines when regarding transportation services. Staff are not consistently adhering to the admission agreement guidelines for transportation services, which is a concern. This oversight compromises their commitment to providing reliable and practical support for the residents in care. On September 28, 2023, between 10:10 AM and 1:15 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Three (3) out of the five (5) staff members confirmed that the facility has an enforced 10-mile radius policy for transportation services. This policy effectively regulates the transport of residents to their medical and dental appointments and social activities, ensuring that all travel remains within the specified boundary. This approach provided consistent support for residents' transportation needs. (Evaluation Report continues LIC 9099-C) This report serves as an amendment to clarify the finding. It does not supersede the complaint investigation findings reflected in the report created 03/29/25. On September 28, 2023, between 10:10 AM and 01:15 PM, the Department interviewed resident members identified as Resident #1 through Resident #3 (R1-R3). Three (3) out of the three (3) resident members stated that the facility is directing residents toward alternative transportation methods. This includes advising residents to secure taxi or Uber rides, or to arrange medical or dental transportation services through family members. Furthermore, all resident members, along with one staff member, confirmed that residents have been explicitly informed that they will not receive reimbursement for transportation expenses incurred for services within 10 miles of the facility. On March 29, 2025, between 09:25 AM and 11:45 AM, the Department interviewed resident members identified as Resident #4 through Resident #9 (R1-R9). Five (5) out of the six (6) residents replied that the transportation van was out of service during 2023; they had to arrange alternative transportation for social, medical, and dental activities. They were unsure about the transportation limited mileage policy and whether residents had to cover transportation expenses out of pocket. On March 29, 2025, between 11:50 AM and 12:30 PM, the Department interviewed staff members identified as Staff #6 and Staff #7. One (1) of the two (2) staff members confirmed that the facility could not provide transportation services with the non-operating van. Residents had to make their transportation arrangements along with an enforced 10-mile radius policy. The Department reviewed Resident #1’s Residence and Care Agreement in California, dated June 6, 2022. This review revealed that the facility's “10-mile radius policy” is inconsistent with the terms outlined in the residential agreement, which outlines a "12-mile radius policy". Additionally, an entry in the facility’s Transportation Log from September 26, 2023, noted an appointment scheduled at 1:30 PM, which exceeded the specified 10-mile limit, further demonstrating the facility's implementation of this policy. Based on the gathered information, sufficient evidence is demonstrated to substantiate the validity of this allegation Based on observations, interviews, record reviews, and analysis, the preponderance of evidence standard has been met; therefore, the allegations that "Staff are not assisting resident with transportation" and "Staff are not adhering to the admission agreement" are determined Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted, and Activities Director Adriana Marquez was provided with a copy of this report and appeals rights. This report serves as an amendment to clarify the finding. It does not supersede the complaint investigation findings reflected in the report created 03/29/25.the state’s words, verbatim · CDSS document, Mar 29, 2025 · control 18-AS-20230925083814

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Apr 22, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed…(2) The licensee shall provide assistance in meeting necessary…transportation… available medical or dental facility… In providing transportation the licensee shall do so directly...arrangements for this service. This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee failed to provide transportation for residents when the van was out of service, as agreed in the Residence and Care Agreement. DMV registration tags were expired. This poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 29, 2025

Plan of correction: The licensee will comply with Title 22 Reg 87465 and arrange transportation services and DMV registration renewal for 2025. A written statement confirming the review of Title 22 Reg 87465 and a copy of the DMV renewal tags must be sent to LPA Dabuet by 04/22/25 at ernand.dabuet@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Apr 22, 2025

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidence by: Based on record reviews and interviews, revealed that the licensee failed to comply with transportation service conditions and enforced a policy that contradicts the admissions agreement. This poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 29, 2025

Plan of correction: The licensee will comply with Title 22 Reg 87507 and the facility's admissions agreement. A written statement confirming the review of Title 22 Reg 87507 and a copy of an addendum to the admissions agreement must be submitted to LPA Dabuet by 04/22/25 at ernand.dabuet@dss.ca.gov. This report serves as an amendment to clarify the finding. It does not supersede the complaint investigation findings reflected in the report created 03/29/25.

Allegation investigated: Licensee did not ensure provision of toilet paper. Licensee did not administer medication as prescribed

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation(s). LPA introduced themselves and disclosed the purpose of the visit to Executive Director Angela Scott-Kapiloff. On 04/25/2024 it was alleged that Licensee did not ensure provision of toilet paper for residents, and Licensee did not administer medication as prescribed. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, and outside sources. Staff members consistently referred to an existing facility policy that limited residents to 2 rolls of toilet paper per week. Staff stated that when a resident needs more than this, it is the family's responsibility to provide the additional toilet paper. Interviews were mixed regarding how strict the policy actually was, and some staff were unsure of the exact limit, offering that residents received 1 or 3 rolls. Management informed that the policy was not in writing, however the directive was corporate policy. Staff offered that some residents and families prefer to supply their own toilet paper due to preference of brand or quality. (Continued on LIC9099-C p.1) Substantiated (Continued from LIC9099 p.1) Review of facility records revealed documentation from the facility requesting families to send additional toilet paper due to their resident running low or going through it quickly. LPA spoke with a staff member who contacted a family to bring additional toilet paper to confirm if the request was done to accommodate the rule, or if it was due to resident preference of brand. The staff member stated that they contacted the family to provide more toilet paper due to the rule of 2 rolls per week. Review of the Residence and Care Agreement revealed no documented policy informing families and residents of the 2 rolls per week rule. The agreement offers that the facility will provide, for a fee, certain personal care supplies if a resident is unable or chooses not to purchase them for themselves. However, the item of toilet paper was not found as a purchasable item from the facility. An additional document referenced in the Residence and Care Agreement pertinent to this procedure was not able to be produced by the facility. Three outside sources were contacted regarding the allegation. One outside source was not aware of any issues surrounding toilet paper at the facility. A second outside source was not able to speak to the allegation due to lack of consent from the resident in question. A third outside source confirmed the facility policy regarding 2 toilet paper rolls per week and advised they were not made aware of the rule prior to their resident moving into the facility. Regarding the allegation, "Licensee did not administer medication as prescribed", the accuracy of R1's medication administration by the facility was brought into question, and that the facility cancelled an eye drop prescription for R1 outside of the doctor's order. Staff members interviewed did not have knowledge of any medication errors for R1, however, the Medication Administration Record during the timeframe of the complaint showed that a PM medication administration was not given on 04/11/2024. No records were found to explain the missing administration, such as documentation error or resident refusal. Review of facility records revealed that the facility received an order from R1's doctor to discontinue an eye drop medication on 04/17/23. Additional records showed that the existing supply for the medication was discarded due to being expired. No evidence was found to support that R1's prescription was discontinued by the facility outside of the physician's order, or that a medication error existed with the eye drops. An outside source familiar with the issue was not able to speak to the allegation due to lack of consent from the resident. R1 was not able to be interviewed due to no longer living at the facility. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violations occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided (Continued from LIC9099 p.1) Staff informed of a laundry basket in R1's room that was made of a natural material that began to harbor mold. Staff informed that R1's responsible party was notified and requested to replace the basket with a new one. Records review revealed a contractor invoice during the timeframe of complaint to replace the flooring in question. This corroborated staff statements that the facility was in the process of correcting the issue. Facility records were found regarding staff member communication with R1's responsible party, requesting for a new laundry basket to replace the old one due to mold on the bottom. This corroborated staff statements that attempts were made to correct the issue. An outside source familiar with the situation was not able to speak to the allegation due to lack of consent from the resident. During an unannounced facility visit LPA directly observed the flooring in question. The bathroom floor had dark brown/black discoloration under the seam that connected the shower to the vinyl flooring. The flooring was observed to be separating and curling up, away from the base. The substance was not fuzzy in texture and did not wipe off when touched. No evidence was found to show that the substance was tested or identified as mold. The laundry basket in question was no longer present in the room upon notification of potential mold on the bottom and was not able to be inspected by LPA. LPA directly observed the new flooring planks to replace the old flooring in the Memory Care section of the facility, corroborating staff statements and records that the facility was in the process of correcting the flooring. Regarding the allegation, "Licensee did not address air conditioner in disrepair", it was alleged that the facility did not take action regarding R1's air conditioning system not working. Staff interviews were mixed regarding this situation. Some staff were aware that it had broken but stated it was fixed, and other staff did not have knowledge of any air conditioning issues. Management informed that the facility had attempted to fix the air conditioning and that R1 was provided a fan and eventually moved to a different room, partially due to the ongoing air conditioning and bathroom floor issues. Review of facility records revealed an invoice from an HVAC specialist for R1's room during the timeframe of complaint. The invoice was approved by management to conduct the recommended work. Additional facility records showed that maintenance was called to fix R1's air conditioner on a different date during the timeframe of complaint and it began working again. (Continued on LIC9099-C p.3) (Continued from LIC9099-C p.2) Additional records showed communication between the facility and R1's responsible party confirming that a contractor was scheduled to fix R1's air conditioner during the timeframe of complaint. Facility records also corroborated the information regarding R1 being moved to a different room in the facility that did not have air conditioning issues. Outside source interviews were mixed regarding the allegation. One outside source advised that the air conditioner worked each time they assisted R1, with no issues. A second outside source familiar with the situation was not able to speak to the allegation due to lack of consent from the resident. LPA directly observed the air conditioner in question during an unannounced facility visit. The air conditioner did not turn on when prompted, however, R1 had already been living in a different room and subsequently moved out of the facility prior to this visit. No resident was living in the room during this visit and repairs were scheduled prior to a new resident moving in. The air conditioner did turn on and worked properly in the room that R1 had moved to, prior to moving out of the facility. Regarding the allegation, "Licensee did not follow resident's Admission Agreement", it was alleged that the Licensee did not provide the agreed upon laundry service and shower assistance to R1, per the admission agreement. Staff interviews revealed that during the timeframe of complaint, caregivers, Med Techs, and housekeeping were washing resident laundry per the laundry schedule for Memory Care residents. Staff members consistently confirmed during interviews that there were no issues with laundry service and resident laundry was being washed according to the schedule and each resident's admission agreement. Staff informed that R1 was mostly independent regarding showers, requiring reminders only, which staff conducted. Staff interviews revealed that the need for R1's care level to increase existed in order to provide additional support for showers. Review of facility records revealed communication between the facility and R1's responsible party regarding R1 declining to take showers. The communication showed suggestions for how to help R1 shower more frequently. Records review also revealed that R1's laundry was scheduled to be completed on Wednesdays, when their room was cleaned. Review of communication logs showed that staff washed R1's laundry and communicated the need for a new laundry basket due to moisture and mold collecting on the bottom. No record evidence was found to show that R1's laundry was not being washed per the laundry schedule and R1's admissions agreement. (Continued on LIC9099-C p.4) (Continued from LIC9099-C p.3) An outside source familiar with the allegation was not able to speak to the situation due to lack of consent from the resident. Regarding the allegation, "Licensee did not ensure provision of hygiene products", it was alleged that when R1 was moved into a substitute room at the facility, the Licensee did not move their belongings into the new room, resulting in R1 not being able to wash their hands, shower, or change their clothing for 15 days. Staff interviews did not corroborate the allegation, as staff informed that R1's belongings were initially moved into the new bedroom. Staff informed that the logistics of R1's move became confused due to the moving company rescheduling, and an internal communication issue resulted in some of R1's belongings being brought back to the former room, as a staff member believed the move was temporary. Records review corroborated staff statements, revealing that some of R1's items were moved back to the former room in error, however, the records showed that R1's belongings were initially moved into the new room. Narrative Charting notes during the timeframe of concern corroborated staff statements that the timing of R1's move was adjusted due to the moving company not being able to assist on the originally scheduled date. Narrative Charting notes also revealed that once R1's items were moved into the new room, staff attempted multiple times to help R1 unpack their belongings, however, R1 refused stating that they would get the items as they needed them. This resulted in R1's belongings remaining in boxes in their new room. Outside source records and facility records additionally revealed that R1 was able to shower on their own independently and have access to their personal care supplies. Records showed that R1 struggled with taking consistent showers and would refuse to take them for periods of time. Additionally, records showed a potential concern of R1 removing the clothing needing to be washed from their laundry basket and attempting to wear it. Narrative charting notes and Medical Administration Records revealed that although R1 was primarily independent, staff interaction occurred during each medication pass and also during mealtimes. No records were found to indicate that R1 was ignored by staff or not checked on for 15 days straight. An outside source familiar with the situation was not able to speak to the allegation due to lack of consent from the resident. (Continued on LIC9099-C p.5) (Continued from LIC9099-C p.4) While the evidence shows that confusion with the logistics of R1's move existed, evidence was not found to clearly show the frequency of R1's showers, hand-washing, or changing of clothes. Evidence does show that staff attempted to assist R1 during the transition of the move and R1 had a pattern of refusing help and refusing to change clothing and shower. R1 was not able to be interviewed regarding the allegations due to no longer living at the facility. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 18, 2025 · control 08-AS-20240425123147

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(D) · Plan of correction due date: Apr 18, 2025

...The following provisions shall apply:...(3) The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:...(D) Hygiene items of general use such as soap and toilet paper. Based on interviews and records, Licensee did not assure provision of hygiene items of general use such as toilet paper in 2 of 69 residents. This posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: Executive Director confirmed that restrictions on resident toilet paper will cease immediately. Executive Director agreed to retrain staff on the facility policy regarding toilet paper and submit the training sign-in sheets to LPA by the POC due date, as proof.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Apr 18, 2025

87465(c)(2) ...facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions. Based on interviews and records, Licensee did not ensure medication was given according to the physician's directions in 1 of 69 residents. This posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: Executive Director agreed to have all Med Techs review medication administration training procedures. Proof of training will be provided via sign-in sheets to LPA by the POC due date, as proof. ED advised that the new MAR system will not allow a medication to not be marked without explaining why.

Allegation investigated: Staff physically abused resident.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Angela Scott-Kapiloff. On 02/28/25 it was alleged that a staff member (S2) physically abused a resident (R1). The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Staff members interviewed unanimously denied ever seeing another staff member hit a resident. Staff interviews revealed that R1 was experiencing a change in condition, resulting in a delusion that they were being hit and harassed by S2 and two other parties. The accused staff member, S2, was aware of the accusation and stated that they elevated it up their chain of command, providing proof that they had been promoted to a new position, resulting them not seeing R1 often. S2 also informed that were not working the day the incident was alleged to have occurred, which was corroborated by staff schedules during the timeframe of complaint. (Continued on LIC9099-C p.1) Unsubstantiated (Continued from LIC9099) Due to the accusation S2 stated that they intentionally avoided being near R1 to reduce R1's delusion that S2 was taunting them. Additional staff interviews revealed that the situation was not plausible to have occurred and that certain details of R1's story were found to be proven false. Staff believed that R1's progression of cognition decline likely caused them to merge both factual and fictitious events together, creating a situation that did not happen. LPA interviewed R1 during an unannounced facility visit and R1 sustained that the incident occurred. However, R1 was not able to be completely qualified as a valid historian, due to R1 not being able to recall basic information, and offering statements during the interview that were implausible. Two outside sources familiar with R1 were contacted regarding the allegation. One outside source confirmed being told by R1 that the event occurred, however no additional information was provided to them to corroborate the claim such as witnesses, date, time etc. The second outside source did not respond to requests for interview. Facility records and medical records were reviewed regarding the allegation. The records revealed that R1 experienced a change in condition due to an acute infection, which resulted in unusual behavior and paranoia. Facility records showed that R1 was being monitored by staff due to the changes, and monitoring was continued throughout their medication regimen to resolve the infection. The evidence indicates that R1 was experiencing a change in condition resulting in a delusion due to an acute infection. Records and interviews revealed that the incident was implausible due to specific details provided by R1 being proven untrue, and record evidence that the staff member in question was neither working the day of the incident in question and was also no longer in the position claimed. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 18, 2025 · control 08-AS-20250228102124

Allegation investigated: Licensee permanently changed resident's accomodations without required notice. Licensee did not answer communications from a representative promptly.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Resident Services Director Nae Brownell. On 12/09/2024 it was alleged that Licensee permanently changed a resident's accommodations without required notice and Licensee did not answer communications from a representative promptly. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, outside sources, and LPA direct observations. Regarding the allegation, "Licensee permanently changed resident's accommodations without required notice", it was alleged that a resident was permanently moved to a different room in the facility without the required written 30-day notice to the responsible party. Staff interviews corroborated the allegation, informing that residents on the second floor of the Memory Care unit were moved to the first floor to accommodate the second level being converted to Assisted Living units. (Continued on LIC9099-p.2) Substantiated (Continued from LIC9099 p.1) Facility management stated that the move was urgent due to the scheduling of the contracted flooring replacements. Management confirmed that verbal notice was provided to all Responsible Parties for the affected residents, however a 30-day written notice was unable to be issued. Staff interviews further revealed that confusion existed among staff and residents/resident families regarding whether the resident moves were temporary or permanent. Review of facility resident rosters before and after the timeframe of complaint confirmed that the Memory Care residents on the second floor were reassigned to first floor rooms. No records were found to show that the Licensee provided the responsible parties involved the required 30-day written notice. The Residence and Care Agreement states that the facility will provide 30-day written notice to residents if a substitute apartment is necessary for a resident. Regarding the allegation, "Licensee did not answer communications from a representative promptly", it was alleged that the Licensee did not respond to inquiries, voicemails, or messages left by a responsible party. Staff interviews corroborated the allegation, informing that management staff did not consistently respond to resident families timely. Staff informed having knowledge of family members contacting the facility multiple times without response from management. Three (3) outside sources familiar with the facility were interviewed regarding the allegation. Two of the outside sources were unfamiliar with the response time from management. One outside source informed of circumstances where messages had been left with management multiple times with no return response. Review of facility records showed written requests made by a resident's responsible party to be responded to by management. The records showed that three attempts were made to three persons in management by the responsible party over a twelve (12) day period with no return response from management. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violations occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Resident Services Director Nae Brownell, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099 p.1) Evidence exists that the Licensee did not provide written notice within the required timeframe of a resident's permanent room substitution in order for the responsible party to set up the phone. However, due to the facility having a communal telephone for use, the telephone access requirement was met. During an unannounced facility visit on 02/21/2025 LPA directly observed the communal phone provided by the facility and confirmed that it was in working order. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Resident Services Director Nae Brownell, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 7, 2025 · control 08-AS-20241209163025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(16) · Plan of correction due date: Mar 28, 2025

87468.2(a)...residents shall have all of the following personal rights: (16) To written notice of any room changes at least 30 days in advance unless a room change is agreed to by the resident, required to fill a vacant bed, or necessary due to an emergency. Based on records and interviews, Licensee did not provide written notice at least 30 days in advance to responsible parties regarding room changes. This posed a potential personal rights risk to 1 of 68 residents in care.the state’s words, verbatim · CDSS document, Mar 7, 2025

Plan of correction: Licensee certified that upon any future room substitutions, the resident/ responsible party will be provided the required written 30-day notice, per the facility's Residence and Care agreement and Title 22 regulations. Licensee agreed to retrain staff on personal/additional personal rights with training sheets to be submitted by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: Mar 28, 2025

87468.1(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately. Based on records and interviews, Licensee did not promptly respond to communications from a resident's representative. This posed a potential personal rights risk to 1 of 68 clients in care.the state’s words, verbatim · CDSS document, Mar 7, 2025

Plan of correction: Licensee agreed to audit the facility's process regarding resident and representative communication, and correct practices contributing to delays in response times. Licensee agreed to retrain staff on personal/additional personal rights with training sheets to be submitted by POC due date.

Allegation investigated: Staff did not answer resident's call button in a timely manner. Licensee did not ensure chemicals were properly stored.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation(s). LPA introduced themselves and disclosed the purpose of the visit to Resident Services Director Nae Brownell. On 01/23/2025 it was alleged that staff did not answer resident's call button in a timely manner and Licensee did not ensure chemicals were properly stored. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations. Staff interviews corroborated the allegation, staff informing that specific days of the week had particularly low staff, resulting in long resident wait times. Staff informed of observing approximately 40-minute wait times for resident pendants to be responded to. Staff informed that residents complained to them about the extended wait times, expressing concern about not being tended to if an emergency occurred. (Continued on LIC9099 p.2) Substantiated (Continued from LIC9099 p.1) Staff informed of instances where there was one (1) caregiver responding to all Assisted Living residents, and staff informing residents that they would return but never coming back to assist them. Staff interviews showed that that staff attempted to assist residents timely, but insufficient staffing had resulted in residents waiting for long periods of time for assistance. Staff informed that families have confronted them about only one (1) staff member working the floor and there not being enough help for residents. Outside source interviews were mixed regarding resident wait times. One outside source informed observing resident wait times between 5-10 minutes. A second outside source informed that staff did not respond for 30 minutes when their resident pushed their pendant for help. A third outside source did not have specific wait times for pendant responses, but expressed concern with how few staff have been observed assisting the residents in memory care. The third outside source informed that staff have admitted that there were not enough caregivers on each shift to meet the residents' needs. Review of facility call button records during the timeframe of complaint revealed that between 01/19/25 11:28pm to 01/24/25 2:59pm, within less than a 5-day period, there were 55 pendant calls with wait times 20 minutes or above, with the longest recorded time being 86 minutes (18 pager announcements to staff) and one call with which there was no response by staff (21 pager announcements to staff before the announcements ceased). This record corroborates the reporting party statements as well as staff and resident interviews that residents commonly waited for extended periods for staff assistance. Regarding the allegation, "Licensee did not ensure chemicals were properly stored", it was alleged that hazardous chemicals were accessible in a first floor storage room and on an outdoor patio. Staff members who were interviewed consistently denied observing or being aware of any chemicals that were accessible to residents. No staff members interviewed had been informed by any resident that chemicals were not properly stored. An outside source informed that a door to a room containing chemicals on the first floor was unlocked during a visit. A second outside source denied observing any chemicals that had been improperly stored or made accessible to residents. During unannounced facility visits on 01/24/25 and 02/21/25 LPA directly observed the first floor laundry room unlocked and unattended by staff. (Continued on LIC9099-C p. 3) (Continued from LIC9099-C p.2) LPA observed cleaning chemicals in unlocked cabinets within this room. During the facility visit on 02/21/2025 LPA observed unsecured plant chemicals and insecticide on the 3rd floor patio. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violations occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Resident Services Director Nae Brownell, to whom a copy of this report, the and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099 p.1) Staff interviews informed that R1 was at baseline the day before and the day of their death. Staff informed that R1 had been observed participating in social activities and resting in their room a few hours prior to their passing. The staff interviewed informed that there were no indications of concern. The information provided by staff was partially inconsistent from the care notes, which documented that R1 was exhibiting symptoms outside of their baseline prior to their passing. Review of facility care notes revealed that R1 experienced a change in condition the day prior to passing away, with increased fatigue and inability to consume medications or food. The care notes showed that staff conducted wellness checks and contacted R1's hospice agency regarding their condition. The Death Report submitted by the facility stated that R1's cause of death was "End of Life Parkinson, pulmonary disease" (sic). The Doctors Worksheet for Death Certificate, dated 01/22/25, completed by a Medical Examiner, stated that R1's immediate cause of death was Cardiorespiratory Arrest, due to End Stage Parkinson's. Additional records of resident pendant response times showed that R1 pushed their pendant the morning of their passing, and staff responded after 41 minutes. Outside source interviews did not corroborate the allegation. Two licensed outside medical professionals familiar with R1's care informed that R1's cause of death was related to their end-stage diagnosis and a cardiac/respiratory event. One outside source stated that they assessed R1 the day before their passing and they were observed to be experiencing lethargy and a lowering heart rate. The outside source did not observe any neglect or lack of supervision from facility staff and did not believe that caregiver supervision contributed to R1's passing. Both outside sources were asked if the possible delay in response time to R1's pendant call contributed to R1's passing. Both medical professionals informed that the staff response time was not related to R1's passing, as R1 was receiving end-of-life care and was on Do Not Resuscitate (DNR) status. Due to this status, no life-saving interventions would have been implemented for R1, as the condition that caused them to pass was a natural progression of their end-stage disease. The outside sources did, however, express concern that R1 may have been unnecessarily uncomfortable or possibly in distress during their passing if pain medication was needed for comfort. The records and interview evidence shows that R1's death was a natural progression of their end-stage disease and did not indicate culpability of the facility for R1's death. Additionally, the evidence showed that staff monitored and checked on R1 according to their care plan and contacted the Hospice agency with changes of condition. (Continued on LIC9099-C p.3) (Continued from LIC9099-p.2) Regarding the allegation, "Licensee did not provide adequate food service to residents", it was alleged that residents were being fed unsanitary/rotten foods, and that staff did not assist residents with feeding. Staff members interviewed denied observing unsanitary or rotten food being served to residents. Staff members informed that some staff eat at the facility and no concerns were noted. Additionally, staff informed that all residents in Assisted Living were capable of feeding themselves, and limits existed regarding the extent to which staff were allowed to help a resident eat, due to the facility not being skilled nursing. Outside source interviews did not corroborate the allegation. Outside sources confirmed directly observing meals served at the facility, an no meals were observed to be rotten or unsanitary. No residents had reported to the outside sources that the food was not of good quality. Review of food menus during the timeframe of complaint were reviewed. The documents revealed that the food item of concern, which staff were alleged to have not assisted residents with eating, was only offered on the "Always Available Menu" and not given as a regular entree. This showed that residents would have had to intentionally order the item for it to be prepared for them outside of the entrée item. During five (5) unannounced facility visits LPA directly observed the food service at the facility. LPA observed dining staff tending to residents, and food accommodations such as meat cut up upon request. During certain visits LPA spoke to residents in the dining room, inquiring about the food. The residents stated the food was good and did not express concern about unsanitary or rotten meals. LPA also observed the cooking equipment used to prepare meals; the kitchen was clean, sanitary, and organized without issue. An outdoor grill was found to have dried food particles, however, interviews revealed that it had not been used in many months and no evidence existed that food was being cooked on the barbecue without being cleaned, or that dried food particles were being fed to residents. Regarding the allegation, "Licensee did not ensure facility was in good repair", it was alleged that the ADA accessible doors did not open upon pushing the button and a balcony patio was hazardous/unsafe. Staff interviews revealed that the push button to the first floor back patio had been disconnected due to a malfunction and was in process of being repaired. Staff members interviewed denied having knowledge or observations of the second or third floor patios being hazardous or in disrepair. (Continued on LIC9099-C p.4) (Continued from LIC9099-C p.3) Staff denied that any resident had expressed concern about either balcony patio. Staff interviews further revealed that the second floor patio was temporarily closed due to the remodeling of the second floor dining room, which the patio balcony was connected to. Outside sources interviewed denied having observations of the second or third balcony being in disrepair. Outside sources denied that any resident had expressed concern regarding the safety of the patio balconies. No records were found to refute or corroborate the allegation. During an unannounced facility visit LPA directly observed the patios in question. The second floor patio was inaccessible due to it only being able to be accessed through the dining room on that level, which was closed due to remodel. LPA observed both patio balconies to be free of clutter. LPA observed both patio balconies to be of sound structure, with high concrete and glass walls well over head height, with safety features. Both second and third patio doors were manual without push button features. Regarding the allegation, "Licensee did not ensure facility temperature was within the required range", it was alleged that an area of the facility was abnormally cold. Staff interviews were consistent regarding the temperature of the 3rd floor being cold. Maintenance staff informed that the temperature was due to the cooling feature of the recently installed boilers, an issue which was in the process of being fixed. Staff informed that the low temperature did not affect the resident rooms and was isolated to a specific hallway. Staff informed that each resident room had an individual thermostat that each resident could adjust to their comfort. An outside source informed observing the area of concern and recalled that the temperature felt approximately in the 60's but they did not have an observation of the thermostat to know the exact temperature. A second outside source was unaware of any portions of the facility being significantly cold. Facility records corroborated staff statements that the issue was in the process of being addressed. Review of email invoices and text messages between management and outside contractors showed that the Licensee was attempting to correct the issue and did not delay in attempting to correct it. Continued on LIC9099-C p.5) (Continued from LIC9099-C p.4) During an unannounced facility visit on 01/24/25 LPA directly observed the area of the facility in question. LPA observed the temperature to decrease in the hallway outside of the 3rd floor boiler room. The same hallway farther away from the boiler room was shown to be warmer, 71 degrees, according to the thermostat. During an unannounced facility visit on 02/21/25 LPA directly observed the same hallway to be nearly consistent in temperature throughout. This corroborates staff statements and records regarding ongoing repairs, and that the issue was corrected. While a portion of the facility was found to be low in temperature, the evidence showed that the Licensee did not allow it to remain unaddressed, and made efforts to fix the issue. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Resident Services Director Nae Brownell, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 7, 2025 · control 08-AS-20250123111801

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 28, 2025

87411(a)Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met, as evidenced by: Based on interviews and records review, Licensee did not ensure staffing was sufficient in numbers and competent to provide the services necessary to meet resident needs in 68 of 68 residents. This posed a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Mar 7, 2025

Plan of correction: Resident Services Director agreed to audit pendant response times and create a plan to reduce them. Training will be provided to caregiving staff regarding response times and meeting resident needs. Training sign-in sheets will be submitted by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Mar 28, 2025

Storage Space and Access... licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, 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, as evidenced by: Based on interviews and direct observations, Licensee did not ensure cleaning solutions and poisonous substances were locked in storage or attended while in use. This posed a health and safety risk to 68 of 68 residents.the state’s words, verbatim · CDSS document, Mar 7, 2025

Plan of correction: Resident Services Director agreed to retrain staff regarding inaccessible/hazardous items and to keep the first floor laundry room locked at all times when not in use. Additionaly, the 3rd floor patio plant tools and chemicals will be placed in a locked storage, only to be accessed by residents who have approval on their LIC602 to use them. Proof of training will be provided by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Resident Services Director Nae Brownell, to discuss the purpose of the visit. Today's visit is in response to two self-reported incidents submitted by the facility regarding a resident death and a resident who with a medical condition who is no longer able to meet their own insulin needs. LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Resident Services Director Nae Brownell, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Mar 7, 2025

Allegation investigated: Lack of supervision resulted in resident elopement.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Angela Scott-Kapiloff. On 12/11/24 it was alleged that the Licensee's lack of supervision for Resident 1 (R1) resulted in R1 eloping from the facility. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Staff interviews consistently showed that R1 was almost completely independent and lived in the Assisted Living section of the building. The interviews did not corroborate that staff provided less supervision than was necessary for R1, as interviews showed that staff were aware that R1 was not able to leave the building unassisted, and redirected R1 when R1 attempted to leave by themselves earlier the day of the incident. Interviews revealed that staff were unaware that R1 came back downstairs later in the day and exited the facility through a door other than the front entrance. (Continued on LIC9099-C p. 2) Unsubstantiated (Continued from LIC9099 p.1) Staff interviews revealed that the elopement was a new behavior for R1, as they were noted to be a low elopement risk and had not attempted to leave the facility unassisted before this incident. Staff interviews additionally revealed that the Licensee adjusted R1's supervision level after the incident by implementing alert charting (status checks with documentation) and escorting R1 to all events. The interviews revealed that staff provided the level of supervision consistent with R1's care plan, R1 experienced a change in condition by eloping for the first time, and the Licensee immediately adjusted the care level/supervision provided to R1 after the incident. R1 was interviewed regarding the incident. R1 was not able to recall why they left the facility or which door they exited through. R1 was only able to recall the events after the incident occurred. Outside source interviews did not refute or corroborate the allegation. Attempts were made to contact the party who assisted R1 in the community after the elopement, but the source did not respond to inquiries. A second outside source familiar with the facility was contacted and confirmed being aware of the incident. However, this source did not conduct an investigation or pursue any additional information regarding the incident. Review of facility and outside source records confirmed staff statements that while R1 was not allowed to leave the building unassisted, they were not a wandering risk. R1's Elopement Risk Assessments show that R1 was a low wandering risk. R1's Needs and Services Plan, as well as an acuity assessment, showed that R1 was completely independent, with the exception of being provided reminders for bathing, using their walker and attending activities. Charting Notes for R1 were absent of any elopement or wandering incidents for R1 prior to this event. The charting notes showed that the Licensee increased their assistance/supervision to R1 after the incident; R1 was placed on alert charting and escorted to all events after the incident. Records showed that R1 explicitly requested less supervision from staff by signing a waiver not to receive checks at night. During two unannounced facility visits, LPA directly observed all facility exits. LPA observed the exits for Assisted Living to be consistent with the needs and supervision level for independent Assisted Living residents. (Continued on LIC9099-C p.3) (Continued from LIC9099-C p.2) The information gathered during the investigation did not show that the Licensee provided inadequate supervision to R1, resulting in the elopement. The evidence shows that R1 did not have a history of elopement behaviors and experienced a change in condition, and that the facility immediately adjusted the care plan to accommodate. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 21, 2025 · control 08-AS-20241211132531

Type of visit: POC

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Angela Scott-Kapiloff, to discuss the purpose of the visit. Today's visit was to collect proof for the completed plan of corrections for deficiencies cited on 1/15/25 during the facility's annual inspection. LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. The facility's plan of corrections was completed and the deficiency is cleared. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jan 24, 2025

Allegation investigated: Licensee did not follow infection control notification policy.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to initiate an investigation regarding the above complaint allegation and deliver findings. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Angela Scott-Kapiloff. LPA was away from the facility from 1:15pm to 2:15pm. On 01/06/2025 it was alleged that the Licensee did not follow the facility's infection control notification policy. The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, outside sources, and records review. Staff interviews revealed that the facility did not experience a Covid-19 outbreak during the timeframe of complaint, therefore community notification was not required. Staff informed that two (2) Covid-19 cases existed concurrently at the facility, which did not reach the level of outbreak status. (Continued on LIC9099-p.2) Unsubstantiated (Continued from LIC9099 p.1) Staff informed that the facility's required infection control protocols were put in place, including Personal Protective Equipment (PPE) carts placed outside of the affected residents' rooms, full PPE donned by staff assisting the affected residents, CDC signs placed on the affected residents' doors, notifications made to the affected residents' responsible parties and physicians, and Public Health notified. Interviews with staff revealed consistent knowledge of facility protocols regarding infection control procedures at the facility. The information provided by staff regarding the infection control protocols that were in place were corroborated by facility records. The facility's Illness Tracking Form during the timeframe of complaint showed that five (5) Covid-19 cases existed at the facility. The tracking showed that at most, two (2) residents were under isolation protocols concurrently. Narrative Charting Notes for the residents in question during the timeframe of complaint corroborated staff statements that the physicians and responsible parties for the residents in question were notified of the positive COVID-19 test results. The infection control process outlined by staff was corroborated by the facility's Infection Control Plan, dated 07/01/2023. The Infection Control Plan was absent of directives regarding when the community should be notified of positive Covid-19 cases. Outside source interview with the facility's infection control trainer revealed that the recommendation was for communities to be notified of COVID-19 when the facility reached outbreak status, which was three (3) or more cases occurring at the same time. The outside source did not express concern regarding the facility's adherence to Covid-19 protocols and regulations. Staff statements regarding contacting Public Health were corroborated through website tracking verification with date and timestamps. LPA directly observed the facility's infection protocol specific to COVID-19. LPA observed the use of PPE, disinfectant and sanitation practices, and CDC signage. The observations made by LPA were consistent with staff interviews, outside source interviews, and records review. The investigation did not produce evidence that the Licensee did not follow their infection control notification policy. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 08-AS-20250106152332

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Executive Director Angela Scott-Kapiloff. The facility's license shows a maximum capacity of 101 non-ambulatory residents, ages 60 and above, 10 of whom may be bedridden. The facility has an approved Hospice Waiver for 18 residents. During today’s inspection there were 75 residents in care. LPA and Resident Services Director Mayra Macedo toured the interior and exterior of the facility and inspected a sample of rooms. 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 linens and hygiene supplies were present, as well as Personal Protective Equipment. 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 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. No pools or bodies of water exist on the premises. Per Executive Director Angela Scott-Kapiloff, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) 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. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 15, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Memory Care Director Parris McDaniel, 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 exited the facility without staff knowledge or assistance. LPA interviewed staff and residents and collected records. A wellness check was completed; no health or safety issues were identified. An exit interview was conducted with Memory Care Director Parris McDaniel, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jun 24, 2024

Allegation investigated: Licensee did not adhere to the admission agreement Licensee did not assist resident(s) with transportation

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the finding on the above mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Executive Director Angela Scott-Kapiloff During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents and outside sources. It was alleged that the Licensee did not adhere to the admission agreement. The Reporting Party (RP) specified that the licensee did not provide basic cable and that the cable bill was not paid therefore the cable television was not working. LPA Domingo reviewed the entire admission agreement and basic cable television was no working. LPA Domingo reviewed the entire admission agreement and basic cable (Continue on LIC9099C) Unsubstantiated Continued from LIC9099) television was paid by the facility, if the resident requested more channels or extended cable television, the cost would be billed directly to the resident with separate billing. Staff 3 (S3) (See LIC811 Confidential Names list), provided LPA with the last three months of paid invoices for the basic cable television service. There was no evidence of the bills not paid. LPA Domingo interviewed Resident 1 (R1) and R1 stated that there has not been any cable television problems that R1 can recall. LPA Domingo interviewed Resident 2 (R2) and R2 stated that the cable television has been working since the day R2 moved in which was one year ago. LPA Domingo interviewed Staff 1 (S1) regarding any knowledge of the cable service being discontinued and S1 stated that there has not been any cable service problems at the facility. It was alleged that the Licensee did not assist residents with transportation. LPA interviewed S1 regarding the provided transportation for the residents and S1 stated that the facility transportation bus has been under repairs for the last 4 months and staff members will transport residents to appointments as needed. LPA Domingo requested S3 to provide documentation on the status of the repairs with the transportation vehicle and there are invoices dating being at the end of December 2023 of continued repairs with the transportation vehicle. The most recent repair receipt dated 03/28/24. R1 was interviewed regarding the transportation vehicle and medical appointments. R1 stated that staff provide transportation to appointments as needed and R1 has not been made aware of any other residents concerns regarding the transportation vehicle. R2 was interviewed and R2 was also not aware of any concerns regarding the transportation vehicle or medical appointments being missed because of the repairs being made with the vehicle. Based on LPA's interviews with residents, staff, outside source interview, and records reviewed there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, to whom a copy of this report, and Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 11, 2024 · control 08-AS-20240405151000

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers were granted entry into the facility by Executive Director Angela Scott-Kapiloff after identifying herself and stating the purpose of the inspection. The facility serves elderly residents, age 60 and above, 101 whom may be non-ambulatory. There is an approved Hospice Waiver for 18 residents. The facility is approved for delayed egress. LPA was accompanied by Scott-Kapiloff for a tour of the facility which was conducted inside and out and included a sample of resident units, the dining area and recreation rooms. There is a fire signal system in place and the carbon monoxide detectors were operational. The last disaster drill was conducted on December 2023. Exterior and interior passageways were free from obstructions. Pull cords, sensor alerts with pendants are present in the facility. LPA observed functionality of signal system. Resident and facility room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens, towels, and washcloths. 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. Hot water temperature in residents’ bathrooms were compliant. [Continued on 809-C] [Continued from 809] Facility has a two-day supply of perishable 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. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closet. Medication room is located on the first floor and second floor. The medication carts were locked and stored in the medication rooms. Medications were labeled and kept in compliance with label instructions. LPA interview confirmed the licensee provides assistance in meeting medical and dental needs. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA also conducted a review of In-service training procedures. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. There is a designated movie room, designated art/craft room and a garden activity patio along with gathering areas throughout the facility. At the time of visit, LPA observed a large group activity taking place on both the main floor and memory care unit. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were sited at the time of visit. A final exit interview and a copy of this report, Licensee/Appeal Rights - LIC 9058 (rev. 01/16), were provided to , Executive Director Scott Kapiloff whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Feb 20, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Amy Rodgers and Juliana Barfield conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Angela Scott-Kapiloff. During today’s visit, LPAs briefly toured the facility, reviewed staff and resident records, and interviewed staff and residents. No deficiencies were cited during today’s visit. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection. An exit interview was conducted with the Scott-Kapiloff, to 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, Feb 7, 2024