Grossmont Gardens Memory Care

Allegation investigated: Licensee did not ensure that admission agreement was signed

***This is an Amended Document*** Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to the Executive Director. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, and records review. On May 8, 2026, Community Care Licensing Division (CCLD) received a complaint alleging the licensee did not ensure that the admission agreement was signed. More Specifically, the Reporting party (RP) alleged that they signed admission documents both in person and through DocuSign as a responsible person for Resident #1 (R1); however, none of the documents were signed or dated by Grossmont Garden Memory Care (GGMC). (Continued on lic 9099C) Substantiated (continued from lic9099) Department review of records reveal R1 was admitted to the facility on March 29, 2025, following transfer from a skilled nursing facility, and required full assistance with Activities of Daily Living (ADLs). Department staff interview revealed that R1's responsible person signed a preliminary packet by hand as well as the DocuSign admissions agreement. Records review revealed that DocuSign Certificates of Completion showed the March 28 and March 29 packets were configured so that only the RP was designated as a signer, while facility staff were carbon-copy recipients only, preventing staff signatures. The handwritten packet contained only the RP’s signature. No GGMC signatures were present in the admission file. Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation occurred and is 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 the Executive Director, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 08-AS-20260508093615

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(c) · Plan of correction due date: Jun 17, 2026

87507(c)Admission agreements shall be signed and dated.., and the licensee or the licensee’s designated representative no later than seven days following admission. This requirement was not met in evidence as: Based on record review, the licensee did not sign and date the admission agreement as required by Title 22, Section 87507(c), for 1 of 1 persons in care (R1), which poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Licensee agrees to retrain all administrative staff on Title 22 admission agreement requirements, including documentation procedures. Proof of staff training, including sign-in sheets and the training materials used, shall be submitted to LPA by 6/17/2026

Allegation investigated: Licensee did not ensure that admission agreement was signed

***This is an Amended Document*** Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to the Executive Director. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, and records review. On May 8, 2026, Community Care Licensing Division (CCLD) received a complaint alleging the licensee did not ensure that the admission agreement was signed. More Specifically, the Reporting party (RP) alleged that they signed admission documents both in person and through DocuSign as a responsible person for Resident #1 (R1); however, none of the documents were signed or dated by Grossmont Garden Memory Care (GGMC). (Continued on lic 9099C) Substantiated (continued from lic9099) Department review of records reveal R1 was admitted to the facility on March 29, 2025, following transfer from a skilled nursing facility, and required full assistance with Activities of Daily Living (ADLs). Department staff interview revealed that R1's responsible person signed a preliminary packet by hand as well as the DocuSign admissions agreement. Records review revealed that DocuSign Certificates of Completion showed the March 28 and March 29 packets were configured so that only the RP was designated as a signer, while facility staff were carbon-copy recipients only, preventing staff signatures. The handwritten packet contained only the RP’s signature. No GGMC signatures were present in the admission file. Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation occurred and is 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 the Executive Director, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 08-AS-20260508093615

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(c) · Plan of correction due date: Jun 17, 2026

87507(c)Admission agreements shall be signed and dated.., and the licensee or the licensee’s designated representative no later than seven days following admission. This requirement was not met in evidence as: Based on record review, the licensee did not sign and date the admission agreement as required by Title 22, Section 87507(c), for 1 of 1 persons in care (R1), which poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Licensee agrees to retrain all administrative staff on Title 22 admission agreement requirements, including documentation procedures. Proof of staff training, including sign-in sheets and the training materials used, shall be submitted to LPA by 6/17/2026

Allegation investigated: Staff did not prevent resident from being assaulted by another resident

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to the facility to invisitagte and deliver findings regarding the above-mentioned allegation. LPA Rodgers identified herself, explained the purpose of the visit, and discussed the nature of the complaint with Executive Director Natalie Carlborg. On June 11, 2026, Community Care Licensing (CCLD) received a complaint alleging that staff did not prevent resident #1(R1) from being assaulted by Resident #2(R2). Additionally, the Department received a self report SOC 341 from the facility on June 16, 2026 regarding the same incident. The Department’s investigation included a facility tour, record reviews, and interviews with staff and outside source. (continued on LIC9099C) Unsubstantiated (continued from LIC9099) Department Interview with outside source revealed that R1 and R2 have been roommates since May 2025 and that no prior issues between the two residents had been reported before this incident. Department Interviews with Staff #1 and Staff #2 revealed that Staff #2 was inside the room cleaning when the incident occurred and witnessed R1 strike R2. Staff reported they immediately called for assistance, responded at once, separated the residents, and de escalated the situation. Staff also reported that R1 appeared confused. Department record review revealed both residents were assessed with no injuries noted, responsible parties were notified, and R1 was transported to hospital for further evaluation. Based on interviews and records, the preponderance of evidence does not support that staff failed to provide adequate supervision. Staff were present, witnessed the event, and intervened promptly. Therefore, the allegation is UNSUBSTANTIATED An exit interview was conducted with Executive Director Carlborg, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 08-AS-20260611112704

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Eryn Kane and Amy Rodgers conducted an unannounced 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 Natalie Carlborg, Executive Director. According to the facility’s license, the facility has a maximum capacity of sixty-four (64) clients, thirty-nine (39) of whom may be non-ambulatory, twenty-five (25) of whom may be bedridden. Hospice waiver for twenty-five (25). Approved delayed egress/secured perimeter. During today’s inspection, there were a total of sixty-three (63) clients in care. LPAs Kane and Rodgers, accompanied by Executive Director Carlborg, toured the interior and exterior of the facility, and inspected several 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 and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 73 F. Hot water temperature at taps accessible to clients were all compliant. Refrigerator and freezer temperature were compliant. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. Required licensing postings were observed in visible areas of the facility. LPAs interviewed/observed staff and residents. LPAs reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. LPAs observed residents in the common areas engaged in their daily routines and activities. Residents appeared well-supported by staff and comfortable in their surroundings. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Natalie Carlborg, Executive Director, 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, Jun 9, 2026

Allegation investigated: Staff are not allowing resident to return to the facility Staff are not communictaing with resident's authorized representatives

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to investigate and deliver findings regarding the above complaint allegations. LPA introduced self and explained the purpose of the visit to Executive Director Angela Scott-Kapiloff. On March 20, 2026, Community Care Licensing Division (CCLD) received a complaint alleging that staff were not allowing Resident #1 (R1) to return to the facility and were not communicating with R1’s authorized representatives, causing confusion regarding whether the resident would be accepted back into the facility. The Department’s investigation included interviews with facility staff, placement agency/responsible party, and a review of facility records. Unsubstantiated (Continued from LIC9099) Department interviews with Staff #1(S1) revealed they reported having ongoing communication with R1’s authorized representative as well as R1’s placement agency. S1 stated the facility intended to reassess R1 prior to return and denied refusing the resident’s return. S1 reported speaking with R1’s attending physician regarding behavioral concerns and R1’s inability to take prescribed medication. S1 stated they informed the hospital social worker that R1 would not be able to return at the current date due to these concerns per attending physician as follows: S1 explained that according to R1 attending physician R1 would require at least three additional weeks in behavioral health services, followed by potential placement at a skilled nursing facility to allow for injectable medication to support behavioral stabilization. Department Interviews with Placement Agency / Responsible Party confirmed communication with S1 regarding R1’s behavioral concerns, medication non-compliance, and the anticipated need for continued behavioral health treatment. They also confirmed staff were communicating updates about reassessment requirements and possible next steps for R1’s care and discharge planning. Based on interviews 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 Angela Scot-Kapiloff, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 26, 2026 · control 08-AS-20260320154428

Allegation investigated: Staff neglected a resident resulting in hospitalization

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to investigate and deliver findings regarding the above complaint allegation. LPA introduced self and disclosed the purpose of the visit to Executive Director Angela Scott-Kapiloff. The Department’s investigation consisted of interviews with facility staff, interviews with outside sources, and a review of facility records. On March 23, 2026, Community Care Licensing Division (CCLD) received a complaint alleging that staff neglected a resident resulting in hospitalization. More specifcailly, Reporting party alleged that a Resident #1(R1) was found outside an unknown amount of time with signs of heat-related illness, raising concerns of possible neglect. Department interviews with Emergency Services reveal that R1 was seated in a chair inside the facility upon their arrival. Department staff interviews as well as records review reveal that supervision and observations were in place prior to the incident for R1. Staff reported that R1 became lethargic but remained communicative, and R1’s baseline mental status did not change during the event. R1 was assisted one-on-one by staff throughout and prior to the incident. Based on interviews with Staff and outside sources, 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 Angela Scott-Kapiloff, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 26, 2026 · control 08-AS-20260323232818

Allegation investigated: Staff did not communicate with resident's authorized representatives

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to investigate and deliver findings regarding the above complaint allegations. LPA introduced themself and disclosed the purpose of the visit to Executive Director Angela Scott-Kapiloff. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, outside sources, and a review of records. On March 23, 2026, Community Care Licensing Division (CCLD) received a complaint alleging that Resident #1(R1) was hospitalized on 02/01/2026 and subsequently discharged to an unknown rehabilitation center. The authorized representative was not notified of the transfer until 03/23/2026. Department interviews with staff, as well as a review of facility records, reveal that licensee staff did not report the incident to the resident’s authorized representative (ALW corridinator) within the required timeframe.The delayed reporting impeded care coordination and placed the resident’s continued participation in the Assisted Living Waiver (ALW) program at risk. Based on interviews and records review, a preponderance of evidence supports that the alleged violation occurred; therefore, the allegation is SUBSTANTIATED. A deficiency is cited on the attached LIC 9099D in accordance with California Code of Regulations, Title 22. A Plan of Correction (POC) was jointly developed with the licensee. An exit interview was conducted with Angela Scott‑Kapiloff, to whom copies of this report, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Substantiatedthe state’s words, verbatim · CDSS document, Mar 26, 2026 · control 08-AS-20260323143555

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1(d) · Plan of correction due date: Mar 26, 2026

87211(a) (1) A written report shall be submitted to the.. person responsible for the resident within seven days of the occurrence..(d) Any incident which threatens the welfare, safety or health of any resident.. This is evidenced by: Based on staff interviews and record review, the licensee did not submit a written report of the incident within seven (7) days for 1 of 61 persons in care (R1), to the ALW placement agency which posses risk to the health, safety, and personal rights of persons in care.the state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: Licensee agrees to retrain all administrative and reporting staff on Title 22 reporting requirements, including timelines and documentation procedures. Proof of staff training, including sign-in sheets and the training materials used, shall be submitted to LPA by 3/26/2026.

Allegation investigated: Neglect to resident resulting in a hospitalization

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and explained the purpose of the visit to Executive Director Angela Scott- Kapilof. The Department’s investigation consisted of a review of facility records, outside records, and interviews with facility staff and outside sources. On October 31, 2025, Community Care Licensing (CCL) received a complaint alleging that neglect resulted in the hospitalization of Resident #1 (R1). Specifically, it was reported that medication mismanagement involving duplicate clonidine patches contributed to R1’s hospitalization on April 19, 2025. Substantiated (Continued from LIC9099) Department review of R1’s Physician’s Report shows diagnoses including cerebrovascular accident (CVA) with right sided hemiplegia, mild cognitive impairment (MCI), and dementia. R1 was admitted to the facility on March 29, 2025, following transfer from a skilled nursing facility, and required full assistance with Activities of Daily Living (ADLs). Departments review of R1’s Medication Administration Record (MAR) shows clonidine patches were documented as applied per physician orders on 3/31/2025, 4/7/2025, and 4/14/2025. Further record review reveal that on April 19, 2025, staff observed a change of condition during the dinner hour. At 8:46 PM, staff contacted emergency services, and R1 was transported to the hospital. Department Hospital records review dated April 19, 2025, confirm that two Clonidine patches were present and removed during R1’s admission: one patch dated 3/28/2025 located on right side of the neck and one undated patch located on the right shoulder. Department interviews with staff revealed they were unable to provide documentation explaining how the duplicate patches occurred. Under Title 22, the licensee is responsible for ensuring medications are administered as prescribed and for maintaining records and oversight to prevent medication errors. The presence of two Clonidine patches is inconsistent with physician orders and MAR documentation and demonstrates a failure to properly assist with medication administration and monitoring. The Department has investigated the above mentioned allegation, and based on interviews and records review, the preponderance of evidence has been met. Therefore, this allegation is deemed substantiated. The following deficiency for failure to ensure proper medication assistance and oversight is cited per California Code of Regulations, Title 22, and is noted on the attached LIC 9099D page. An exit interview was conducted with Executive Director Angela [Last Name], whose signature below confirms receipt of this report and the Licensee Appeal Rights (LIC 9058 03/22). (Continued from LIC9099) Department record review of R1's physician report revealed R1 is diagnosed with cerebrovascular accident (CVA) with right-sided hemiplegia, along with mild cognitive impairment (MCI) and dementia. It further revealed R1 was non-ambulatory and needed full assistance with Activities of Daily living (ADL's) R1 move in date to the facility was March 29, 2025 and was transported to the facility from a skilled nursing facility. Department records review revealed hospice services visits began July 24, 2025, with a primary diagnosis of Neurocognitive disorder along with Lewy bodies and related issues of Muscle weakness, Cerebral atherosclerosis and Abnormal weight loss. Department review of hospice documentation also included maximum assistance and up in wheelchair as and tolerated for R1. Records review further reveal hospice services for wound care began on August 8, 2025. Hospice documentation shows wound care was provided per physician orders, including daily dressing changes, multiple weekly treatments, and nutritional support. Department review of facility records, outside source records, as well as outside source interviews and staff interviews reveal facility staff implemented non-skilled interventions within their scope and per physician orders, such as R1 sitting for periods of time in wheelchair, repositioning and offloading, and documented communication with hospice and the R1's responsible party. Department records review further reveal wound care products, nutritional supplements and medications were administered as ordered. However departments review of the Medication Administration Record (MAR) and facility care notes reveal multiple medication and nutritional supplement drink refusals by R1. Department review of facility records, outside source records, as well as outside source interviews and staff interviews reveal R1's equipment orders per Hospice physician orders, reveal that that pressure-relief equipment, including an alternating pressure pad and a low air loss mattress, was delivered and installed prior to hospitalization in October 2025. This agency has investigated the complaint alleging that the licensee failed to provide timely wound care and failed to ensure appropriate equipment was in place for the resident. The Department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report and Licensee Rights (LIC 9058 03/22) was provided. Executive Director Angela Scott- Kapilof signature on this form confirms receipt of these rights.the state’s words, verbatim · CDSS document, Mar 3, 2026 · control 08-AS-20251031114353

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 3, 2026

87465(a) A plan for incidental medical ...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met, as evidenced by: Based on record review and interviews, one (1) out of sixty (60) residents did not receive proper assistance with thier (R1) self administered medications, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 3, 2026

Plan of correction: Executive Director stated an In-service will be conducted on assiting residents with self-administered medications by POC date.

Allegation investigated: Staff leaves residents soiled for extended periods of time. Staff does not ensure residents' showering needs are being met. Staff does not ensure residents' are provided daily activities.

LPA Amy Rodgers conducted an unannounced visit to deliver complaint findings and explained the purpose of the visit to Executive Director Angela Scott-Kapilof. The investigation included reviews of facility and outside records, and interviews with staff and outside sources. On 2/16/2026, the Department received a complaint regarding the above mentioned alligations. Regarding the allegation: Staff leaves residents soiled for extended periods of time, specifically, residents are walking around soiled and ignored. Department interviews with staff, including caregivers, med techs, the assessment nurse, and the Resident Services Director, consistently indicated that incontinent residents are checked and changed frequently, with toileting schedules occurring every 1-2 hours and as needed. During multiple unannounced visits, the Department did not observe any odors of urine or feces and observed staff actively responding to residnets incontinence needs.. Department interviews with outside sources did not report concerns regarding prolonged soiling. (continued on LIC9099C) Unsubstantiated (Continued from LIC9099) Regarding the allegation: Staff does not ensure residents’ showering needs are being met, specifically, residents goes without showers because they don’t have enough people to help. Department interviews with staff reported that residents are scheduled for showers twice weekly or more frequently based on individual needs. Some residents choose to take fewer showers, while others require multiple showers due to incontinence episodes. LPA observed shower schedules were posted and interviews confirm the schedule is being followed. Throughout several unannounced visits, the Department observed residents to be clean, well groomed, and without signs of neglect. Department interviews with outside sources reveal observations of residents well groomed and clean. Regarding the allegations: Staff do not ensure residents are provided daily activities specifically, no activities were observed. Department staff interviews, management statements, and outside source observations indicate a full daily activity program is offered, with engagement documented throughout the day. During onsite observations, residents were seen participating in balloon tennis, puzzles, group activities, TV programs, and supervised leisure time. Evening hours were described as “calming periods,” which the Department confirmed through observation. Department interviews with outside sources reveal seeing regular activities during their visits. Based upon the information obtained during the investigation it is determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the violations occurred and is therefore UNSUBSTANTIATED. An exit interview was conducted with ED Angela Scott- Kapiloff and copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Mar 3, 2026 · control 08-AS-20260216152140

Allegation investigated: Facility staff are not following reporting requirements

LPA Amy Rodgers conducted an unannounced visit to deliver complaint findings and explained the purpose of the visit to Executive Director Angela Scott-Kapilof. The investigation included reviews of facility and outside records, and interviews with staff and outside sources. On 2/19/2026, the Department received a complaint alleging that facility staff were not following reporting requirements, specifically that management instructed staff not to document incidents in the internal reporting system. Department interviewed multiple staff regarding reporting practices. Staff consistently described documenting incidents in the electronic system, notifying the POA, and escalating concerns as needed. Staff did not report being instructed to withhold documentation. Department review of recent in-service trainings and staff interviews reveal management has been reinforcing guidance on objective, factual documentation. Department review of incident reports, progress notes, and related documents revealed no gaps or indicators of withheld information. LPA observations and outside source interviews showed no discrepancies between staff statements, written records, or required notifications. Based upon the information obtained during the investigation it is determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the violation occurred and is therefore UNSUBSTANTIATED. An exit interview was conducted with ED Angela Scott- Kapiloff and copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 3, 2026 · control 08-AS-20260219061503

Allegation investigated: Staff did not ensure the residents' call buttons were not in disrepair

LPA Amy Rodgers conducted an unannounced visit to deliver findings regarding the allegation that the facility’s call signal system was not operating properly. LPA identified herself and discussed the allegations mentioned above with Executive Director Angela Scott- Kapiloff. During the course of the invistigation LPA toured the facility, tested portions of the call system, interviewed staff, received statements from outside sources, and conducted a records review. (Continued on LIC9099C) Substantiated LPA Rodgers conducted an unannounced complaint investigation on 02/26/2026 regarding concerns related to the facility’s call signal system. On 02/26/2026 at approximately 1:25 PM, LPA activated a bathroom call cord in the 200 hallway with assistance from maintenance staff. No auditory or visual alert activated. Maintenance staff reported battery replacement in that hallway had not yet been completed. At approximately 1:43 PM, LPA entered Room 401 and asked the resident to pull the bedside call cord. LPA positioned herself to observe both the resident room and the med tech room. No alert activated, and no staff response occurred. When LPA checked with staff in the Medication room, staff confirmed they did not hear or observe any alert. LPA observation confirmed no alert sound was produced from the computer alert system located in the medication room. Department interviews with staff reveal inconsistent reports regarding how long the call system had been experiencing intermittent outages. Despite the malfunctioning call system, Department observations during multiple unannounced visits showed residents to be clean, odor free, groomed, and regularly attended to by staff throughout hallways and common areas. Staff were consistently observed assisting residents with redirection, incontinence care, mobility, and activities. Outside sources who visit the facility frequently also reported that residents are well cared for, clean, and supported by staff. These combined observations do not indicate an immediate threat to the health and safety of residents. Based on LPA direct observations and interviews and records review, the preponderance of evidence has been met that alleged violation 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 LIC9099D and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 3, 2026 · control 08-AS-20260226092609

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1) · Plan of correction due date: Mar 4, 2026

87303 Maintenance and Operation (i)(1)Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more.. shall have a signal system... This requirement was not met in evidence as: Based on observation/interview/record review the licensee did not maintain a operational signal system for 60 of 60 persons in care which posed a potential Health, Safety, or Personal Rights risk to persons in carethe state’s words, verbatim · CDSS document, Mar 3, 2026

Plan of correction: The Administrator reported that the pager system has been repaired and all pagers have been placed back into service. The administrator conducted retraining on 2/27/2026. The staff has also initiated daily/montly random checks of the signal system to ensure it is functioning properly. Adminsitrator will provide a written letter to LPA to confirm such continous checks by 3/18/2026

Allegation investigated: Neglect of a resident resulting in serious bodily injury Neglect of the resident resulting in a pressure injury

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to the Executive Director, Jennie Ayersman. The Department’s investigation consisted of a review of facility and outside records, as well as interviews with staff, residents, and outside sources. On September 13, 2023, Community Care Licensing (CCL) received a complaint alleging that neglect resulted in serious bodily injury and neglect to a resident, resulting in serious pressure injury. Sufficient information and statements via interviews of staff were obtained to substantiate the allegation of neglect/lack of supervision on the part of the facility staff, resulting in a serious injury to Resident 1 (R1). [Continued on LIC9099] Substantiated [Continued from LIC9099 2 of 3] R1 sustained unwitnessed falls on August 8, 2023, August 9, 2023, and August 12, 2023, the last causing a left femoral fracture. Medical records were obtained from the hospital, and multiple staff members were interviewed. Staff 1 (S1) was interviewed, and S1 reported that the residents, including R1, were being properly checked. Staff 2 (S2) provided contradicting information and made statements to the contrary. According to statements provided by the S3, the nocturnal shift staff have been an issue at the facility, as residents were consistently found to be saturated with urine or soiled, indicating that they were being neglected and not checked on as required. In addition, the proper response time of the falls sustained by R1 appears to have been delayed due to staff not adhering to scheduled safety checks. On September 13, 2023, Community Care Licensing (CCL) received a complaint alleging that neglect resulted in serious bodily injury to a resident, resulting in a pressure injury. R1 sustained a left femoral fracture due to a fall at the facility on August 12, 2023. A review of historical diagnosis, as of September 30, 2023, does not list the pressure sore for R1. August 22, 2023, encounter notes have R1 with a left femoral fracture and have a leg immobilizer on. R1's sacrum and buttocks were reported as being clear with no skin breakdown. R1 was noted as being unable to communicate all their needs and was unable to report the location of their pain. R1 was placed in a splint brace to mobilize their leg for recovery. Written instructions were included with their hospital discharge documents as to the care and monitoring of the splint brace and leg. Statements obtained from interviews with staff tend to show that the splint brace on R1’s leg was not properly monitored or adjusted as instructed on the discharge document. Due to the lack of appropriate monitoring, the splint brace caused a stage III pressure injury on R1's ankle. Medical records documenting the pressure injury were obtained from the hospital. Outside source 1 (OS1) was interviewed, and advised that R1 was susceptible to pressure injuries due to their age and condition. On September 8, 2023, a video encounter notes R1 was brought in on August 12, 2023, for an unwitnessed fall and was found to have a closed non displaced fracture at their left femur. R1 was advised not to bear [Continued on LIC9099] [Continued from LIC9099C 3 of 3] weight for six weeks. Further noted, per Staff 3 (S3), skin is good, no pressure sores. On September 12, 2023, R1 was brought into the Emergency Department after the care facility staff discovered a new left ankle pressure ulcer from wearing their left femoral fracture brace. The emergency Department documented that R1 was brought in and diagnosed with a stage 3 pressure injury on their left ankle. R1 fractured their femur 5 weeks ago and has been wearing a removable brace. A pressure ulcer was discovered today at the facility. S3 reported that they did not take off or adjust the brace until today, when they noticed the new pressure injury. Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). At this time, per Health and Safety Code Section 1569.2(c), an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division. A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Jennie Ayersman, Executive Director, 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 29, 2026 · control 08-AS-20230913143222

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jan 30, 2026

Facilities must ensure a plan for medical care, and residents receive the necessary medical care for their conditions and needs. This requirement was not met, as evidenced by: Based on observations, interviews, and records reviewed, one (1) out of sixty (60) residents did not receive the necessary medical care for their (R1) condition, which posed an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2026

Plan of correction: Licensee agrees to provide LPA with documentation of training dates within 24 hours by an approved vendor.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jan 30, 2026

(f) Basic services shall at a minimum include:(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing... This requirement was not met as evidenced by: Based on records and interviews, the licensee did not provide personal assistance and care as needed in one (1) of eighty-seven (87) persons in care (R1), which posed an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2026

Plan of correction: Licensee agrees to provide LPA with documentation of training dates within 24 hours by an approved vendor.

Allegation investigated: Staff do not keep the facility free from a scabies outbreak Staff are not properly reporting an incident involving the residents Staff are not following infection control requirements

LPA Rodgers conducted an unannounced visit to further invistigate and deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Angela Scott- Kaplioff. On June 3, 2024, the Community Care Licensing Division (CCLD) received an online complaint alleging infection control concerns related to a scabies outbreak in the facility’s memory care unit. More specifically, the reporting party claimed a scabies outbreak within memory care affecting at least 20 residents in the prior month; the facility was not forthcoming with families, staff, or visitors; the facility was not isolating affected residents, and rashes were spreading, including to staff; and residents were confused and walking around itching and scratching. The Department’s investigation consisted of a records review, interviews with staff, and interviews with outside sources. (continued on LIC9099C) Unsubstantiated (Continued form LIC9099) The records review included Medication Administration Records (MARs) and Physician’s Orders for three residents (R1, R2, R3) residing in the facility, focusing on scabies-related treatments such as Permethrin and Ivermectin. Department records from an outside treating facility indicate that Residents #1–3 were treated for rash symptoms; a formal diagnosis of scabies was never documented, however, precautionary treatment was performed by the outside treating agency. The facility’s Infection Control Plan was reviewed and noted as last updated on July 7, 2023. The Department’s annual inspection in May 2024 revealed that extra linens, hygiene supplies, and Personal Protective Equipment were present. Interviews with multiple staff and residents during May 2024 did not reveal concerns that the facility was failing to follow its infection control plan. Further interviews with staff and an outside source indicated that staff were following infection control protocols. The MARs and Physician’s Orders reviewed showed that R1, R2, and R3 received rash directed therapy in June 2024, including Permethrin (topical) and Ivermectin (topical and oral). Orders specified full-body topical application from neck to toes with shower-off instructions and repeat dosing intervals, consistent with commonly accepted scabies treatment practices. Times of treatments were documented for several residents. The records alone do not confirm or refute communication practices with families, staff, or visitors. Due to the nature of cognitive abilities in a memory care setting, isolation measures would not typically be part of the Department’s or the facility’s protocol. The presence of timely treatment orders and administrations for multiple residents demonstrates the facility’s action to address residents with infectious conditions. With limited documentation beyond medication records, there is insufficient evidence at this time to establish that the facility failed to notify families or failed to follow infection control procedures. Based on the records review, interviews with staff and an outside source there is not a preponderance of evidence to prove the alleged violations occurred. Therefore, the allegation is: UNSUBSTANTIATED. An exit interview was conducted with Executive Director Angela Scott- Kaplioff, 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 21, 2026 · control 08-AS-20240603230623

Allegation investigated: Staff did not ensure resident had enough liquids, resulting in dehydration

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced herself and disclosed the purpose of the visit to Executive Director Natalie Carlborg. CCLD’s investigation involved unannounced facility tour/welfare checks and review of facility care and medical records. The Department also interviewed relevant staff, clients, and outside sources. On 2/18/25, it was alleged that facility staff did not ensure the resident had enough fluids, resulting in dehydration. Staff 1 (S1) was interviewed and revealed that hydration is offered during meals and snacks and medication pass, but they do not track how much a resident drinks unless there is a specific order. Substantiated (Continued from LIC9099 2 of 3) Staff 2 (S2) was interviewed and stated that the R1 did not notice any changes with R1. S2 stated R1 was at baseline. Staff 3 (S3) was interviewed and confirmed that there was no hydration monitoring in place for R1, but hydration is offered during activities, medication pass and at all meals. S3 stated that they rely on caregivers to report concerns to the medication technologist, who report any changes to the medical physician. Interviews with three (3) residents were conducted, and they did not express any concerns regarding hydration. LPA observed residents in the dining room during activities, meals, and snacks, and fluids were being offered to residents. Residents who needed assistance were being assisted with drinking fluids. Outside Source 1 (OS1) was interviewed and stated that R1 had experienced multiple episodes of unresponsiveness, vomiting, and shallow breathing while at the facility. OS1 raised concerns about R1’s hydration status, and requested staff to ensure R1 was receiving adequate fluids. OS1 communicated to the facility that R1 had been hospitalized due to dehydration. Outside Source 3 (OS3) was interviewed and stated that the facility did do their due diligence with sending R1 to the hospital when there were episodes of unresponsiveness, vomiting, and shallow breathing while at the facility. A review of facility records and incident documentation for R1 revealed that the facility did not document if the resident was refusing hydration therefore there was no means of tracking if the resident received adequate hydration. According to a progress note dated 01/21/2025, OS1 reported that R1 had been hospitalized and diagnosed with dehydration. (Continued from LIC 9099C 3 of 3) The Department has investigated a complaint with the above allegation. The Department has found that there is a preponderance of evidence to prove that the alleged violation did occur; therefore, the allegation is substantiated. A deficiency is 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 the Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 17, 2025 · control 08-AS-20250218154245

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Dec 17, 2025

Type B CCR 87465(a)(1)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical …The licensee shall arrange, or assist in arranging, for medical…appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on records review and interviews, facility personnel did not provide basic care services to (R1) one out of 62 residents. This posed a potiential health risk to a resident in care.the state’s words, verbatim · CDSS document, Nov 17, 2025

Plan of correction: Administrator agrees to conduct a incidental medical and dental needs and service care plan training for and Resident Care Coordinator and the Assessment Nurse by 12/17/2025.

Allegation investigated: Licensee is retaining a resident with a higher level of care need. Staff do not communicate with the resident's responsible party as necessary. Staff do not ensure that residents' confidential information is safeguarded. Staff are administering medications to residents that are not authorized. Staff do not safeguard residents' personal possessions. Staff do not ensure that the resident's representative has prompt access to review the resident's records.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced herself and disclosed the purpose of the visit to Executive Director Natalie Carlborg. CCLD’s investigation involved unannounced facility tour/welfare checks and review of facility care and medical records. The Department also interviewed relevant staff, clients, and outside sources. On 2/26/25, it was alleged that the licensee is retaining a resident with a higher level of care need. Resident records, including the Physician’s Report (LIC 602) and Needs and Services Plan (LIC 625), were reviewed. The documentation confirmed that the resident does not require 24-hour skilled nursing care and is receiving services within the scope of what is permitted. There were no indications that the resident had a prohibited condition or required care beyond what the facility is authorized to provide. Unsubstantiated Continued from LIC9099 2 of 4 Staff interviews confirmed that the resident receives assistance with activities of daily living (ADLs), medication management, and intermittent home health services, all of which are allowable under RCFE regulations. Executive Director stated that the resident’s condition is regularly assessed and that any changes in condition are communicated to the physician and the responsible party. Additionally, there was no evidence that the resident had been denied access to appropriate medical care or that the facility failed to coordinate with outside providers when needed. Observations during the visit showed the resident was alert, oriented, and participating in daily activities. There were no signs of neglect or unmet medical needs. The facility demonstrated compliance with Health and Safety regulations, which prohibits retention of residents who require care beyond the facility’s capabilities unless appropriate waivers or support services are in place. On 2/26/25, it was alleged that the staff does not ensure that residents' confidential information is safeguarded. During the investigation, staff interviews confirmed that all employees receive training on confidentiality and resident rights upon hire and annually thereafter. Staff demonstrated knowledge of procedures for handling and storing resident records in compliance with regulations which requires that resident records be kept confidential and stored in a manner that ensures privacy. Observations during the facility visit confirmed that resident files are stored in a locked cabinet in a secure office area accessible only to authorized personnel. No records were observed left unattended or in public view. Medication Administration Records (MARs), physician orders, and care plans were reviewed and found to be properly maintained and secured. Staff were observed logging out of electronic systems when not in use, and no breaches of confidentiality were identified during the visit. Additionally, there were no complaints or incident reports on file indicating that any resident’s personal or medical information had been disclosed inappropriately. The facility’s practices are consistent with Health and Safety regulations, which requires that facilities protect the confidentiality of resident records and only release information to authorized individuals. (Continued from LIC9099C 3 of 4) On 2/26/25, it was alleged that the staff are administering medications to residents that are not authorized. Based on the investigation conducted, which included interviews with facility staff, residents, and outside sources such as responsible parties and the residents’ physicians, there is insufficient evidence to support the allegation that facility staff are administering medications to residents without proper authorization. A thorough review of centrally stored medication records, physician orders, and Medication Administration Records (MARs) revealed that all medications administered were prescribed by a licensed physician and documented in the residents’ files. Staff interviews confirmed that only trained and authorized personnel are responsible for medication administration, and staff demonstrated knowledge of proper procedures during observed medication passes. Outside sources, including physicians and responsible parties, verified that all the medications were authorized and consistent with the residents’ care plans. No inconsistencies were found between physician orders and the medications administered. On 2/26/25, it was alleged that the staff do not safeguard residents' personal possessions. Based on the investigation, which included interviews with facility staff, residents, and responsible parties, as well as a review of facility policies, incident reports, and personal property records, there is no evidence to support the allegation that facility staff are not safeguarding residents’ personal possessions. Residents and responsible parties interviewed did not express concerns about missing or mishandled belongings, and several confirmed that their items were secure and accounted for. Staff interviews indicated that the facility has procedures in place for documenting and protecting residents’ personal property, including the use of inventory forms and secure storage when needed. A review of these records showed that personal items were properly logged and no recent complaints or theft reports were found. Observations during the visit confirmed that residents’ rooms were orderly and that personal belongings appeared to be respected and maintained. On 2/26/25, it was alleged that the staff do not ensure that the resident's representative has prompt access to review the resident's records. Outside sources were interviewed and they confirmed they were able to access records upon request. Staff were interviewed and they were aware of the regulations that pertain to resident's representative access to records. (Continued from LIC9099C 4 of 4) This agency has investigated the complaint alleging that the licensee failed to protect the resident from harm and the licensee failed to facilitate medical care for the resident. The Department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report and licensee rights (LIC 9058 03/22) was provided. Executive Director Natalie Carlborg's signature on this form confirms receipt of these rights.the state’s words, verbatim · CDSS document, Nov 17, 2025 · control 08-AS-20250226115919

Allegation investigated: Licensee was not protecting resident from physical abuse.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Natalie Carlborg, Executive Director. On 5/1/25 it was alleged the Licensee was not protecting resident from physical abuse. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Staff interviews revealed that Resident 1 (R1) was touched inappropriately by Resident 3 (R3) when R3 wandered into R1’s room. R1 was fully clothed at the time and was able to instruct R3 to leave. R3 complied and exited the room. R1 immediately reported the incident to facility staff. (Continued on LIC9099C) Substantiated (Continued from LIC9099 2 of 3) Staff interviews revealed that Resident 1 (R1) was touched inappropriately by Resident 3 (R3) when R3 wandered into R1’s room. R1 was fully clothed at the time and was able to instruct R3 to leave. R3 complied and exited the room. R1 immediately reported the incident to facility staff. Staff also reported that Resident 2 (R2) was asleep in their room when R3 entered and inappropriately touched R2 while R2 was fully clothed. R2 instructed R3 to leave the room, and R3 complied. R2 also immediately reported the incident to staff. Resident interview revealed R1 stated they were in their room when R3 entered without permission. R1 reported that R3 approached them and touched them inappropriately over their clothing. R1 stated they immediately told R3 to leave the room. R3 complied and exited. R1 reported feeling uncomfortable and informed staff of the incident right away. R1 stated they did not sustain any physical injuries but were upset by the incident and requested that R3 not be allowed to enter their room again. R2 stated they were asleep in their room when they awoke to find R3 in the room. R2 reported that R3 touched them inappropriately over their clothing. R2 stated they told R3 to leave, and R3 exited the room without further incident. R2 reported the incident to staff immediately. R2 expressed concern about safety and requested that staff ensure R3 does not enter their room again. Records review revealed R3 does not have a documented history of wandering behaviors or inappropriate behaviors. The wandering and inappropriate behavior was identified by staff and R3 was sent to the hospital for evaluation. Incident Reports dated 4/1/25 document the two separate incidents involving R3 entering the rooms of R1 and R2 and making inappropriate physical contact. Both reports (SOC341) were completed by staff and submitted to the Community Care Licensing and the Ombudsman office. There was documentation of immediate protective measures taken to prevent recurrence, such as increased monitoring and hospitalization for evaluation. (Continued from LIC9099C 3 of 3) Staff Communication Logs and Shift Notes from the dates of the incidents reflect proactive interventions. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation 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 Natalie Carlborg, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 17, 2025 · control 08-AS-20250501161630

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Dec 17, 2025

Residents in all residential care facilities for the elderly shall have...the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature…This requirement was not met as evidence by; Based on interviews and records reviewed licensee did not provide resident rights to two (2) of sixty three (62) persons in care which posed a potential Health and Safety risk to person in care.the state’s words, verbatim · CDSS document, Nov 17, 2025

Plan of correction: The facility agrees to conduct a training on personal rights with all staff by 12/17/2025. The facility will send LPA the sign in sheet with the training contents by 12/117/25

Type of visit: Collateral

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Collateral visit. LPA was greeted by, identified herself to, and discussed the purpose of the visit with Natalie Carlborg, Executive Director. During today's visit, LPA observed residents during mealtime/Activities, reviewed residents files and typed interviews. There were no deficiencies observed during this visit. An exit interview was conducted with Natalie Carlborg, Executive Director, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 03/22) were provided at the end of the visit.the state’s words, verbatim · CDSS document, Nov 7, 2025

Type of visit: Collateral

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Collateral visit. LPA was greeted by, identified herself to, and discussed the purpose of the visit with Natalie Carlborg, Executive Director. During today's visit, LPA observed residents during mealtime/Activities, reviewed residents files and typed interviews. There were no deficiencies observed during this visit. An exit interview was conducted with Natalie Carlborg, Executive Director, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 03/22) were provided at the end of the visit.the state’s words, verbatim · CDSS document, Oct 29, 2025

Type of visit: Collateral

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Collateral visit. LPA was greeted by, identified herself to, and discussed the purpose of the visit with Natalie Carlborg, Executive Director. During today's visit, LPA observed residents during mealtime, reviewed residents files and typed interviews. There were no deficiencies observed during this visit. An exit interview was conducted with Natalie Carlborg, Executive Director, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 03/22) were provided at the end of the visit.the state’s words, verbatim · CDSS document, Oct 24, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced visit to initiate a case management visit. LPA Rodgers identified herself and was granted entry by Executive Director Natalie Carlborg and stated the purpose of the visit. The incident involved Resident #1 (R1) (see LIC 811 – Confidential Names List), who experienced an unwitnessed fall in R1’s room on October 18, 2025. R1 reported to staff that they may have fallen and complained of pain. Staff contacted emergency services, and R1 was transported to the emergency department, where they were diagnosed with a broken femur. R1 subsequently underwent surgery on October 19, 2025. R1’s responsible party and primary care physician were notified of the injury and the transport to the emergency department, in accordance with reporting requirements. Later in the day on October 18, 2025, staff were escorting Resident #2 (R2) to their room when R2 reported that they had been in an altercation with R1. Later that evening, R2 also reported conflicting details regarding the altercation; however, some of these claims were determined to be not plausible given R2’s condition and circumstances. Record review reveals that R2 had a recent medical diagnosis involving an infection. The Department reviewed the physician reports for both R1 and R2, which confirmed that both residents have a diagnosis of dementia. During today’s visit, Licensing Program Analyst (LPA) Rodgers interviewed staff, toured the facility, and requested and obtained documents relevant to the incident. LPA informed (ED) Carlborg that additional follow-up via telephone or in-person visits may be necessary. No deficiency were noted or cited during the visit. An exit interview was conducted with ED Carlborg. A copy of this report, the LIC 811, and the Licensee Appeal Rights (LIC 9058) were provided at the conclusion of the visit. The signature below confirms receipt of these documents..the state’s words, verbatim · CDSS document, Oct 23, 2025

Allegation investigated: Due to lack of supervision, residents bother other residents Staff are not assisting residents with eating

Licensing Program Analyst (LPA) Amy Domingo conducted a virtual visit, via video conference, to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Executive Director Natalie Carlborg. The Department's investigation involved unannounced facility tour/welfare checks and review of facility care and medical records. The Department also interviewed relevant staff, clients, and outside sources. On 12/6/23, it was alleged that due to a lack of supervision, residents bother other residents. The facility provided staffing schedules for the past 30 days, which showed consistent coverage across all shifts. Interviews with staff confirmed that procedures are in place to ensure coverage during call-outs or Continue on LIC9099C Unsubstantiated emergencies, including the use of on-call staff and agency personnel when necessary. The facility maintains documentation of initial and ongoing training, including topics such as resident rights, supervision, and behavioral management. Staff interviewed demonstrated knowledge of their responsibilities and resident care needs. LPA interviewed three (3) residents, none of whom reported feeling unsafe or unsupervised. Residents stated that staff are generally available and responsive. No residents reported being bothered by others due to a lack of supervision. LPA interviewed three (2) outside sources, none of whom reported feeling unsafe or unsupervised. Residents stated that staff are generally available and responsive. No outside sources reported their loved ones being bothered by others due to a lack of supervision. During the visit, LPA observed staff actively supervising residents in common areas. No incidents of resident-to-resident conflict were observed, and residents interviewed did not report concerns about supervision. On 12/6/23, it was alleged that staff are not assisting residents with eating. LPA interviewed [#] staff members, all of whom stated that residents who require assistance with eating are identified in their care plans and are assisted during meals. Staff demonstrated knowledge of residents’ dietary needs and assistance levels. Training records reviewed confirmed that staff received instruction on providing assistance with activities of daily living, including eating, as required LPA interviewed three (3) residents, including those identified as needing assistance with eating. Residents reported that staff are available during meals and provide help when needed. No residents expressed concerns about being neglected or not receiving assistance during mealtimes. LPA interviewed two (2) outside sources that reported there are staff available during meals and provide help when needed. No outside sources expressed concerns about their loved ones not receiving assistance during meal times. LPA observed staff assisting residents in a timely and respectful manner. Residents were seated comfortably, and staff were seen offering verbal prompts, physical assistance, and monitoring residents as appropriate. No concerns were noted during the observation period. The Department has investigated a complaint with the above allegation. The Department has found that although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted with the Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 20, 2025 · control 08-AS-20231206151509

Allegation investigated: Licensee does not ensure the facility has adequate staff to meet the care needs of residents. Staff did not ensure resident was provided assistance getting dressed. Resident was left in soiled clothing for an extended period of time.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings in the above-mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Executive Director Natalie Carlborg. During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents, and outside sources. On 12/05/2023, the department received a complaint alleging Licensee does not ensure the facility has adequate staff to meet the care needs of residents. Records reviewed of staff schedules and time sheets for the past 30 days showed consistent coverage across all shifts, including awake night staff. (Continue on LIC9099C) Unsubstantiated LIC9099C 2 of 3 The facility maintains a posted schedule that meets or exceeds the minimum staffing requirements based on the number and needs of residents. Resident care logs reflected timely assistance with activities of daily living (ADLs), medication administration, and supervision. Staff 1 (S1) confirmed that staffing levels are reviewed weekly and adjusted based on resident acuity and census changes. Staff 2 (S2) reported that staffing is sufficient to meet resident needs and that additional support is brought in when needed. Staff 3 (S3) stated that medication passes and care routines are completed on time and without delay due to staffing. Resident 1 and 2: Reported that staff are available when needed and provide timely assistance with personal care and supervision. Outside source 1 (OS1) and Outside source 2 (OS2): Expressed satisfaction with the level of care and stated that staff are responsive and attentive. LPA observations during the visit, staff were observed assisting residents promptly, engaging in supervision, and maintaining a calm and organized environment. No signs of resident neglect, delayed care, or under staffing were observed. On 12/05/2023, the department received a complaint alleging Staff did not ensure the resident was assisted in getting dressed. Record review of R1's appraisal/Needs and Services Plan indicated the need for assistance with dressing due to limited mobility. Daily care logs for the past 30 days documented consistent assistance with dressing during morning care routines. No incident reports or complaints were documented regarding refusal or failure to assist with dressing. S1 confirmed that R1 requires and receives assistance with dressing daily. Staff are assigned specific ADL tasks during each shift. S2 reported that they assist R1 each morning and that the resident is cooperative and appreciative of the help.S3 stated that the resident is always dressed appropriately and has not expressed concerns about lack of assistance. LIC9099C 4 of 4 OS1 and OS2 confirmed that staff help them get dressed every morning and that they are satisfied with the care provided. OS1 and OS2 reported no concerns and stated that the resident is always well-groomed and appropriately dressed during visits. LPA observed residents to be clean, well-groomed, and appropriately dressed at the time of the visit. Staff were observed assisting other residents with Activities of Daily Living (ADLs) in a respectful and timely manner. On 12/05/2023, the department received a complaint alleging resident was left in soiled clothing for an extended period of time. Record Review of R1's Appraisal/Needs and Services Plan indicated the need for assistance with toileting and hygiene due to limited mobility. Daily care logs documented routine checks and assistance with toileting and clothing changes, including overnight care. No incident reports or internal documentation indicated that the resident was left in soiled clothing or experienced skin breakdown due to neglect. S1 stated that staff are assigned to conduct regular incontinence checks and assist residents with hygiene as needed, including during night shifts. S2 reported that R1 was checked every two hours and changed promptly when needed. No delays in care were reported. S3 confirmed that the resident has not had any skin issues or hygiene related complaints. OS1 and OS2 denied being left in soiled clothing and stated that staff respond quickly when assistance is needed. OS1 and OS2 reported no concerns about hygiene or care and stated that the resident is always clean and well cared for during visits. LPA observed residents to be clean, well-groomed, and appropriately dressed at the time of the visit. Staff were observed assisting other residents with toileting and hygiene in a timely and respectful manner. The Department has investigated a complaint with the above allegations. The Department has found that although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted with the Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 08-AS-20231205151407

Allegation investigated: - Staff did not meet incontinence care needs of residents - Staff did not meet resident's bathing needs - Staff did not ensure residents had clean linens - Insufficient staff to meet the care needs of residents

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver investigative findings. Upon arrival, LPA was greeted by Executive Director Executive Director Natalie Carlborg. LPA identified herself and explained the purpose of the visit. Community Care Licensing (CCL) initiated an investigation in response to a complaint received on July 17, 2023, that staff did not meet the incontinence care needs of residents, staff did not meet residents' bathing needs, staff did not ensure residents had clean linens and insufficient staff to meet the care needs of residents To investigate these allegations, the Department conducted an onsite facility inspection, reviewed facility records and medical documentation, and conducted multiple interviews with facility staff, residents, and external sources. (continue at LIC9099C) Unsubstantiated (Continued from LIC9099) ( Page 2 of 3) It was alleged that staff did not meet the incontinence care needs of residents. More specifically, the Reporting Party (RP) reported that during the night, they found seven residents double diapered and very wet when providing incontinence care. RP stated that despite reporting this to management, the issue persisted. Staff interviews revealed that incontinence care was provided per schedule and that double-diapering was not a standard practice. Resident interviews revealed no concerns regarding incontinence care. Records review revealed that incontinence care schedules and staffing assignments were consistent with regulatory requirements. The Department’s observations revealed that residents were not observed in soiled or double-diapered conditions during visits conducted around the time of the allegation. It was further alleged that staff did not meet residents’ bathing needs. More specifically, RP stated that staff were not assisting residents with showers. Staff interviews revealed that showers were being provided according to the facility’s schedule. Resident interviews revealed no concerns regarding bathing assistance. Records review revealed that shower schedules and hygiene documentation were consistent with regular bathing practices. The Department’s observations revealed that residents appeared clean and well-groomed during visits conducted around the time of the allegation. It was further alleged that staff did not ensure residents had clean linens. More specifically, it was alleged that management instructed staff not to change soiled linens for two to three days due to excessive laundry. Staff interviews revealed that while one staff member reported delays in linen changes due to laundry volume, no staff confirmed that this was a directive from management. Resident interviews revealed no concerns regarding the cleanliness of their bedding. Records review revealed that laundry schedules and linen inventory logs for July 2023 did not reflect any service delays. The Department’s observations revealed that resident beds had clean linens with no visible soiling or odors during visits conducted around the time of the allegation. (Continued on LIC9099C) Continued from LIC9099C) (Page 3 of 3) It was further alleged that there was insufficient staff to meet the care needs of residents. More specifically, RP stated that the facility was understaffed, particularly during the night shift, resulting in unmet care needs, including management of behavioral issues. Staff interviews revealed that while there were occasional challenges during shift transitions, particularly between evening and night shifts, these were temporary and did not result in unmet care needs. Staff also reported that management was responsive and made adjustments when necessary. Resident interviews revealed no reports of unmet care needs or delays in receiving assistance. Records review revealed that staffing schedules for the relevant timeframes were consistent with the facility’s Plan of Operation and regulatory staffing requirements. The Department’s observations revealed that staff were present and engaged with residents, and no immediate health or safety concerns were noted during visits conducted around the time of the allegation. Based on interviews, direct Department observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred. Therefore, the allegations are determined to be UNSUBSTANTIATED. An exit interview was conducted with Executive Director Natalie Carlborg, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 8, 2025 · control 08-AS-20230717111145

Allegation investigated: Resident death due to staff neglect Improper transfer resulting in injury Medication not given as prescribed Facility retained resident against their will Staff does not have medication training Staff drank alcohol while on duty Staff used drugs while on duty

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings in the above-mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Executive Director, Natalie Carlborg. During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents, and outside sources. On 07/05/2023, the department received a complaint alleging a resident's death due to staff neglect. LPA reviewed Resident 3’s (R3's) Appraisal/Needs and Services Plan, and the physician’s report indicated multiple chronic health conditions. Daily care logs and medication administration records showed consistent documentation of care provided, including vital signs monitoring, medication compliance, and physician follow-up. The Unusual Incident/Injury Report and Death Report were submitted to the Department within the required timeframe. Unsubstantiated (LIC9099C 2 of 6) Interview with Staff 1 (S1) confirmed that the resident was receiving appropriate care and supervision in accordance with their care plan. Staff responded immediately when the resident was found unresponsive and contacted emergency services. Interview with Staff 2 (S2) described the events leading up to the incident and confirmed that the resident had not expressed any new complaints or symptoms prior to the event. Interview with Staff 3 (S3) verified that all medications were administered as prescribed and that the resident’s condition was stable during the days leading up to the incident. Interview with Outside source 1 (OS1) stated they were satisfied with the care provided and had no concerns about staff attentiveness or neglect. Confirmed that the resident’s death was consistent with their known medical conditions and not indicative of neglect. LPA observed the facility appeared clean, organized, and appropriately staffed at the time of the visit. Staff were observed following care protocols and referencing resident care plans during shift transitions. On 07/05/2023, the department received a complaint alleging that medication was not given as prescribed. LPA reviewed R2’s physician orders dated included prescriptions for R2's medical needs. The Medication Administration Records (MARs) for the past 30 days showed consistent documentation of medication administration with no missed doses or discrepancies. Centrally stored medication logs were complete and matched the medications on hand. Interview with S1 confirmed that all staff responsible for medication administration are trained and certified. Stated that MARs are reviewed weekly for accuracy. Interview with S2 demonstrated knowledge of Resident 1’s medication regimen and described the facility’s double-check system for medication passes. Interview with S3 reported no issues with medication refusals or errors for R2. Outside Source 1 (OS1) stated they receive their medications daily and have not experienced any missed doses. Responsible Party: Reported no concerns regarding medication administration and confirmed that the resident’s health has been stable. LPA observed medications were observed to be properly labeled, stored in a locked cabinet, and organized by resident. Staff were observed following proper procedures during a medication pass, including verifying the resident, medication, dosage, and time. LIC9099C 3 of 6 On 07/05/2023, the department received a complaint alleging improper transfer resulting in injury. Record review R5’s Appraisal/Needs and Services Plan indicated the need for two-person assist with transfers and use of a gait belt. There was no Unusual Incident/Injury Report due to no fall was reported. The report indicated no fall occurred and that the transfer was completed per protocol. Interview with S1 confirmed that staff involved in the transfer were trained and certified in proper transfer techniques. Interview with S2 stated they use a gait belt and followed the two person assist protocol. They denied any deviation from the resident’s care plan. Interview with S3 reported that the resident was assessed immediately after the complaint of pain and that the responsible party and physician were notified. Interview with OS2 reported being notified promptly and expressed no concerns about the staff’s handling of the situation. LPA observed staff were observed assisting another resident using proper body mechanics and transfer techniques, including the use of gait belts and verbal cues. Transfer equipment (e.g., gait belts, walkers) was available and in good condition. On 07/05/2023, the department received a complaint alleging the facility retained a resident against their will. Review of R5’s Admission Agreement and Needs and Services Plan did not include any legal restrictions or conservatorship limiting their ability to leave the facility. No documentation was found indicating that the resident was placed on any form of hold or restriction. The facility’s Resident Rights Policy clearly states that residents may leave the facility voluntarily unless medically or legally restricted. Interview with S1 stated that R5 has not expressed a desire to leave the facility. Interview with S2 confirmed that the resident was not physically or verbally restrained and that staff only encouraged the resident to wait until a responsible party could be contacted. Interview with S3 reported that the resident was calm and cooperative and that no intervention was required. OS2 stated there has not been any signs or symptoms of R5 expressing they are being kept against their will. OS2 confirmed they are always contacted by the facility when there are changes in R5's behavior and appreciated that staff ensured the resident’s safety while respecting their rights. LPA observed Facility posted Resident Rights in a visible location, including the right to leave the facility voluntarily. No signs of restraint, isolation, or coercion were observed during the visit. LIC9099C 4 of 6 On 07/05/2023, the department received a complaint alleging staff does not have medication training. Records Reviewed of staff training files reviewed for five staff members responsible for medication assistance included: Certificates of completion for initial 6-hour medication training. Documentation of 8 hours of annual medication training. Competency assessments signed by a qualified professional Training logs were current and matched the staff schedules for medication administration. S1 confirmed that all staff who assist with medications have completed the required training and are monitored for ongoing compliance. S2 provided a copy of their training certificate and described the procedures followed during medication passes. S3 confirmed they do not assist with medications and are aware of the facility’s policy regarding medication handling. LPA observed staff administering medications using proper procedures, including: Verifying resident identity, checking medication labels and MARs. Documenting administration immediately after delivery. Medications were stored securely and labeled appropriately. On 07/05/2023, the department received a complaint alleging that staff drank alcohol while on duty. Records Reviewed of staff personnel files included signed Code of Conduct and Drug-Free Workplace Policy agreements. There were no disciplinary actions, incident reports, or documentation indicated staff impairment or alcohol use while on duty. The Facility policy strictly prohibits the use of alcohol or controlled substances during work hours. S1 denied any knowledge of staff consuming alcohol on duty and confirmed that all staff are trained on the facility’s substance use policy. S2 denied the allegation and stated that alcohol is not permitted on the premises. Both appeared alert and professional during the visit. S3 confirmed that staff are subject to disciplinary action and possible termination if found under the influence while working. R5 and R5 reported no concerns about staff behavior or professionalism. Both stated that staff are attentive and respectful. OS1 expressed satisfaction with the care provided and stated they had never observed or been informed of any inappropriate staff conduct. LIC9099C 5 of 6 During unannounced visits, staff were observed performing duties appropriately, with no signs of impairment. No alcohol or related paraphernalia was observed in staff areas or common spaces. On 07/05/2023, the department received a complaint alleging that staff used drugs while on duty. Records Reviewed of staff personnel files included signed Code of Conduct and Drug-Free Workplace Policy agreements. No disciplinary actions, incident reports, or documentation indicated staff impairment or alcohol use while on duty. Facility policy strictly prohibits the use of alcohol or controlled substances during work hours. S1 denied any knowledge of staff consuming drugs on duty and confirmed that all staff are trained on the facility’s substance use policy. S2 denied the allegation and stated that alcohol is not permitted on the premises. Both appeared alert and professional during the visit. S3 confirmed that staff are subject to disciplinary action and possible termination if found under the influence while working. R5 and R6: Reported no concerns about staff behavior or professionalism. Both stated that staff are attentive and respectful. OS2 expressed satisfaction with the care provided and stated they had never observed or been informed of any inappropriate staff conduct. During unannounced visits, staff were observed performing duties appropriately, with no signs of impairment. No drug or related paraphernalia was observed in staff areas or common spaces. On 07/05/2023, the department received a complaint alleging that staff did not provide residents with medical treatment. Resident records reviewed for five randomly selected residents showed documentation of timely physician visits, medication administration, and follow-up care. Incident reports and progress notes reflected appropriate staff response to changes in condition, including contacting physicians and responsible parties. No documentation indicated delays or refusals to provide medical treatment. LIC9099C 6 of 6 On 07/05/2023, the department received a complaint alleging that staff did not provide residents with medical treatment. Resident records reviewed for five randomly selected residents showed documentation of timely physician visits, medication administration, and follow-up care. Incident reports and progress notes reflected appropriate staff response to changes in condition, including contacting physicians and responsible parties. No documentation indicated delays or refusals to provide medical treatment. S1 confirmed that the facility has protocols in place for responding to medical needs, including contacting physicians, hospice, or emergency services as appropriate. S2 described procedures for monitoring resident health and initiating medical intervention when needed. S3 reported that staff are trained to observe and report any signs of illness or injury immediately. R5 and R6 reported satisfaction with the care provided and stated that staff respond promptly when they feel unwell. OS2 and OS3 confirmed that the facility communicates effectively and has arranged medical care when needed. Residents appeared well-groomed, alert, and comfortable during the visit. Staff were observed checking on residents and documenting care in real time. There were no signs of untreated illness or injury were observed. The Department has investigated a complaint with the above allegations. The Department has found that although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted with Natalie Carlborg, Executive Director to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 08-AS-20230705125821

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management Visit. LPA was greeted by and met with Resident Care Coordinator, Lima Taiti to discuss the purpose of the visit. Today's visit is in response to a complaint that was unrelated to the facility. LPA briefly interviewed staff and conducted a brief records review. An exit interview was conducted with Resident Care Coordinator, Lima Taiti, who was provided with a copy of this report. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jul 30, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Domingo was welcomed by, identified herself to, and discussed the purpose of the visit with Natalie Carlborg, Executive Director. According to the facility’s license, the facility has a maximum capacity of sixty four (64) clients, all of whom must be ambulatory. During today’s inspection, there were a total of fifty six (56) clients in care. Age range 60 and over, 56 non-ambulatory, of which 15 may be bedridden. Hospice waiver for 15. Approved delayed egress/secured perimeter LPA Domingo, accompanied by Executive Director, Natalie Carlborg, toured the interior and exterior of the facility, and inspected each room. 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 and 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’s ambient internal temperature was 72 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 118 F, Bathroom #1 sink was 110 F, and Bathroom #2 sink was 110 F. Refrigerator temperature was 34 F and freezer temperature was -3 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. 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. LPAs interviewed/observed staff and residents. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Natalie Carlborg, Executive Director, 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, Jun 12, 2025

Allegation investigated: Staff did not meet resident's incontinence needs. Staff did not meet resident's food service needs. Staff did not meet resident's hygiene needs.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings of the complaint investigation. LPA introduced herself, was granted entry, and met with Natalie Carlborg, Executive Director, to whom she disclosed the reason for the visit. During the investigation, LPA Domingo conducted a facility tour, conducted interviews, and collected pertinent resident records. On January 5th, 2023, Community Care Licensing (CCL) received a complaint alleging that staff did not meet residents' incontinence needs. LPA observed incontinence supplies at the facility in the bathrooms and in the residents' rooms, and storage areas. Interviews revealed that staff assist the residents with changing and cleaning after using the bathroom, and if the resident soiled their adult brief due to incontinence. Interviews revealed that the residents take showers on regular assigned shower days or as needed. (Continued on LIC9099C) Unsubstantiated (Continue from LIC9099) Interviews revealed staff did not let the residents stay in a soiled brief, and staff will provide incontinence care as needed. LPA observations revealed a sufficient amount of incontinence products in the facility. LPA also observed that the facility was not malodorous of urine or feces. LPA Domingo did not observe any residents during the visit who needed incontinence care. It was alleged that staff did not meet residents' food service needs. Interviews revealed that the staff assist residents with meals as needed and when the residents' service plans stated that there is a need to assist the residents during meals. The residents have meals in the room when requested. Records reviewed that R1 was independent with meals. R1 was able to push the meal tray and move the tray on their own. Records reviewed showed meals were provided and delivered to R1's room upon request. The resident was admitted on October 16, 2024, and previously resided at the family residence. On November 13, 2024, a Safety/Wellness check, police came, and they did not file a report, nor were there any findings that R1 needed any assistance. The resident moved out of the facility on November 15, 2024, per family request, and no known address was shared with the facility. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements, and the information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted, and a copy of this report, along with Licensee Rights (LIC 9058 03/22), was provided to Natalie Carlborg, Executive Director whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, May 14, 2025 · control 08-AS-20241105102141

Allegation investigated: Licensee did not provide sufficent staff to meet residents needs Licensee did not maintain a clean facility

Licensing Program Analysts (LPAs) Amy Rodgers conducted an unannounced visit to further investigate the complaint and to deliver findings regarding the above-mentioned allegations. LPA was welcomed by, identified herself to, and discussed the purpose of their visit with Executive Director Natalie Carlborg. On 12/30/24 it was alleged that the licensee did not provide sufficient staff to meet residents needs and licensee did not maintain a clean facility. The Department’s investigation consisted of an unannounced facility visit, records review, and interviews with staff, residents, and outside sources. (Continued on 9099-C) Unsubstantiated (Continued form 9099) Although the reported party stated they observed residents who needed a higher level of care, residents with incontinence needs not being met, and very low staffing; outside sources, resident interviews and residents’ family members stated they felt their needs were being met. Staff interviews indicated that there are enough staff to meet the needs of the residents. A review of the schedule for the entire month of November and December 2024 also revealed the facility was adequately staff. A facility tour did not corroborate the insufficient staffing, residents were observed being assisted by care staff as appropriate on three (3) separate visits. Staff interviews also confirmed the practice of changing and toileting residents every two (2) hours. Records review as well as interviews with the licensee, staff, and medical personnel, were conducted and revealed that although some residents required more incontinence and toileting care, there wasn’t any documentation of concern for neglect, abuse, or non-accidental injuries were noted. A review of resident records that were assessed at a high level revealed residents were assisted by direct care staff as well as receiving assistance from outside sources, and no concerns were noted. Reporting party further stated they observed some of the residents rooms are unclean and unkempt along with the building in disrepair. Resident family interviews and LPA observations reveal residents’ clothes are cleaned and laundered several times a week. Additionally, staff interviews corroborated that the few residents who require it get their sheets laundered daily. Staff interviews revealed that the hallways, common area both inside and out are cleaned in a scheduled manner and as needed. Outside sources who frequent the facility were interviewed and they state resident rooms are mostly free from malodors and when concerns are addressed to the staff, the staff respond in an appropriate manner to address the malodors. A facility tour on three (3) separate visits did not corroborate the unclean or unkempt rooms or the building was in disrepair. The Department has investigated the above-mentioned allegation and based on observations, interviews conducted, and records reviewed there was insufficient evidence to support that the licensee did not provide sufficient staff to meet residents needs and licensee did not maintain a clean facility. Therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Executive Natalie Carlborg to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 08-AS-20241230111305

Allegation investigated: Staff are administering injectable medications

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to open an investigation on the above allegation. LPA was granted entry into the facility and met with Natalie Carlborg Executive Director, to whom LPA disclosed the reason for the visit. Community Care Licensing (CCL) has investigated the above listed complaint allegation. The investigation consisted of review of facility records, interviews with staff and outside sources. On November 18, 2024 Community Care Licensing (CCL) received a complaint alleging Staff are administering injectable medications. Continued on LIC9099C Unsubstantiated Continued from LIC9099 Staff 1 (S1), (Please see confidential names on LIC811), was interviewed and verified that there were no residents given injectable medications at the facility. S1 clarified that there was a conversation of oral medications that could possibly be given to hospice residents when they were unable to swallow crushed medications. S1 clarified that it was only a topic of conversation and there were no staff members asking medication technologists to administer any injectable medications to any residents at the facility. S1 clarified again that the topic of conversation was not injectable medication. Documents were collected which revealed the facility was not providing any residents injectable medications. Staff 2 (S2) provided documentation that the facility is not currently or has not in the past administered injectable medications to any residents. The facility policy was reviewed and only licensed nurses or physicians are authorized to give residents injectable medications. The Department investigated the above allegation and was not able to meet the preponderance of evidence standard to prove that the alleged violation occurred. Therefore, the above allegation is unsubstantiated. An exit interview was conducted with Natalie Carlborg Executive Director, and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Nov 22, 2024 · control 08-AS-20241118143000

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Natalie Carlborg, Executive Director. Today’s visit was in response to an incident which licensee self reported via an LIC624 Incident Report. On 11/8/24 the facility reported an AWOL of Resident #1 (R1 – See LIC811 Confidential Names List for identification of R1). R1 was found uninjured, the family was notified, law enforcement also was notified all in timely manner. The staff followed the facility elopement/AWOL protocol and R1 is being evaluated for appropriate placement at the current facility. LPA briefly toured the facility, performed a welfare check on residents in care, interviewed staff, and obtained copies of pertinent facility records. No deficiencies were observed or cited on this date. An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (03/22) were left with the Executive Director, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Nov 14, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Natalie Carlborg Executive Director. Today’s visit was in response to an incident which licensee self reported via an LIC624 Incident Report. The report described Resident #1 (R1 – See LIC811 Confidential Names List for identification of R1)… LPA Domingo interviewed staff, and obtained copies of pertinent facility records. No deficiencies were observed or cited on this date. An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (03/22) were left with the Executive Director, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Sep 24, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Domingo was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Suzette Johnson. According to the facility’s license, the facility has a maximum capacity of sixty four (64) clients, all of whom must be ambulatory. During today’s inspection, there were a total of fifty six (56) clients in care. Age range 60 and over, 56 non-ambulatory, of which 15 may be bedridden. Hospice waiver for 15. Approved delayed egress/secured perimeter LPA Domingo, accompanied by Administrator, toured the interior and exterior of the facility, and inspected each room. 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 and 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’s ambient internal temperature was 72 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 118 F, Bathroom #1 sink was 110 F, and Bathroom #2 sink was 110 F. Refrigerator temperature was 34 F and freezer temperature was -3 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. 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. LPAs interviewed/observed staff and residents. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance and surety bond. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Administrator Suzette Johnson, 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, May 13, 2024

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Dang Nguyen and Juliana Barfield conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Suzette Johnson. Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/27/2023), involving Staff #1 (S1) and Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPAs performed a facility tour. At the time of the visit, R1 was off-site and unable to be interviewed. However, a welfare check was performed on other residents in care. LPAs also reviewed pertinent care and investigative records and interviewed other relevant residents and staff. According to R1’s latest LIC602 Physician’s Report (dated 10/23/2023), R1 was diagnosed with Dementia. Their doctor stated that while R1 was “confused/disoriented,” R1 was also able to follow instructions and able to communicate needs. According to staff interviews: Multiple managers and caregivers noted that R1 had a tendency towards tactile stimulation, sometimes touching things or others out of curiosity. During the evening of 12/23/2023, R1 touched Resident #2’s (R2) shoulder, which bothered R2. Staff #2 (S2) said they saw S1 slap R1’s arm. S2 reported their concerns about the incident to facility management. In their written statement, S1 said they “grab[bed]” R1’s hand to redirect them away from R2. There were no injuries to either resident. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Per staff interviews, personnel records, and interview of Resident #3 (R3): there was another incident occurring on 12/28/2023, involving S1 and R3. On this date, S1 was speaking on their personal cell phone inside R3’s bedroom. R3 became annoyed and asked S1 to stop. S1 did not, so R3 used their own cell phone to document S1’s actions. When S1 saw this, they physically took R3’s own cell phone away, against their will, to delete the photo which R3 took of them, before returning the phone to R3. R3 said during the scuffle over the phone, R3’s arm brushed up against a wall. R3 stated that they did not believe S1 intended to hurt them, and that S1 was going after their phone, not R3 themselves. LPAs observed that although R3 was diagnosed with Dementia (per their latest LIC602 Physician’s Report dated 12/19/2023), R3 spoke coherently and knew the present year, the present city they were in, the name of the facility, and the name of the current US President. R3 was able to be qualified as a credible witness for this case. R3’s description of incident to CCLD was consistent with the description they earlier gave to Licensee. LPAs observed a very minor scab on R3’s left elbow, which R3 attributed to the incident with S1. According manager interview and personnel records, Licensee’s terminated S1 employment on 01/04/2024, citing S1’s “violation of Resident’s Rights” as one of the reasons. A preponderance of evidence exists to show that Licensee’s staff (S1), through their actions, did not uphold resident dignity and privacy. Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plan of Corrections were jointly developed with the licensee. An exit interview was conducted with Johnson, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jan 5, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Feb 4, 2024

87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff...” This requirement was not met, as evidenced by: Based on records and interviews, Licensee’s staff (S1) did not treat 2 of 56 residents (R1 and R3) with dignity, which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 5, 2024

Plan of correction: Per manager interview and personnel records, S1’s employment at the facility ended on 01/04/2023. Licensee agreed to retrain its remaining direct care staff on Resident’s Personal Rights (as articulated in CDSS form LIC 613C-2), and to submit the training sign-in sheet to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.2(a)(1) · Plan of correction due date: Feb 4, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in…personal care and assistance…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee’s staff (S1) did not uphold the personal privacy of 1 of 56 residents (R3), which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 5, 2024

Plan of correction: Per manager interview and personnel records, S1’s employment at the facility ended on 01/04/2023. Licensee agreed to retrain its remaining direct care staff on Resident’s Personal Rights (as articulated in CDSS form LIC 613C-2), and to submit the training sign-in sheet to LPA, by the POC due date.

Allegation investigated: Staff interfere with residents' sleep

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegation. LPA met with Executive Director, Suzette Johnson. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff interfered with residents’ sleep by waking them up early to get them ready for the day. Outside source interviews revealed the NOC shift, which works 10pm-6am was waking the residents up between 3:30am-4:30am. It was reported the NOC shift were getting residents up and ready for the day and taking them to the common/dining room area where the residents were falling asleep at the tables. Evidence obtained revealed the residents were tired and falling asleep in the dining room area waiting for breakfast, which didn’t start until 7:30am. The Executive Director’s (ED) interview revealed there were approximately eighteen (18) residents that wake up early and the NOC shift assists those residents first. Continued on an LIC 9099C. Substantiated The ED also stated there was one (1) caregiver and one (1) Medication Technician on NOC shift, and an AM staff that starts at 5:00am to assist NOC shift for one (1) hour before their shift ends. Staff interviews revealed it’s impossible to get all multiple up by breakfast if they start at 5:00am. Therefore, staff must start waking residents up as early as 3:00am to fulfill the facility’s requirement of getting the residents up and ready. Staff interviews confirmed they wake the residents up at 3:00am-3:30am to get them ready and the residents are placed in the dining room area and are falling asleep, while they wait for breakfast to be served. Residents sleep is being interfered by staff due to waking up as early as 3:00am to get ready for a 7:30am breakfast. Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Executive Director, Suzette Johnson whose signature below confirms receipt of these rights. It was also alleged staff do not maintain the facility in clean condition. It was reported Room #101’s carpet had blood stains and other carpets were dirty as well and not being shampooed or cleaned. On 09/06/23, LPA observed Room #101 and observed stains on the carpet along with a strong odor. The odor was intense causing the LPA to have to exit the room quickly. LPA observed other resident rooms and discovered stains and strong odors. LPA also observed all resident hallways had new flooring as the carpets were already replaced. Staff interviews revealed they had gotten used to the smell/odors, which were caused by the old carpets. Staff also confirmed the carpets were being replaced by the new owners. The Executive Director’s (ED) interview revealed the carpets were not in clean condition and needed to be replaced. The ED explained the facility had new ownership and she was new as well but was already working on replacing all the carpets with flooring. The ED explained there was a delay with replacing all the carpets with flooring due to some issues with the contractor. However, everything was now on track and Room #101’s carpet was next on the list to be replaced. All residents have a Major Neurocognitive Disorder and did not witness odors in their rooms. The ED provided proof of documentation that all resident carpets were being replaced with flooring. In addition, the ED also provided documentation to show the timeline and delays with the contractors. The ED was able to prove the work began when they took over ownership, and time was needed to replace all the carpeting. Today, LPA confirmed all residents room carpets have been replaced with flooring. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Executive Director, Suzette Johnson whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 08-AS-20230828154350

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 3, 2023

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews the licensee did not ensure residents had comfortable accommodations for 10 out of 52 [R1-R10] residents in care which posed a potential health and personal rights risk to residents.the state’s words, verbatim · CDSS document, Oct 20, 2023

Plan of correction: Executive Director stated an In-service will be conducted on Personal Rights to include ensuring residents sleep is not interered with. ED also stated additional staff has been hired for the NOC shift.