Greenwood Assisted Living

Type of visit: Required - 1 Year

At approximately 9:05AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Executive Director/Administrator, Frank Nola. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for 41 non-ambulatory and 6 bedridden residents for a total capacity of 47 residents. Facility has an approved hospice waiver for 8 individuals. Upon arrival, LPA was informed that there were 25 Residents in care and 8 staff members on-site. Facility currently has a Probationary License for 2 years per their Stipulation Waiver and Order, Legal Case #7225086303C, effective 07/15/2026 - 07/15/2028. Facility's Stipulation Waiver and Order, Legal Case # 7225086303C, effective 07/15/2026, was reviewed with Executive Director/Administrator. At approximately 10:25AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Executive Director/Administrator, and Staff Member, Jolly Carungcong. The following was observed: facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 23 bedrooms, 2 shower rooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins and dangerous items were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for resident use. A sample size of 6 facility sinks were tested and were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility has a total of five (5) delayed egress doors. All delayed egress doors were tested and operational. Facility fire extinguishers were last inspected March 2026. Facility's smoke and carbon monoxide detectors are hardwired Continued on LIC809C Continued from LIC809 and were last inspected March 2026. Facility's sprinkler and fire system is inspected every 5 years with the last inspection conducted May 2023. Facility's sprinkler system is scheduled to be inspected again May 2028. Facility's last emergency/disaster drill was conducted April 2026. It was observed that facility's April 2026 drill was conducted with only Morning/AM staff members and did not include Evening/PM or Night/NOC staff members. Facility's Emergency Disaster Plan and Infection Control plan were last reviewed and updated July 2026. During walkthrough it was observed that multiple instances of food located in the facility fridges and food storage areas were expired, improperly stored, or unlabelled/not dated. All observed instances were disposed of during visit. It was also observed that facility did not have an adequate supply of emergency water accessible in the event they needed to shelter in place for 72 hours. LPA reviewed staff files. Staff files were all found to be well organized and thorough. Staff files had current First Aid/CPR certification, and were found to have completed annual training. Administrator's Certificate for Frank Nola (6072967740) was current with an expiration date of 01/05/2027. LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date to finish file review and medication audit. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, Plan of Corrections, Appeal Rights, and Copy of Probationary License discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 29, 2026

Allegation investigated: Staff do not answer residents calls for assistance timely Staff do not treat resident with respect

At approximately 9:05AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a complaint investigation regarding the above allegations and met with Executive Director, Frank Nola, and Care Director, Jolly Carungcong. During the course of the investigation, the Department conducted interviews, and made observations. The following allegations were investigated, “Staff do not answer residents calls for assistance timely, and Staff do not treat resident with respect." Complaint alleged that a resident called for help but did not receive help from a facility staff member for at least 20 minutes. Complaint also stated that this resident wanted help to use their commode and were told by facility staff to "go in their diaper." Complaint did not provide any additional information on when these incidents occurred or resident names. It was observed that the facility does have a signal system as required. Facility programs resident call Continued on LIC9099C Unsubstantiated Continued from LIC9099 pendants with a personalized music tone that will play when pressed. Facility staff know which resident is calling based on the music being played. Facility does not have a pendant log system to review response times. LPA conducted interviews with facility staff and a resident. 5 of 5 facility staff interviews stated that facility staff are to respond to resident pendant calls as soon as possible. Staff interviews revealed that there is no specific protocol or policy for pendant response times. Interviews also revealed that out of 23 residents, there are only 5 or 6 residents that have a call pendant available to press. Interviews with Executive Director and Care Director, stated that it is expected that all facility staff respond to pendant calls as soon as possible and to help any resident that is calling. 4 of 5 staff interviews stated that there are zero residents at the facility that use a bedside commode, while 1 interview stated that there is 1 resident that uses a bedside commode. 5 of 5 staff interviews stated that most of the residents receive help with incontinence care or are taken to the restroom as needed. Interview conducted with Resident stated that they have observed staff to respond to their pendant button or to other resident pendants or calls for help quickly. Interview with Resident revealed that they have not observed facility staff to speak to them or to other residents at the facility in rude or inappropriate way and stated that the facility staff members treat them with kindness. Based on interviews conducted and observations made, these allegations are Unsubstantiated. A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director and Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 21-AS-20251105082237

Type of visit: Case Management - Annual Continuation

At approximately 2:00 PM Licensing Program Analyst (LPA) Elias Magdaleno arrived to conduct an Annual Continuation of a 1-year required annual inspection that was started on 9/29/2025 and was greeted by Administrator Jolly Carungcong. Physical Plant inspection and Resident Record review was completed during previous visit. At approximately 2:15 PM LPA conducted review of five (5) staff records. All required documentation present. At approximately 2:40 PM LPA and Administrator conducted a spot check of medication and medication records. Medication is centrally stored and locked. Annual inspection has been completed. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Oct 8, 2025

Type of visit: Required - 1 Year

At approximately 12:25 PM, Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to conduct a required 1-year annual inspection and was greeted by Administrator Jolly Carungcong. Facility is a Residential Care Facility for the Elderly (RCFE) with twenty-two (22) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for eight (8), with four (4) Hospice residents currently in care, and is approved for all non-ambulatory residents, six (6) of which may be bedridden. At approximately 12:30 PM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one (1) story home, was a comfortable temperature, and passageways were free from obstructions. Fire extinguishers were last inspected 4/25. Smoke and Carbon Monoxide detectors are hardwired and last inspected by third party vendor on 5/25. Water temperatures measured 115.7-, 113.7-, and 115.1 degrees F in a spot check of resident accessible sinks, which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. LPA conducted a spot check of resident bedrooms and observed them to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA observed at least a two (2) day supply of perishable and seven (7) day supply of non-perishable food, as well as an emergency water supply. Food was found to be stored in a safe manner with open items covered. There is a shaded seating area in the backyard with outdoor space for activities. Delayed egress doors in back patio were tested and found operational. Facility has an internet access device and internet available to residents in care, and the phone was observed operational during today's inspection. Continued LIC809C... Continued from LIC809... Facility conducts twice yearly disaster drills, and the most recent drill was conducted 5/25. Facility was advised to conduct quarterly disaster drills to maintain compliance. LPA reviewed facility's emergency disaster plan which was last updated 7/25. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights. At approximately 1:40 PM LPA conducted a review of five (5) resident records. All required documentation present. Jolly Carungcong Administrator Certificate 7027194740 expires 1/6/2026. All fees are current as of this time. Updated copies of the following documents were gathered during this visit: Liability Insurance LIC500 - Personnel Report LIC308 - Designation of Responsibility LIC610E - Emergency Disaster Plan The annual inspection will be completed by the Department at a later date. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 29, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 05/09/2025, Licensing Program Analyst (LPA) Felias met with Executive Director, Frank Nola, and Administrator, Jolly Carungcong for a Case Management visit to follow up on substantiated complaint allegations; Complaint Number 21-AS-20231017092122. On March 27, 2024, the Department concluded an investigation which alleged that Staff neglect/lack of supervision resulted in a resident sustaining a serious injury and staff did not assist residents in a timely manner. The Licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities and California Code of Regulations (CCR) Title 22, § 87411(a) Personnel Requirements – General. At the time of the complaint visit on March 27, 2024, an immediate civil penalty of $500.00 was issued and the Licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code §15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation." This is evidenced by the facility not providing care, supervision, and timely medical treatment that resulted in multiple falls, hospitalization, surgery, left hip fracture, and a right hip fracture. Today, 05/09/2025, the Department is issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000.00. However, since an immediate civil penalty of $500.00 was previously issued on March 27, 2024, the amount of the civil penalty issued today will be $9,500.00. Exit interview conducted. A copy of the report issued. Appeal rights provided. Signature on this report acknowledges receipt of the appeal rights found on page two of LIC 421D.the state’s words, verbatim · CDSS document, May 9, 2025

Allegation investigated: Facility Staff hit resident in care

At approximately 9:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with Executive Director, Frank Nola, and Administrator, Jolly Carungcong. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Facility staff hit resident in care.” Complainant alleged that on 07/23/2024, facility staff was seen striking Resident 1 (R1). Complainant stated that incident was seen from the street through R1’s window.The Department conducted interviews with staff and involved parties, reviewed police report and made observations. Complaint alleges that staff were observed hitting a resident in care. Interviews conducted with involved parties stated that during a visit conducted on 07/25/2024, R1 did not have any visible signs of injury or bruising observed. Continued on LIC9099C Unsubstantiated Continued from LIC9099 Photographs of R1 provided to the Department showed that R1 had yellow discoloration on their forehead from March, April and June 2024 which was before the alleged incident of July 2024. Facility documents reviewed indicated that the facility documented when R1 was observed to have skin changes, and that R1’s responsible party was notified appropriately. Interview conducted with Administrator and correspondence provided stated that R1’s Primary Care Physician believed that the discoloration from March, April and June 2024 could be from R1’s medication. Staff denied allegation that they hit the resident. Staff interviews and witness statement provided conflicting information and LPA was unable to confirm that the allegation occurred. Therefore, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Executive Director and Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 15, 2024 · control 21-AS-20240725132325

Allegation investigated: Lack of supervision

At approximately 9:15AM, Licensing Program Analyst (LPA) Felias and Licensing Program Manager (LPM) Victoria Bertozzi arrived unannounced to initiate a Complaint Investigation regarding the above allegation and met with Executive Director, Frank Nola, and Administrator, Jolly Carungcong. LPA and LPM requested and reviewed documents and conducted interviews. Complaint alleges that Resident 1 (R1) was observed lying in the road bleeding and unresponsive near the facility. Report indicated that a witness knocked on the facility door but no one came so they returned to the resident and called 911. It was reported that a second witness arrived and also attempted to knock on the facilty door with no response. Eventually an individual exited the building so a witness was able to make contact with facilty staff who then came outside and responded. Continued on LIC9099C Substantiated Continued from LIC9099C R1 was transported to the hospital. CCL staff confirmed that R1 does have a dementia diagnosis and is not able to leave the facility unassisted. Per interview with Administrator, it appears that R1 eloped from the courtyard that has a gate that leads outside of the facility. Facility's response was to padlock the exterior gates of the facility. CCL staff notified the Administrator that locking exit doors in that manner is a fire clearance violation and requested that facility have the fire department come out to determine if the padlocks are permitted. This allegation is Substantiated. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted. Copy of report, LIC809D, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Administrator and Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 18, 2024 · control 21-AS-20240913093214

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Sep 19, 2024

87705 Care of Persons with Dementia: (b) In addition to the requirements as specified in Section 87208... plan of operation shall address... residents with dementia, including: (2) Safety measures to address behaviors such as wandering... This requirement is not met as evidenced by: Based on documents reviewed, the Licensee did not comply with the section cited above. Resident 1 (R1) eloped from facility. R1’s Physician Report states they have dementia and are unable to leave unassisted. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2024

Plan of correction: Licensee to submit a written plan of updated procedures for elopement prevention and provide response from fire department regarding the padlocks on exterior gates by POC due date of 9/19/2024

Type of visit: Case Management - Annual Continuation

At approximately 9:15AM, Licensing Program Analyst (LPA) Felias and Licensing Program Manager (LPM) Victoria Bertozzi arrived unannounced to continue a Required 1 Year visit and met with Administrator, Jolly Carungcong, and Executive Director, Frank Nola. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for 41 non-ambulatory and 6 bedridden residents for a total capacity of 47 residents. Facility has an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there were 21 Residents in care and 7 staff members on-site. At approximately 9:30AM, LPA and LPM reviewed staff files and client medication. Staff files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was observed to be centrally stored and secure. Administrator's Certificate for Jolly Carongcung (7027194740) current with expiration date of 01/06/2026. LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Active and Current Administrator Certificate Documents to be submitted to Community Care Licensing (CCL) by due date of 10/18/2024. No Deficiencies Cited during Visit. Exit interview conducted. Copy of report discussed and provided to Administrator and Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 18, 2024

Type of visit: Required - 1 Year

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Administrator, Jolly Carungcong, and Executive Director, Frank Nola. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for 41 non-ambulatory and 6 bedridden residents for a total capacity of 47 residents. Facility has an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there were 19 Residents in care and 6 staff members on-site. At approximately 9:15AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:20AM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 26 bedrooms, 2 shower rooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins and dangerous items were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for resident use. Facility sinks were tested and were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Administrator's Certificate for Jolly Carungcong (7027194740) is current with an expiration date of 01/06/2026. LPA reviewed resident files. Resident files were all found to be well organized, thorough and contained the required documentation. Fire extinguishers were last inspected October 2023. Smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency drill was conducted in July 2024. LPA unable to complete the Annual Inspection. Annual Continuation Visit to be conducted at a later date. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator and Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 31, 2024

Allegation investigated: Staff neglect/lack of supervision resulted in a resident sustaining a serious injury Staff did not assist residents in a timely manner

At approximately 1:30PM, Licensing Program Analyst (LPA) Felias delivered findings for a Complaint investigated by the Department regarding the above allegations and met with Licensee, Mark Bello, and Administrator, Jolly Carungcong. Complaint Findings were delivered in person at the Santa Rosa Regional Office. During the course of the Investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “Staff neglect/lack of supervision resulted in a resident sustaining a serious injury, and Staff did not assist residents in a timely manner.” The Department reviewed facility records, facility logs, and conducted interviews with medical providers, residents, families, and facility staff. Continued on LIC9099C Substantiated Continued from LIC9099 “Staff neglect/lack of supervision resulted in a resident sustaining a serious injury” - Resident 1 (R1) was admitted to the facility in June 2023. Facility reported that on 7/18/2023, R1 had decreased appetite and was having a hard time standing so R1’s Responsible Party was called, came to the facility and had R1 sent to the hospital where they were diagnosed with a left “displaced intertrochanteric hip fracture.” Per interviews with staff, R1 did not have an observed fall, however, 4 of 8 staff interviewed noted R1 complaining of pain, refusing care, and not feeling well on 7/17/2023. Interviews and multiple reports revealed that by 7/18/2023, R1 was complaining of pain and was not able to stand. Per interview and medical record review, R1’s leg was observed to be swollen on 7/18/2023. Review of R1’s medical records dated 07/18/2023 noted that facility staff informed emergency personnel that R1’s leg was observed to be swollen since 07/17/2023. Per report, R1 had complained of hip pain on 07/16/2023 but was observed to still be able to bear their own weight. Review of facility’s 24-hour log dated 07/15/2023 and 07/16/2023, showed staff did not note any changes observed for R1. Facility reported that R1 had an unwitnessed fall on 10/08/2023, which staff responded to when they heard R1 calling for help. Per report, R1 was “visually assessed” by staff because R1 did not want to be touched. Two staff members assisted R1 into their wheelchair and then staff called the Administrator who called R1’s Responsible Party. R1’s Responsible Party arrived at facility and requested that R1 be sent to the hospital. R1 was sent to the hospital where they were diagnosed with a right “femoral neck fracture” per obtained medical records dated 10/08/2023. Review of Facility’s 24-hour log dated 10/08/2023, did not note any changes observed. Review of R1’s Physician’s Report dated 06/08/2023, stated that R1 had a dementia diagnosis, had auditory, visual, and motor impairment, and needed assistance with their Activities of Daily Living (ADLs). Review of R1’s Needs and Services Plan, dated 06/24/2023, stated that R1 used a walker and needed help with ambulating and transferring. Review of R1’s Needs and Services Plan dated 06/24/2023, stated that R1 used a walker and required stand-by assistance with ambulating and transferring. Staff interviews conducted reported that they do not look at or have access to resident files and rely on facility management to inform them of resident care needs. Facility staff were unable to identify fall interventions to mitigate R1’s risk for falls. Interviews stated that interventions with R1’s Responsible Party were discussed but nothing was put in place. Review of facility records showed no indication that a care conference was held or that a reappraisal was completed. Review of Facility’s documentation indicated that in the event of a fall or post-fall assessment, staff are to report, access for serious injury and current condition, obtain fall history, assess environment, assess future fall risk, and analyze the fall and create a post fall action plan. Review of Facility’s Program Plan for “Policy and Protocol for Emergencies” stated the following: “Any and all medical emergencies that require assistance will be handled by first calling 911, notifying the resident’s physician, following with communication with the family or responsible party. Continued on LIC9099C Continued from LIC9099C Some items that would be a medical emergency and 911 would be called are, but not limited to the following; expected heart attack, expected stroke, resident found unconscious, their breathing is compromised, seizures, uncontrolled bleeding, falls, etc.” This allegation is Substantiated. “Staff did not assist residents in a timely manner” – Reporting Party stated that they have observed staff sleeping on the facility premises while on duty and have seen staff not responding to residents when they call for help. 3 of 4 staff interviews conducted stated that they had not observed or seen staff sleeping during facility hours. 1 of 4 staff interviews conducted stated they have seen staff members sleeping while on duty. 2 of 2 Resident interviews conducted stated that they have pressed their pendants multiple times before they received a response from care staff. Wait times were reported to be between 20 minutes to an hour. During a Department visit conducted on 11/28/2023, Community Care Licensing (CCL) staff observed that it took 16 minutes for care staff to respond to Resident 2’s (R2’s) pendant call and that they had pressed their pendant about 5 times. CCL staff were informed by the responding caregiver that they were unable to respond to the resident due to doing laundry and helping someone in the bathroom. CCL staff noted that while waiting for care staff to respond to R2’s pendant call, they observed one caregiver cleaning the dining room, one caregiver escorting a resident out of the dining room, and one caregiver walk past R2’s room. This allegation is Substantiated. Based on the Department’s interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An immediate Civil Penalty in the total amount of $500 has been issued for a violation that resulted in the sickness or injury of a resident in care (See LIC-421IM) An additional civil penalty may be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).** Exit interview conducted. Plan of Corrections reviewed and developed with Licensee and Administrator. Copy of report, LIC9099-D, LIC-421IM, and Appeal Rights discussed and provided to Licensee and Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 27, 2024 · control 21-AS-20231017092122

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 28, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)...residents...shall have...personal rights:(4) To care, supervision, and services that meet...individual needs and...delivered by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidenced by: based on interviews conducted, records reviewed, and observations made, Licensee did not ensure that resident was assessed and emergency services sought. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2024

Plan of correction: Licensee to submit written plan outlining direct care staff training to be conducted. Plan shall include who is conducting the training, and cover these areas: Observation of a Resident, Fall Assessment Protocol, and 911 Emergency Services Protocol. Licensee to conduct In-Service Training for all direct care staff. Plan to be submitted by POC due date of 03/28/2024. Training to be submitted no later than 04/10/2024 and include Date of Training, Training Topics, Job Role, Staff Names, and Signatures.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Mar 28, 2024

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met as evidenced by: based on interviews conducted, records reviewed, and observations made, Licensee did not respond to residents in a timely manner. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2024

Plan of correction: Licensee to submit written plan outlining direct care staff training to be conducted. Plan shall include who is conducting the training and cover this area: Responding to Resident Call Buttons Timely. Licensee to conduct In-Service Training for all direct care staff. Plan to be submitted by POC due date of 03/28/2024. Training to be submitted no later than 04/10/2024 and include Date of Training, Training Topics, Job Role, Staff Names, and Signatures.

Type of visit: Office

An Office meeting was conducted today in the Santa Rosa Regional Office. The following individuals were present in the meeting: Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Victoria Bertozzi, Licensing Program Analyst, Caitlynn Felias, Licensee, Mark Bello, and Administrator, Jolly Carungcong. The purpose of the office meeting was to hold an Informal meeting to address areas of concern identified by the Department. The following areas were discussed during the meeting today: We amended Complaint 21-AS-20230417124321 which also has a 2nd level appeal under review. We delivered findings for Complaint 21-AS-20231017092122, issued citations, and noticed the facility that additional civil penalty may be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). We cited the facility for Administrator Qualifications and Duties related to concerns around: Incidental, Medical, and Dental Care Staff Training Facility 911 policies and procedures Facility documentation policies and procedures Resident Care Plans Visitation Eviction Procedures Copies of Regulation 87464 Basic Services, 87411 Personnel Requirements – General, 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities, 87633 Hospice Care of Terminally Ill Residents, and 87224 Eviction Procedures were provided. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Continued on LIC809C Continued from LIC809 The Department discussed the Technical Support Program (TSP) should the facility be open to having TSP work with them on concerns listed above. Exit interview conducted. Plan of Corrections reviewed and developed with Licensee and Administrator. Copy of report, LIC809-D, and Appeal Rights discussed and provided to Licensee and Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 27, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(h)(5) · Plan of correction due date: Mar 28, 2024

87405 Administrator - Qualifications and Duties: (h)Administrator shall have the responsibility to: (5) Provide or ensure the provision of services to...residents with appropriate regard for... physical & mental well-being and needs... Requirement wasn't met as evidenced by: based on interviews, records reviewed, & observations, Administrator didn't ensure R1 received required services outlined in appraisal, by directing staff or updating care plan, when it was evident assistance w/ incontinence care was insufficient & they were notified. This poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Mar 27, 2024

Plan of correction: Licensee to have Administrator review Regulation 87405 - Administrator Qualifications and Duties and submit a written policy defining Administrator Role and Responsibilities. Plan to be submitted by POC due date of 03/28/2024.

Allegation investigated: Staff left resident soiled for an extended period of time Staff did not provide clean linen to resident in care

At approximately 1:20PM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint investigated by the Department regarding the above allegations and met with Administrator, Jolly Carungcong. During the course of the Investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated, “staff left resident soiled for an extended period of time, and staff did not provide clean linen to resident in care”. During the investigation the Department reviewed facility records, requested facility logs, conducted interviews with Hospice providers, residents, families, and facility staff. Resident 1 (R1) was admitted to Greenwood Assisted Living in September of 2021, and placed on hospice care around that same time. R1 became bed bound around November of 2022. Continued on LIC9099C Substantiated Continued from LIC9099 Interviews conducted with facility staff stated that first aid was applied after R1 sustained the cut lip. Based on information obtained these allegations are Unsubstantiated. A finding that the complaint is Unsubstantiated means that although the allegations may have happened there is not a preponderance of evidence to prove that the allegation occurred. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents. Continued from LIC9099 During our investigation we learned four (4) of the nine (9) staff interviewed, and two (2) of the hospice staff interviewed (an RN and Home Health Aide), observed R1 to be left in soaked or soiled briefs, and found R1 to be lying on their back numerous times in a week. Please note hospice staff visited R1 at the facility twice or more a week. R1’s responsible parties were interviewed, and it was noted they also observed R1 in soiled briefs, and not repositioned. R1's care plan stated they were to be changed and repositioned every 2 hours. The facility indicated they had a log of dates/times with staff initials as to when R1 was changed and repositioned however they were not able to provide copies of these logs. It was reported by a visitor of R1 that they observed R1’s linens to be soiled and reported it to facility staff. The visitor visited the next day after reporting the soiled linens to staff and observed the soiled linens to have not been changed. Visitor stated that they were told by facility staff that changing R1’s linens was the Hospice agency’s responsibility. Interviews conducted with Hospice providers stated that there were multiple times that R1’s linens were found to be soiled. Review of R1’s Hospice Care Plan dated 07/19/2022, stated that Hospice is responsible for changing linens once per week. Review of R1’s Admissions Agreement dated 09/25/2021 stated that “fresh linen is provided weekly or as necessary.” Facility’s Program Plan states the following: “basic services for all residents in the facility include cleaning residents’ beds and linens weekly, or more often as needed.” Investigation findings revealed the facility did not ensure they followed R1’s Care Plan. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted. Plan of Corrections reviewed and developed with Administrator. Copy of report, LIC9099-D, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Dec 19, 2023 · control 21-AS-20230417124321

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87633(d) · Plan of correction due date: Dec 20, 2023

*Amended* 87633 Hospice Care of Terminally Ill Residents:(d)Licensee shall ensure... the hospice care plan is current... matches the services actually being provided, & that client’s care needs are being met at all times. Requirement was not met as evidenced by: based on interviews, records reviewed, & observations, staff failed to meet R1’s bladder & bowel needs based upon statements obtained during investigation which indicated R1 was found frequently to be in urine or bowel soaked briefs & soiled linens.This poses an immediate health & safety risk.the state’s words, verbatim · CDSS document, Dec 19, 2023

Plan of correction: Licensee to submit a plan that addresses how Facility will comply with the requirements of 87633(d) going forward by POC due date of 12/20/2023. Licensee to conduct In-Service Training with all direct care staff to discuss repositioning, incontinence care, linen services, and updating service plans policies. Training to be submitted by POC due date of 12/29/2023 and include Date of Training, Training Topics, Job Role, Staff Names, and Signatures.

Type of visit: Case Management - Annual Continuation

At approximately 12:05PM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Administrator, Jolly Carungcong. Upon arrival, LPA was informed that there were 18 Residents in care and 6 staff members on-site. At approximately 12:15PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA followed up on self-reported incidents that were submitted to Community Care Licensing (CCL). Incident Report 1/SOC-341: CCL received an incident report and SOC-341 on 04/25/2023 and 04/26/2023. The incident report states that on 04/19/2023, Resident 1 (R1) informed Hospice personnel that Staff Member 1 (S1) slapped their leg when they were providing care with Staff Member 2 (S2). Hospice Personnel observed no bruising or visible injury to R1's leg and reported the conversation to Facility's Executive Director. Executive Director conducted an internal investigation. During investigation, R1 reported to Executive Director that Staff Member 3 (S3) was present during the incident. Executive Director conducted interviews with staff members involved and found that on the night of 04/19/2023, S3 was working with S1 and S2 but was not in the room when they were providing care. S3 entered R1's room at a later time to put away laundry. Report continued to state that R1 required a two person assist when provided care, and did not like being changed as their hips hurt. Internal Investigation resulted in facility re-assigning S1 and S2 to different residents. Facility made all appropriate notifications per regulation. LPA discussed R1 with Administrator. Review of R1's Physician Report stated that R1 is bedridden and has a diagnosis of Mild Cognitive Impairment. Review of R1's Care Plan stated that R1 needs assistance with their care and is also being provided hospice services. Per conversation with Administrator, R1 has not had any allegations of abuse since April 2023. Facility reassigned staff members to ensure that R1's preferences are taken into consideration for who provides their care. R1 has had no further complaints regarding their care. Continued on LIC809C Continued from LIC809 Incident Report 2: CCL received an incident report on 07/25/2023. The incident report states that on 07/18/2023, Resident 2 (R2) was observed to be in pain and was unable to stand up as normal. Facility notified Responsible Party and R2 was transported to the hospital for further evaluation. Hospital evaluation determined that R2 had a fractured femur. Facility does not know how fracture occurred as previous shifts observed R2 to be walking well and to not be in pain on 07/16/2023 and 07/17/2023. Report also states that R2 went out with family on 07/16/2023 and there were no reports of pain. Facility made all appropriate notifications per regulation. LPA discussed R2 with Administrator. Review of R2's Physician Report stated that R2 is non-ambulatory with a diagnosis of dementia. Review of R2's Care Plan stated that R2 needs frequent reminders and assistance when ambulating or transferring. As of today, 10/09/2023, R2 returned to the facility in September 2023 but had another fall on 10/08/2023. As of today, R2 is currently out of the facility. Incident Report 3: CCL received an incident report on 09/25/2023. The incident report states that on 09/19/2023, Resident 3 (R3) had a witnessed fall when being transferred. Facility Administrator conducted an assessment and observed no visible injury. R3 also reported that they were okay but wanted a Tylenol for neck pain. R3 was later found unconscious in the facility's TV room. Facility contacted Emergency Personnel and R3 was taken to the hospital for evaluation. Hospital evaluation determined that R3 had a hip fracture and will be admitted for rehabilitation. Facility made all appropriate notifications per regulation. LPA discussed R3 with Administrator. Review of R3's Physician Report stated that R3 has a history of stroke which resulted in paralysis of their left side. R3 does not have a diagnosis of Mild Cognitive Impairment or Dementia and is able to communicate their needs. Review of Care Plan stated that R3 needs assistance with care and is able to communicate when they need help. Per conversation with Administrator, Facility plans to conduct a care conference with R3's Responsible Party to update R3's care plan upon their return to the facility. LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Active and Current Administrator Certificate Continued on LIC809C Continued from LIC809C Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Thursday, 11/09/2023. No Deficiencies cited during visit. Exit interview conducted. Copy of report, and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 9, 2023