Grossmont Gardens Senior Living

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced Case Management – Other visit in relation to residents that were recently relocated to this facility from another licensed community. LPA identified themselves and met with Executive Director Lynn Torino to discuss the purpose of the visit. During the visit, LPA reviewed the resident records, assessed continuity of care, and observed residents in care to ensure needs were being met following the transition. No deficiencies were observed during today’s visit. An exit interview was conducted with Executive Director Lynn Torino, and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, Aug 17, 2026

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 Lynn Torino and stated the purpose of the visit. Today’s visit was in response to an incident which licensee self reported via an LIC624 and SOC341 Incident Report received at the Community Care Licensing Regional Office on July 24, 2026. The report described an witnessed verbal confrontation between staff #1(S1) and Resident #1 (R1 – See LIC811 Confidential Names List for identification). 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) Torino 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 Torino. 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, Aug 3, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver investigation findings. LPA was granted entry into the facility and met with the Executive Director, to whom she disclosed the purpose of the visit. Community Care Licensing (CCL) has completed the investigation into the allegation that neglect and lack of care and supervision by facility staff resulted in the death of Resident 1 (R1), identified on the LIC 811 Confidential Names List. The investigation consisted of a review of facility records, review of the Medical Examiner’s report, review of photographic evidence, interviews with staff and outside sources, and review of physician orders and dietary records. Department records review revealed physician documentation that R1 had multiple significant medical conditions, including dementia and oropharyngeal dysphagia. Physician’s Reports dated January 26, 2024, and May 8, 2025, documented that R1 required a soft and bite-sized diet and a minced and moist diet with thin liquids. Both physicians specifically ordered that R1’s food be modified to reduce the risk of choking. These diet orders were on file and available to staff at the time of the incident. (Continued LIC 9099C) (page 2 of 3) (Continued form LIC9099) Department interviews revealed that on the night of January 1, 2026, R1 approached staff and requested something to eat. R1 was seated in a wheelchair in the hallway near the nurse station. Department interviews revealed that R1 was unsupervised at the time and that Staff #1 (S1) prepared a peanut butter and jelly sandwich for R1. S1 acknowledged that she knew R1 was on a soft diet but did not check the dietary information board posted at the entrance to the dining room. S1 reported that she considered a peanut butter and jelly sandwich to be a “soft” food and therefore appropriate. S1 provided R1 with an uncut, whole sandwich that was not minced or cut into bite-sized pieces as required by the physician-ordered diet. According to witness statements, S1 returned to the dining hall after handing the sandwich to R1. Approximately five minutes later, S1 returned to the hallway and observed R1 with a pale face and hands to the throat, consistent with choking. Statements from staff confirm that R1 had taken a single bite from the sandwich when the choking event occurred. Staff #2 (S2) responded after hearing S1 call for help, and Staff #3 (S3) initiated the Heimlich maneuver. S3 reported that some food particles were expelled, but R1 remained unresponsive. R1 was placed on the floor and CPR was initiated until paramedics arrived. Facility staff provided paramedics with R1’s active Physician Orders for Life-Sustaining Treatment (POLST), which directed Do-Not-Resuscitate status, and paramedics subsequently discontinued resuscitation efforts. R1 was pronounced deceased at 2245 hours. R1's death certificate issued by the San Diego County Medical Examiner lists the cause of death as asphyxia due to choking, with dementia listed as a contributing condition. The Medical Examiner’s investigation noted that a food bolus was lodged in the epiglottis and that food particles were present in both main bronchi. The manner of death was determined to be accidental. The Department incorporated the Medical Examiner’s findings and confirmed that the choking event occurred while R1 was eating the unmodified sandwich prepared by staff. (page 3 of 3) (Continued on LIC9099C) Department interviews with the Executive Director revealed that the facility kept a dietary information board posted at the first-floor dining room entrance and that R1’s diet information had been posted on the board prior to R1’s death. Photographs were taken by the Department and confirmed its presence and accessibility to staff. A photograph of a sample of the half sandwich was also obtained. Department interviews with staff revealed that staff are instructed to review dietary expectations, including checking the dietary board before preparing food for residents. Interviews further revealed that S1 did not follow this procedure. The Department IB investigation documented that the facility maintained systems intended to support dietary compliance, but that the systems were not effectively used by staff during the incident involving R1. Based on review of records, interviews, photographic evidence, and the Medical Examiner’s findings, it is determined that staff failed to follow R1’s physician-ordered special diet and failed to provide appropriate supervision while R1 was eating. These failures directly contributed to R1 choking on food that was not prepared according to ordered specifications. R1’s death occurred as a result of choking on an improperly prepared food item that staff knowingly provided, and R1 was left unsupervised despite documented swallowing impairment. Based on interviews and review of documentation, the allegation identified above is SUBSTANTIED. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. The deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and is noted on the attached LIC 9099-D. An immediate civil penalty in the amount of $500 is being assessed on an LIC 421IM for the death of R1, in accordance with Section 1548(c)(1) of the Health and Safety Code. At this time, pursuant to Health and Safety Code Section 1569.49, a civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division.the state’s words, verbatim · CDSS document, Jul 10, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312 · Plan of correction due date: Jul 11, 2026

1569.312 Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision.. This requirement is not met as evidenced by: Based on interviews and record review, R1 was left unattended while eating a non-prescribed diet. R1 subsequently choked and died as a result of the incident. The licensee did not ensure that supervision was provided to 1 out of 395 residents (R1), which posed an immediate health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Jul 10, 2026

Plan of correction: The licensee will arrange for an outside vendor to provide staff training on resident care and supervision, including safe meal assistance practices, choking risk awareness, and monitoring requirements during high-risk activities such as eating by POC date Licensee will submit proof of completed vendor training and updated internal training records to the Department by 8/12/2026

Allegation investigated: Staff do not keep facility free from bedbugs.

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to open a complaint regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Chris Neale. The Department’s investigation included an unannounced visit, interviews, observations, and review of pest control records. It was alleged that the staff do not keep facility free from bedbugs. Interviews revealed that on June 19, 2026 the department received the above mentioned complaint. Staff interviews revealed that maintenance staff have established procedures that are in place that once the concern of the bed bugs arise, both facility staff and the contracted pest control company complete a thorough inspection of the area. Interviews revealed that if the room or area is positive for bed bug activity, they notify the residents and then complete treatment. Interviews with residents did not reveal any current concerns and confirmed that staff are performing frequent checks and acted promptly in getting the rooms treated. Unsubstantiated Continued... A review of outside source documentation revealed that the pest control inspections occur every two weeks, and any areas of concern are rechecked for new activity. LPA observations during a tour of the rooms showed that resident rooms had no signs of infestation. Based upon the information obtained during this investigation, the allegation is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Chris Neale, Executive Director, to whom a copy of this report and the Licensee’s Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 26, 2026 · control 08-AS-20260619152339

Allegation investigated: unlawful eviction

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Chris Neale The Department’s investigation consisted of unannounced facility visits and interviews with facility staff, the resident, and outside sources. On June 8, 2026, Community Care Licensing Division (CCLD) received a complaint alleging unlawful eviction. More specifically, it was alleged Residen #1(R1) wished to return to the facility and agreed to conditions required for readmission; however, the Facility declined to accept the resident back. (continued on LIC9099-C) Unsubstantiated (continued from Lic9099) Department interview with R1 revealed they did not wish to return to the facility due to medication management requirements and reported they gave the facility a verbal notification in person on 5/29/2026 and that they will no longer be living at the facility. She did however leave some belonging in the room. Department staff interview revealed the resident left the facility on her own and reported to the executive director on 5/29/2026 they would not be returning. Staff also reported the resident was eligible for readmission however would need to participate in medication management upon return. Department outside source interview revealed R1 payment for May 2026 was made to the facility , but payment for June 2026 was withheld because the resident was no longer residing at the facility. Department interviews revealed that no written eviction notice was issued. Interviews with all parties indicated there was a verbal notice of move out. Facility interviews confirmed that R1 is able to resume occupancy. Based on interviews and records review, the preponderance of evidence standard has not been met; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Chris Neale, 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-20260608101921

Allegation investigated: Staff does not keep the facility free of pests

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to invistigate and deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive DIrector Chris Neale. The Department’s investigation included unannounced visits, interviews with staff, residents, outside sources, observations, and review of pest control records. On June 5, 2026, Community Care Licensing Division (CCLD) received a complaint alleging staff do not keep the facility free of pests, specifically that multiple rodents and roaches were observed in resident rooms, beds, hallways, and the break room in the East Building on the second floor. Unsubstantiated Staff interviews revealed no direct observations of rodents or roaches and stated they had not observed droppings or nesting inside the facility. Resident interviews revealed that some residents reported seeing a rodent during May and the week of the 6/8/2026, but no droppings or nesting were reported. Outside source interviews revealed no sightings or evidence of rodents or roaches. Executive Director interview revealed the facility addressed potential entry points, placed monitoring traps, and found no droppings, nests, or exterior holes. Records review revealed there is Pest control reports from April–June 2026 documented rodent activity outside the building, but no interior rodent or roach activity. LPA observations revealed observed no droppings, nesting, or pests inside resident rooms while on previous recent visits and and confirmed steel wool installation in 5 bedrooms and exterior 4 exterior bait stations. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Neale and a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jun 10, 2026 · control 08-AS-20260605102846

Allegation investigated: Staff do not ensure the residents room are properly maintained

Licensing Program Analyst (LPA) Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Adminsitrator Neale. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents and LPA observations On March 5, 2026, Community Care Licensing Division (CCLD) received a complaint alleging staff do not ensure the residents’ rooms are properly maintained. More specifiicaly, clutter and unsanitary condiations as well as lifted flooring in some rooms. Staff interview revealed Residents #1 and #2 (R1 and R2) can be confrontational at times when approached regarding cleaning or clutter, and that room cleaning assistance is sometimes declined by the residents.Resident interview revealed both R1 and R2 stated they were willing to allow staff to help them clean their rooms and did not report refusing assistance. LPA observations revealed excessive clutter throughout the rooms, including numerous small plastic bags and personal items on the floors, thick cobwebs on lamp, food debris on the floor, stains on flooring ranging from approximately 1 inch to 10 inches, and damaged flooring in the entry to Bedroom #2 and Bathroom #2 where flooring was lifted or missing sections. Based on relevant interviews and observatino , 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 9099D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Administrator Neale, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. Substantiated (continued from LIC9099a) (Room 2 of 3) Regarding allegation: Staff are verbally abusive to the residents. LPA interviews with multiple staff, residents, and family members revealed no evidence to corroborate the statements made by the reporting party. Staff interview revealed no staff had witnessed or participated in verbally abusive conduct. Resident interview revealed no concerns regarding staff speaking disrespectfully or aggressively. Outside source interview revealed no knowledge of verbal abuse occurring. .LPA observations revealed staff interacting with residents in a professional manner. Regarding Allegation: Staff did not provide healthful accommodations for the residents. More specifically facility staff leave resident bowel and urine messes in hallways for days and do not provide cleaning supplies to staff. LPA interviews with housekeeping staff, caregivers, and management revealed that approved cleaning products and protective equipment are available on each floor and accessible to staff at all times, and no evidence was found to support improper cleaning practices when responding to resident toileting incidents. Staff interview revealed facility approved cleaning supplies are stocked and available 24 hours a day. Resident interview revealed no concerns about environmental cleanliness .LPA observations revealed common areas and hallways to be clean and orderly. Regarding Allegation: Staff did not follow proper food handling techniques. More specifically kitchen staff do not follow proper food handling protocols. LPA interviews with multiple staff members, including kitchen staff and caregivers, as well as interviews with residents and family members, did not reveal any evidence to support the allegation. Staff interview revealed food handling procedures are followed consistently. Resident interview revealed no concerns related to food preparation or sanitation. LPA observations revealed kitchen areas clean and properly maintained. Continued from LIC9099A-C) Page 3 of 3 Allegation: Staff did not properly maintain the facility grounds. More specifically: LPA interviewed maintenance staff and caregivers and reviewed observations from previous visits, which showed that resident scooters and wheelchairs regularly cause wall damage that maintenance consistently repairs, and LPA did not observe any outstanding spills or staining on floors or walls during the investigation.Staff interview revealed maintenance completes repairs as needed. Resident interview revealed no concerns regarding the condition of facility grounds.Outside source interview revealed no maintenance related issues reported. Records review revealed maintenance logs documenting ongoing repairs and services LPA observations revealed no outstanding or unaddressed maintenance hazards. Allegation: Staff lock residents in their bedrooms More specifically staff are not allowed keys to enter residents rooms. LPA observed key storage accessible to med tech staff, and staff interviews confirmed that residents may lock their doors by choice; LPA interviewed a random selection of residents with locked doors and confirmed their personal rights were not being violated, as staff knock before entering and use facility keys appropriately to ensure access. Staff interview revealed residents are permitted to lock their rooms for privacy. Resident interview revealed no reports of being prevented from exiting rooms. Outside source interview revealed no concerns relating to locked rooms. LPA observations revealed residents freely moving about the facility without restriction. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator Neale, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 28, 2026 · control 08-AS-20260305111816

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303 · Plan of correction due date: May 28, 2026

87303(a) Maintenance and Operation“The facility shall be clean, safe, sanitary and in good repair at all times. Based on observation and interviews, LPA observed excessive clutter, cobwebs, food debris, stained flooring, and damaged flooring in resident bedrooms and bathrooms. .This posed a potential health and safety risk to 3 out 395 residents. .the state’s words, verbatim · CDSS document, May 28, 2026

Plan of correction: Facility replaced flooring and worked with Residents to maintain a clean and sanitary enviornment. POA Cleared at time of vist

Allegation investigated: Facility staff is not properly addressing issue of pests

Licensing Program Analysts (LPAs) Amy Rodgers and Eryn Kane conducted an unannounced visit to the facility to deliver investigative findings regarding the above mentioned allegation. LPAs identified themselves, explained the purpose of the visit and nature of the complaint to Chris Neale, Executive Director. The Department’s investigation included a facility tour, record reviews, as well as interviews with residents and staff. On May 18, 2026 the Department received the above mentioned complaint which alleged facility staff is not properly addressing the issue of bed bugs. Staff interviews reveal that maintenance staff have established procedures in place and implemented them promptly. These measures are followed by regular reinspection conducted by both facility staff and the contracted pest control company. Resident interviews reveal no current concerns and confirmed that staff are performing frequent checks. A review of outside documentation reveal that pest control inspections occur monthly, and any areas of concern are rechecked for new activity. No reoccurrences have been noted in the summary reports reviewed. LPA observations showed that resident rooms had no signs of infestation. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed UNSUBSTANTIED. An exit interview was conducted with Chris Neale, Executive Director, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 21, 2026 · control 08-AS-20260518103729

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPAs) Amy Rodgers and Eryn Kane conducted a continuation of an unannounced Required Annual Inspection. LPAs conducted the visit with Executive Director, Chris Neale. The facility has an approved fire clearance for delayed egress in the East Building on the first and fourth floor only. LPAs, accompanied by Executive Director, toured the interior and exterior of the facility, and inspected multiple rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Doors, windows and screens, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured between 109 and 117 degrees F. The refrigerator temperature was 40 F and freezer temperature was 0 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. There was a swimming pool with a locked gate surrounding the pool. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Required licensing postings were observed in visible areas of the facility. LPAs interviewed multiple staff and residents. The interviews did not raise any significant licensing concerns. LPAs reviewed multiple staff and resident records. 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 Executive Director, Chris Neale 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 21, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Eryn Kane and Amy Rodgers conducted an unannounced visit to continue a Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Administrator Chris Neale. During today’s visit, LPAs toured the facility property. LPAs also reviewed resident files. Due to time constraints, the inspection will be continued on a separate date. An exit interview was conducted with Administrator Neale, 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 19, 2026

Allegation investigated: Staff are not assisting resident with showering

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced complaint visit to the facility to deliver findings on the above‑mentioned allegation. LPA gained access to the facility, identified themselves, and met with Chris Neale to discuss the purpose of the visit. LPA conducted interviews with a resident , facility staff, and reviewed relevant resident records. On April 8, 2026, the Community Care Licensing Division (CCLD) received a complaint alleging staff are not assisting the resident with showering. More specifically, Resident #1 (R1) reported being unable to shower or wash their independently due to physical limitations and shoulder pain. R1 has physical limitations and, according to the Assessment/Care Plan dated 11/04/2025, R1 is to receive standby assist for showering, reminders for dressing, and is listed as independent with grooming. The care plan does not list transfer assistance. The Physician’s Report dated 10/09/2025 indicates that R1 is capable of completing self care tasks slowly and that additional help is welcomed but not required. Department interviews with R1 reveal never informing management about needing additional help and believed bathing assistance was included in their contract. Some staff interviews reported that R1 often requires more help than standby assist and stated they assisted R1 when requested. A review of records did not show documentation of staff refusing assistance or prior concerns reported to the facility. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Chris Neale, and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 14, 2026 · control 08-AS-20260408163041

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Chris Neale, Executive Director. Today's visit was in response to a report of suspected dependent adult elder abuse (SOC341) to CCLD San Diego Regional Office (received on 03/20/2026). According to the SOC341: Resident #1 (R1) was escorted to the bank by Staff #1 and Staff #2. Staff interviews as well as R1 interviews reveal staff escorted R1 due to assisting with Medi-Cal information and part of the process was to collect documents. During today’s visit, LPA performed a facility tour / welfare check, collected records, and interviewed R1 and staff. An exit interview was conducted with Chris Neale, Executive Director. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Mar 26, 2026

Allegation investigated: Staff caused an injury to a resident

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to commence a complaint Investigation and deliver a finding regarding the above allegation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Chris Neale. On March 5, 2026, the Community Care Licensing Division (CCLD) received a complaint alleging that Resident #1 (R1) slipped from their wheelchair during transport and sustained an injury. Department records review showed that the facility submitted a self-report on January 20, 2026, stating that R1 slipped from a locked wheelchair during transport and sustained a head injury requiring stitches. Department interviews, observations, and staff demonstrations revealed that R1 had not been properly secured with the seatbelt. Staff #1 (S1) did not follow the written instructions posted inside the transport van regarding proper restraint of wheelchair residents and failed to apply the lap belt to R1. As a result, R1 slipped from the wheelchair during a stop and was injured. (Continued on LIC9099C) Substantiated (continued form LIC9099) Based on relevant interviews observations and staff demonstration, the preponderance of evidence has been met that alleged violation 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 Chris Neale. 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, Mar 11, 2026 · control 08-AS-20260305111816

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468(a) · Plan of correction due date: Mar 12, 2026

87468(a) – Personal RightsSpecifically:Residents have the right to be safe, comfortable, and free from harm.Failing to secure a resident during transport violates their right to safe and healthful accommodations. Based on interview and observation, the licensee failed to provide safe transportation procedures resulting in R1 injusry.This posed an immediate health and safety risk to 1 out 1 residents.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: LPA verified staff drivers have knowlege on how to put bottom seatbelt on wheelchair residents. Outside source training will be conducted on 3/11/2026 andl staff will provide proof of training by POC date.

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

Allegation investigated: Facility premises are not properly maintained by facility staff, posing a risk to residents in care

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to further investigation and deliver a finding regarding the above allegation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Chris Neale. The department's investigation involved an unannounced facility tour and interviews of relevant staff and outside sources as well as a review of records. On 02/19/2026, it was alleged that the facility premises are not properly maintained and that uneven asphalt in the rear parking lot caused a resident fall, resulting in injuries. (Continued on LIC9099C) Unsubstantiated (Continued from LIC9099) LPA conducted a visit to the facility and observed the parking lot and surrounding walkways. LPA did not observe any large holes, severe cracks, or buckling that would pose an immediate danger to residents. Some patched areas were noted in the driveway and along the wheelchair accessible walkway. LPA interviewed the Executive Director and maintenance staff. Staff reported the parking area and driveway are cleared of debris once a week. Facility provided documentation showing a capital project plan is in place to repave the parking lot; however, resurfacing is scheduled to take place after construction projects have concluded. Department interviews reveal that the maintenance director is inspecting the parking lot weekly and is preforming repairs to maintain a safe environment to residence. Based on records and interviews and department observations, a preponderance of evidence does not exist to show that Licensee did not take the required steps to properly maintain facility premises. The allegation is therefore UNSUBSTANTIED. An exit interview was conducted with Executive Director Neale, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 2, 2026 · control 08-AS-20260219135141

Allegation investigated: Staff do not ensure the facility is free from pests

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to commence a complaint Investigation and deliver a finding regarding the above allegation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Chris Neale. The department's investigation involved an unannounced facility tour and interviews of relevant staff and outside sources. On 2/26/2026, it was alleged that the licensee did not take the required steps to prevent rodents at the facility. More Specifically, rodents were seen in rooms and hallway in a selct area of one of the buildings on campus. (Continued on LIC9099C) Unsubstantiated (Continued from LIC9099) Department Interviews with facility staff and residents aligned to show that, about two weeks before the complaint time frame, they observed rodents inside the facility, prompting facility staff to closely inspect rooms in the East building of the community and take mitigation measures for rodent activity. Department Interviews with staff and the Executive Director further corroborated that, long before the complaint time frame, Licensee had already contracted with a professional outside company to perform preventive pest/rodent control services every two weeks at the facility. The facility maintenance staff also implemented additional preventive measures to deter rodent infestation. The area/rooms in question has sliding glass doors that lead to an outside area, and the surrounding outdoor areas were observed to have rodent traps. According to current regulations, the presence of rodents at a facility, in and of itself, is not a regulatory violation. Regulations instead speak to the maintenance of food areas, covered trash cans, and solid waste practices as the required actionable steps for mitigating rodents. Based on records and interviews and department observations, a preponderance of evidence does not exist to show that Licensee did not take the required steps to prevent rodents at the facility. The allegation is therefore UNSUBSTANTIED. An exit interview was conducted with ED Neale, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 2, 2026 · control 08-AS-20260226101123

Allegation investigated: Staff left a resident soiled for an extended period of time Staff did not timely address a resident's change in medical condition

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Executive Director Chris Neale and discussed the purpose of the visit and elements of the complaint. The investigation consisted of records review, interviews with facility staff, residents and resident familiy members as well and observations during an unannounced visit. On December 17, 2025 Community Care Licensing (CCL) it was reported that staff left a resident soiled for an extended period and staff did not timely address a resident’s change in medical condition. Unsubstantiated Continued form LIC9099) Regarding the allegation that staff left R1 soiled for an extended period. More specifically, RP reported staff left R1 soiled for hours without assistance. Department interviews reveal that R1 confirmed requiring staff assistance for toileting and incontinence care. R1 reported occasional delays for staff response, but clarified this is not typical, as staff usually respond within a reasonable time. R1 also stated that staff assist with bed transfers and toileting multiple times daily. Department Interviews reveal the Executive Director indicated that pendant calls are answered promptly and that the Gardens area is staffed to meet resident needs, with additional support available from the South Building if necessary. Department interviews with residents, family members, and staff did not reveal any major concerns related to staff response times or incontinence care. Some individuals noted minor delays in answering call lights; however, there was no indication of inadequate supervision. Department records review of facility documentation and records did not produce evidence of neglect or prolonged soiling. During the visit, the Licensing Program Analyst observed R1’s room and noted no foul odors or unsanitary conditions. Regarding the allegation that staff did not timely address R1’s change in medical condition. More specifically, R1 throwing up for three days straight before nursing addressed R1. Department review of facility records reveal evaluations completed on January 18, August 6, and November 4, documenting reassessment of R1’s needs, including assistance with transfers, dressing, and toileting. Following the evaluations ED revealed that the facility encouraged R1 to relocate for closer proximity to care staff and coordinated two-person transfers when required. No evidence was presented that the facility failed to notify physicians or responsible parties of incidents. Interviews with staff and outside sources revealed no concerns regarding failure to address changes in condition. The Department has investigated the above-mentioned allegations and based on observation, interviews, and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Executive Director Neale whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Feb 6, 2026 · control 08-AS-20251217151827

Allegation investigated: Facility staff are not following proper food handling protocols

LPA Amy Rodgers conducted an unannounced visit to investigate and deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Administrator Neale. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. On January 9, 2025, Community Care Licensing Division (CCLD) received a complaint regarding the facility had bread racks in the walk in Fridge that had mold/fuzzy fungus. Interviews with multiple staff members, that frequent the kitchen as well as the walk in refrigerator, reveal they have never witnessed mold in any part of the fridge or on food. LPA observations and photo evidence reveal the facilities only walk in refrigerator to be organized into categories, floor and shelves were clean, and bread was kept in racks. Bread had delivery dates. The bread rack itself was observed by LPA and did not have mold or fungus. Based on interviews and direct LPA observations, 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 [Administrator Neale, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 14, 2026 · control 08-AS-20260109163242

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Chris Neale Today's visit was in response to licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 1/5/2025. [See LIC 811 Confidential Names List for a description of R1]. Per the report, R1 passed away on 1/5/2026. LPA collected pertinent records, and interviewed relevant staff. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Executive Director Neale to whom a copy of this report, 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 7, 2026

Allegation investigated: Staff did not maintain adequate communication access to ensure timely communication with medical providers.

LPA Rodgers conducted an unannounced visit to the facility to further investigate and deliver findings regarding the above complaint allegations. The visit was conducted via email with Executive Director Chris Neale. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, review of phone records, and LPA observations. On December 18, 2025 at 10:51 PM, the Community Care Licensing Division (CCLD) received a complaint alleging that staff did not maintain adequate communication access to ensure timely communication with medical providers. (Continued on LIC9099) Unsubstantiated (Continued from LIC 9099) The Department Investigation revealed that a local hospital began calling the facility at 9:46 PM regarding a resident’s return. Facility records show the on-duty LVN (Licence Vocational Nurse) returned calls at 10:57 PM and 11:02 PM to confirm that the resident could return to the facility and that staff would be present for the residents return to the facility. The resident arrived at the facility at 1:10 AM. Staff interviews confirmed that after 8:00 PM, calls are routed to the on-duty LVN, who carries a work cell phone and monitors voicemail-to-email messages. LPA observations confirmed the voicemail-to-email system is in place and accessible to the on-duty LVN. Records review did not show evidence that the facility failed to respond to the hospital’s request for communication. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Chris Neale. A copy of this report and Licensee Rights (LIC9058 03/22) were provided, and their signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Dec 31, 2025 · control 08-AS-20251222085658

Allegation investigated: Facility charged resident for care services which were not provided Facility staff did not provide food service to meet residents preferences Facility staff did not provide assistance to resident Facility was in disrepair

LPA Rodgers conducted an unannounced visit to the facility to further investigate and deliver findings regarding the above complaint allegations. The visit was conducted via email with Executive Director Chris Neale. The Department’s investigation included unannounced facility visits, interviews with facility staff, residents, and outside sources, as well as a review of facility records. On March 21, 2025, the Community Care Licensing Division (CCLD) received a complaint alleging the above. It was alleged that the facility charged Resident #1(R1) for care services that were not provided, did not provide food service to meet residents’ preferences, did not provide assistance to the resident, and was in disrepair. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. (Continued on LIC9099) Unsubstantiated (Continued from LIC9099) (Page 2 of 3) It was alleged that Resident #1 (R1) was charged for Level 1 care services from October 30, 2024, through February 2025, despite a cancellation request from R1’s Responsible Person. The Department records review revealed that on October 15, 2025, R1's Responsible Person was informed of a change in R1’s contracted services, effective October 13, 2025, to Level 1 care with bathing assistance up to 3(three) times weekly, as documented in the Resident Change Form. R1 was assessed for a change in condition, and the Change Form was presented to R1's Responsible Person. Staff interviews confirmed that although the Responsible Person disputed the charges and did not pay for Level 1 care from October 2024 through May 2025, services continued per the care plan to support R1’s health and safety. Interviews with other residents indicated similar services were consistently provided. It was further alleged that meals were delivered late, cold, incomplete, and did not meet R1's preferences. Department interviews revealed the facility had implemented changes to reduce tray service and promote communal dining. Resident interviews revealed satisfaction with meal quality and timeliness, including room service, and understood trays were delivered after dining room service concluded. The department interviews with the Food Service Director revealed the availability of dietary accommodations, including alternative menus and individualized counseling. The department staff interviews and records further revealed that missed meals were tracked, and efforts were made to ensure proper food temperature. The Resident Handbook outlined structured mealtimes and flexible room service policies. The department observations confirmed clean kitchen conditions, posted dietary notes, and active meal preparation. It was further alleged that staff failed to assist R1 after a courtyard fall and missed scheduled showers. No documentation of the fall was found, and R1 was unavailable for interview, having moved out without providing contact information. The direct staff witness was also unavailable. Regarding missed showers: The department interviewed with staff revealed R1 was scheduled for twice-weekly showers and offered additional assistance. However, R1’s shower/grooming logs were unavailable. The department records reviews reveal that for current residents, showed consistent service provision, and staff were observed actively assisting residents during the Department’s visit. Based on available evidence, the Department determined the allegation was not substantiated. (Continued on LIC9099C) (Continued form LIC9099C) (Page 3 of 3) It was further alleged that the facility is in disrepair. More specifically, R1’s toilet overflowed on January 23, 2025, flooding the room without proper sanitization; multiple leaks were reported; and a courtyard crack caused a fall. Department interviews and records review revealed the flooding was promptly addressed by maintenance, and a SERVPRO inspection found no elevated moisture or microbial growth. R1 was temporarily relocated during repairs and ventilation. The department interviewed resident and revealed residents consistently reported that maintenance issues, when brought to the attention of staff, are addressed promptly and effectively Department observations during multiple site visits confirmed clean, well maintained common areas and no evidence of major cracks in community pathways. Based on interviews, and records review and department observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director via email. A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided to both via E-mail.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 08-AS-20250321094306

Allegation investigated: Staff did not prevent a resident from attempting to sexually assault another resident while in care The staff did not prevent a resident from invading another resident's privacy Staff are causing a resident to fall while in care

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, Chris Neale. During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents, and outside sources. On 6/5/25, the department received a complaint alleging that a resident attempted to sexually assault another resident and that staff failed to intervene or prevent the incident. Staff interviews revealed that staff have not witnessed R2 going into R1's room at any time. Staff stated that R2 has never exhibited inappropriate behaviors while at the facility. Staff interviews revealed that R1 has a history of paranoia and delusional thoughts. Unsubstantiated Outside source 1 (OS1) was interviewed and confirmed that the facility had communicated behavioral concerns and interventions with R1. OS1 stated that R1 has been having increased behaviors, and the facility staff have been meeting with OS1 with plans of moving R1 to the assisted living area of the facility. OS1 does not believe any resident entered R1's room or attempted any inappropriate behaviors with R1.Records review showed that the facility had documented behavioral plans, and a plan was in place to move R1 to a higher level of care. Records reviewed verified that R1 had a diagnosis of advanced Parkinson's, increased confusion, delusional thoughts, and paranoia. LPA observations confirmed that staffing ratios and supervision practices were in place and consistent with regulatory requirements. On 6/25/25, it was reported that the resident entered another resident’s room without permission and staff failed to prevent the invasion of privacy. Staff interviews revealed that staff were aware of the resident’s behavior and had implemented monitoring and redirection protocols. Staff interviews revealed that R2 was never seen entering R1's room at any time. Outside source interviews did not provide evidence that privacy rights were violated. Records review showed that the facility had policies in place regarding resident privacy, and staff followed procedures. LPA observations confirmed that room assignments and supervision were appropriate, and there were care plans in place to address R1's increased behaviors. On 6/25/25, it was alleged that staff actions contributed to a resident falling.Staff interviews indicated that the resident had a documented fall risk and staff were following the care plan. There were no recent falls documented or witnessed. OS1's interview confirmed that R1 had a history of falls due to medical conditions. OS1 and the facility staff plan of care was to move R1 to a higher level of care. The move to the assisted living area provided closer supervision. OS1 was supportive with the move from the independent living area to the assisted living area. Records review showed that fall prevention protocols were in place. 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 were deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were given to Executive Director, Chris Neale.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 08-AS-20250625121958

Allegation investigated: Licensee did not ensure adequate staffing to meet resident needs Facility staff did not meet residents bathing needs Facility staff did not meet residents toileting needs Facility staff did not respond to residents' call buttons in a timely manner Staff did not provide residents with timely meals

LPA Rodgers conducted an unannounced visit to the facility to further invisigate and deliver findings regarding the above complaint allegations. The visit was conducted via email with Executive Director Chris Neale. The Department’s investigation included unannounced facility visits, interviews with facility staff, residents, and outside sources, as well as a review of facility records. On March 14, 2025, the Community Care Licensing Division (CCLD) received a complaint alleging the above alligations. More specifically, the Reporting Party (RP) alleged that inadequate staffing impacted residents’ care in the following areas:Bathing: missed scheduled showers; Toileting: soiled briefs not changed in a timely manner. Response to call buttons: delayed by over an hour. Meal service: delays in receiving meals, including late or forgotten room tray deliveries and missed escorts to the dining room. (continued on LIC 9099C) Unsubstantiated (Continued from LIC9099) Regarding the allegations of Inadequate staffing resulting in unmet resident care needs, including bathing, toileting, and meal service. The Department interviews revealed that residents were generally satisfied with the care provided. They reported receiving timely assistance with bathing, toileting, grooming, and meals. Staff acknowledged that some residents occasionally refused care services, such as bathing or grooming, but stated that efforts were made to re-approach and provide assistance. Regarding meal service, staff confirmed that room trays were delivered after dining room service concluded, in accordance with facility policy. One outside source expressed concern about staffing levels and their potential impact on both personal care and meal delivery. However, they also noted that resident refusal contributed to missed services. The Department reviewed facility records, which showed a reduction in room tray service following administrative efforts to encourage communal dining and manage service demand. No evidence was found of systemic delays or failures in providing care or meals. Regarding the allegation that the delayed response to resident call buttons led to unmet care. Staff reported that the facility transitioned to a new call system in early 2025, which allows staff to receive alerts and document their response times. Due to the timing of the transition, call button logs were not available for the review period. However, staffing documentation confirmed consistent coverage. Resident interviews did not reveal concerns regarding call button response times. Residents reported that staff responded when needed and were generally attentive. The Department conducted an in-depth review of facility documentation, including staffing schedules, timekeeping records, hygiene schedules, and care logs. The review confirmed that staff were scheduled to provide care services consistently during the period in question. Documentation showed that residents were scheduled for regular bathing and grooming services, and staff recorded completed care, refusals, and follow-up attempts. Observations made during the visit confirmed that residents appeared clean, well-groomed, and were receiving assistance. The department observations confirmed that meals were being served in a timely and organized manner. LPA observed staff responding to residents during the visit without delay. Based on interviews, and records review and department observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director via email. A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided to both via E-mail.the state’s words, verbatim · CDSS document, Dec 15, 2025 · control 08-AS-20250314110932

Allegation investigated: Staff did not keep facility clean from spread of infectious disease

LPA Rodgers conducted an unannounced visit to the facility to further invisigate and deliver findings regarding the above complaint allegations. The visit was conducted via email with Executive Director Chris Neale. The Department’s investigation included unannounced facility visits, interviews with facility staff, residents, and outside sources, as well as a review of facility records. On 5/28/2025, it was alleged that staff did not keep facility clean from spread of infectious diseases. More spefically, staff on the 1st and 4th floors of the East Building were not properly disinfecting the facility during a scabies outbreak, resulting in reinfection among residents and staff. Department interviews with staff revealed that all affected residents were aware they had contracted scabies, and that all dermatological reactions were prophylactic. Residents were receiving appropriate treatment, including Ivermectin and topical creams..(continued on LIC9099C) Unsubstantiated (Continued from LIC 9099) Staff reported that personal protective equipment (PPE) was available and used during care, and that laundry for infected individuals was separated and handled according to infection control protocols. Housekeeping staff cleaned resident rooms and common areas daily, using hospital-grade disinfectants on high-touch surfaces. However, staff interview responses were inconsistent. While several staff members stated that infection control protocols were followed, others expressed frustration after contracting scabies, attributing their exposure to lapses in infection control practices. Some staff reported concerns included delays in receiving PPE, inconsistent disinfection of shared equipment, and lack of enforcement of resident isolation. Department interviews with Executive Director Jones confirmed that treatment was provided and that PPE was made available to all staff. The Department's interviews with residents consistently reported that staff had been responsive and helpful during the outbreak. Residents confirmed that information about infection control had been posted on their doors and throughout the facility. They stated that staff assisted with medication application, and none reported experiencing severe symptoms or requiring hospitalization. Residents also noted that the facility was kept clean and that staff were attentive to their needs. The department also reviewed documentation and confirmed that the facility posted signs regarding PPE use and infection control protocols as well as in-service trainings on 2/12/2025, 3/20/2025, and 3/27/2025. Email communications showed that Executive Director Jones notified residents, families, and public health authorities, including San Diego Public Health and the CDC. Incident reports and other documentation confirmed the Licensee’s efforts to manage the outbreak and support affected individuals. During many unannounced visits, LPA observed the facility to be clean and well-maintained. Housekeeping staff were seen actively cleaning and sanitizing surfaces. Infected laundry was properly bagged and labeled for isolation. Hospital-grade disinfectant wipes were available throughout the facility. No signs of unsanitary conditions were observed. Based on interviews, and records review and department observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director via email. A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided to both via E-mail.the state’s words, verbatim · CDSS document, Dec 15, 2025 · control 08-AS-20250528101453

Allegation investigated: Reporting requirements Lack of staff to meet residents needs

Licensing Program Analyst LPA Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Chris Neale. The department conducted interviews with facility staff, residents, and a resident’s family member, reviewed staffing schedules and time clock records, and conducted on-site observations. On 1/21/2025, Community Care Licensing (CCL) received a complaint alleging that licensee staff failed to report the location of a resident to a responsible party. Resident #1(R1) sustained a fall on 1/18/25 and was initially scheduled to be transported to a specific hospital. Due to emergency medical routing protocols, R1 was redirected to a different hospital by EMS personnel. Facility documentation and staff interviews confirmed that the POA was notified of the incident and the initial hospital destination. Follow-up communication was documented, and there was no evidence that the facility failed to meet reporting requirements. (Continued on LIC9099) Unsubstantiated (Continued from LIC9099) It was further alleged, Lack of staffing to meet resident needs. More specifically, that the facility did not maintain adequate staffing levels, resulting in delays or deficiencies in resident care. Staff interview revealed that the facility maintains consistent staffing coverage across all shifts and staff are assigned to provide care and support to residents as scheduled. No concerns regarding staffing adequacy were expressed by facility personnel. Resident #1(R1) interview revealed that the resident was oriented to person and situation, reported being able to manage their own personal care needs, and stated she did not require assistance with showers or toileting. R1 expressed no concerns about staff and described them as kind and helpful. Outside source #1 (OS1) interview revealed that the R1 often refuses assistance from staff, particularly with showers and incontinence care. An indepth records review revealed that staffing schedules and time clock data for the relevant period were consistent with reported coverage and indicated that staff were present during all shifts. Outside Source two (OS2) as well well as other residents on the same floor as R1 do not express concerns regarding staffing LPA observations revealed No immediate concerns regarding staff responsiveness or resident care were observed during the site visit. Based on interviews, and records review and department observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to ED Neale whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 08-AS-20250121164109

Allegation investigated: Staff did not meet resident's needs

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to further investigate and deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Chris Neale. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. On 12/27/2024, it was alleged that licensee staff did not meet residents' needs. More specifically, Resident #1 (R1) was not adequately supervised, resulting in a fall and hypothermic. (continued on LIC9099C) Unsubstantiated (Continued from LIC9099) Staff interviews revealed that R1 was considered independent, used a walker, and was not known to be a fall risk. Staff confirmed that safety checks were conducted in the morning and evening, as well as during the NOC shift. They further report R1 was social, independent, and regularly seen walking with her walker. They acknowledge that R1 reported and they observed cold-like symptoms the night before the incident, but no additional concerns were noted. Outside source interview confirmed that R1 was independent but had recently shown signs of weakness. The family had declined additional care services due to financial limitations. Records review showed that R1 was receiving additional safety checks as of October 2024. No prior falls were documented. LPA observations and interviews confirmed that the facility had systems in place for routine safety checks and that R1 resided in the assisted living area. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred. Therefore, the allegation is UNSUBSTANTIATED An exit interview was conducted with Executive Director Chris Neale. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to ED Neale whose signature below verifies receipt of these right. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 08-AS-20241227172739

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Amy Rodgers conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Chris Neale. During today’s visit, LPA performed a facility tour, collected pertinent records, and interviewed relevant staff. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/1/2025), involving Resident #1 (R1) being sent to the hospital for a fall and facial injury. According to the care assessment (dated 7/23/2025), R1 use a wheelchair and walker to ambulate. According to care notes and staff interviews, most of the previous falls were minor and occurred during independent transfers from bed to wheelchair or chair to wheelchair, as well as during attempts to ambulate without assisted devices to the restroom, which is located just a few steps from his bed. Outside Source #1(OS1) confirmed that no limping or stumbling was observed prior to the incident and R1 was walking from the restroom without an assisted device. Outside Source #1(OS1) reports they witnessed the fall and they reported R1 seemed to have passed out while walking and fell face first on the floor. The incident was reported immediately to staff and emergency services were called as protocol. No deficiencies were cited during today’s visit. An exit interview was conducted with ED Neale, to whom a copy of this report, 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, Dec 2, 2025

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Amy Rodgers conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Chris Neale. During today’s visit, LPA performed a facility tour, collected pertinent records, and interviewed relevant staff. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 11/24/2025), involving Resident #1 (R1) being sent to the hospital for an ankle pain, returning the same day [See LIC 811 Confidential Names List for a description of C1. According to the physicians' report, R1 ambulates with a walker. According to care notes and staff interviews, R1 did not report any ankle pain or swelling prior to the incident. Staff confirmed that no limping was observed prior to the incident. R1 is typically only seen going to the dining room and returning to her room, with limited interaction with other residents. LPA observed that R1’s room is located just a few feet from the dining area. No deficiencies were cited during today’s visit. An exit interview was conducted with ED Neale, to whom a copy of this report, 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, Nov 25, 2025

Allegation investigated: Lack of supervision resulting in resident injury

Licensing Program Analyst (LPA) Rodgers, conducted an unannounced visit to futher invistigate and deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Administrator/Asstistant Executive Director Lane Hermosillo. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. On 01/12/25, it was alleged that a lack of supervision resulted in a physical altercation between Resident #1 (R1) and Resident #2 (R2), causing injury to R1. Staff interviews revealed that R1 was escorted to the smoking area where R2 was already present. After verbal exchanges, staff separated the residents and observed no further issues. Approximately 30 minutes later, R1 returned with a bleeding hand. Staff responded by calling emergency services and providing first aid. Staff described both residents as verbally expressive but not previously physically aggressive. (Continued on LIC9099C) Resident interviews were inconsistent. R1 had limited recall but stated R2 scratched them. R2 stated R1 initiated the altercation after being told not to touch R2’s lighter. R2 admitted to swinging back and believed their fingernail may have caused the injury. Outside sources (R1’s financial contact and R2’s sister) were unaware of prior issues and described the incident as surprising. Records review confirmed staff response, hospital transport, and police involvement. R1 was relocated to a different floor post-incident to prevent further contact. LPA observations confirmed both residents remain at the facility with no further incidents. The smoking area has a partial divider but is not fully enclosed. Conclusion: Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred. Staff responded appropriately, and the incident appears to have been spontaneous and unforeseeable. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Reginald Jones, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Unsubstantiated (Continued form LIC9099) Resident interviews were inconsistent when trying to recall the incident.. R1 had limited recall but stated R2 scratched them. R2 stated R1 initiated the altercation after being told not to touch R2’s lighter. R2 admitted to swinging back and believed their fingernail may have caused the injury. Outside sources were unaware of prior issues and described the incident as surprising. Records review confirmed staff response, hospital transport, and police involvement. R1 was relocated to a different floor post-incident to prevent further contact. LPA observations confirmed both residents remained at the facility after the incident with no further incidents. The smoking area has a partial divider but is not fully enclosed. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred. Staff responded appropriately, and the incident appears to have been spontaneous and unforeseeable. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator/Assistant Executive Director Lane Hermosillo, 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, Nov 21, 2025 · control 08-AS-20250113154056

Allegation investigated: Neglect/Lack of supervision resulted in resident's daily needs not being met Staff threw water at resident's face Staff did not ensure resident's podiatry care needs were met

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to further invisigate and conclude the complaint investigation regarding the above-mentioned allegation. LPA introduced herself and disclosed the purpose of the visit and met with Administrator/Asstistant Executive Director Lane Hermosillo. On 10/30/2024, it was alleged that Neglect/Lack of supervision resulted in resident's daily needs not being met, staff threw water at resident's face and staff did not ensure resident's podiatry care needs were met. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. (Continued on LIC90999 Unsubstantiated (Continued from LIC9099) It was alleged lack of Neglect/Lack of supervision resulted in resident's daily needs not being met. More specifically, it was alleged that a memory care resident was being allowed to sleep, eat, and eliminate on the floor without appropriate staff intervention. Interviews and records review confirmed that the resident has a cultural preference for sleeping on the floor, which the facility has attempted to accommodate through environmental adjustments and redirection. While occasional incidents of urination were acknowledged, staff reported that these are promptly addressed. No evidence was found to support claims of defecation or neglect. It was further alleged that Staff threw water at resident's face. More specifically, that a staff member threw water in a resident’s face following a request for water. The incident was reportedly linked to a behavioral episode involving law enforcement. Staff interviews revealed no witnesses to the alleged act, and the resident was observed to have access to water at the time of the visit; however, the water container was full and sitting on the dresser. The resident has a diagnosis of dementia with behavioral and perceptual challenges, and no corroborating evidence was found. It was further alleged Staff did not ensure resident's podiatry care needs were met. More specifically, Concerns were raised regarding residents’ access to podiatry services. The investigation identified two residents with podiatry related issues. Records showed that one resident is enrolled in an external care program and has a documented history of refusing services, while the other has a pattern of non-compliance with care routines. Staff interviews confirmed that podiatry services are regularly offered, and facility observations revealed posted notices advertising mobile podiatry access. No evidence was found indicating systemic neglect or failure to provide access to care. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator/Assistant Executive Director Lane Hermosillo 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 21, 2025 · control 08-AS-20241030125909

Allegation investigated: Neglect/Lack of supervision resulting in hospitalization due to choking

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA introduced herself and disclosed the purpose of the visit and met with Exeutive Director Chris Nealen and Associate Director Lynn Torino The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, the resident’s responsible party, and a review of resident records. On October 18, 2024 it was reported to Community Care Licensing(CCLD) that staff failed to provide appropriate supervision and dietary accommodations, resulting in a choking incident involving Resident #1 (R1). More specifically, the Reporting Party (RP), alleged that staff failed to follow R1’s prescribed mechanical soft diet and did not supervise them during meals. RP stated R1 choked during lunch on 07/01/2024, CPR was performed, and R1 was hospitalized with broken ribs. RP also reported prior concerns about inappropriate food being served and lack of monitoring.(Continued on LIC9099C) Unsubstantiated (Continued from LIC9099) Page 2 of 3 R1 was admitted to the facility on 12/10/2023. Upon admission, R1’s care plan included a physician’s order for a pureed diet with nectar-thick liquids. R1 had multiple medical diagnoses including aspiration risk, cognitive impairment, and visual limitations. A swallow evaluation dated 01/23/2024 recommended a mechanical soft diet with mildly thick liquids and supervised trials of thin liquids. R1 was hospitalized on 06/18/2024 for pneumonia and returned on 06/24/2024. On 07/01/2024, R1 experienced a choking incident during lunch and was transported to the hospital. Staff interviews revealed that ED Jones was present during the incident. ED Jones confirmed that 911 was called and CPR was performed. ED Jones stated that a physician’s order is required to change diets. A caregiver (Staff #2) reported placing R1 at the dining table and stepping away. Upon returning, she found R1 slumped over and called for help. Another caregiver (Staff #3) did not witness the incident but confirmed CPR was performed. A kitchen staff member (Staff #4) described dietary procedures and stated staff are expected to check the dietary list daily. Resident interviews revealed that R1 stated they could feed themselves but did not recall the choking incident or dietary details. Other residents interviewed either did not witness the incident or could not recall it. Additional residents were interviewed but did not provide relevant information. RP stated R1 had a mechanical soft diet and was not supervised while eating. RP reported that R1 had previously aspirated on different occasions and was served inappropriate foods at the facility. RP stated R1 was hospitalized with broken ribs and now resides in a skilled nursing facility. Records review revealed that a physician’s order dated 01/23/2024 prescribed a mechanical soft diet with mildly thick liquids. A speech therapist recommended supervised trials of thin liquids only as well as a mechanical soft diet. Emergency response documentation confirmed CPR was preformed and food was removed from the airway. No documentation was found requiring one-on-one supervision during meals.LPA observations revealed that residents were receiving appropriate diets. Dietary lists were posted and accessible to staff. No immediate hazards or concerns were observed during meal service. (Continued on LIC9099-C) (Continued form LIC9099C) page 3 of 3 No documentation was found requiring one-on-one supervision during meals. The department observations revealed that residents were receiving appropriate diets. Dietary lists were posted and accessible to staff. No immediate hazards or concerns were observed during meal service. (Continued on LIC9099-C) Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred. Resident #1 was receiving the prescribed diet, staff responded to the choking incident by performing the Heimlich maneuver and contacting emergency services, and there is no documentation requiring enhanced supervision during meals. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Reginald Jones, 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, Nov 7, 2025 · control 08-AS-20241018163625

Allegation investigated: Staff are not ensuring that resident is administered their medication(s) as necessary Staff are not ensuring that resident gets fed Staff are forcing resident to stay in their room Staff are preventing residents from participating in private visitations Staff are not responding to Resident's Representative's requests for communication in a timely manner

Licensing Program Analyst LPA Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Chris Neale. On May 13, 2024, Community Care Licensing (CCL) received a complaint alleging staff are not ensuring that resident is administered their medication(s) as necessary, not ensuring that resident gets fed, are forcing resident to stay in their room, are preventing residents from participating in private visitation, sand are not responding to Resident's Representative's requests for communication about resident in a timely manner. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. (Continued on LIC9099) Unsubstantiated (Continued from LIC9099) (page 2 of 3) It was alleged that staff are not ensuring that residents are administered their medication(s) as necessary. More specifically, it was alleged that staff failed to ensure that Resident #1(R1) received their prescribed medications. Staff interviews revealed that medications, including insulin and oral prescriptions, were offered per physician orders and that refusals were documented in the MAR. Staff acknowledged that the resident frequently declined insulin and blood glucose checks, and that he was informed of the risks associated with non-compliance. Resident interview confirmed that he often refused insulin because he did not like how it made him feel and did not always communicate this to staff. The resident’s representative stated that the resident reported missed doses but also acknowledged his tendency to refuse care. Records review revealed consistent documentation of medication refusals and a temporary supply issue on 5/7/24, which was addressed by staff using community supplies and contacting the pharmacy and POA. LPA observations confirmed that staff were aware of the resident’s medication regimen and followed procedures for offering and documenting care. It was also alleged staff are not ensuring that resident gets fed. More specifically, it was alleged that staff failed to ensure that R1 received meals as required. Staff interviews revealed that meals are served three times daily in the dining room and that residents are encouraged to attend. Staff stated that the resident occasionally declined meals due to personal preference or mood, but was always offered the opportunity to eat. Resident interview revealed that he sometimes chose not to eat because he did not want to be around others or was upset with staff. The resident’s representative stated that the resident reported missing meals but also acknowledged his tendency to isolate. Records review did not show consistent documentation of meal refusals or tray service, but there was no indication that meals were withheld. LPA observations confirmed that meals were being served during the visit and that residents were present in the dining area. Staff were observed offering meal options and encouraging participation. It was also alleged staff are forcing resident to stay in their room. More specifically, it was alleged that staff restricted R1 to his room. Staff interviews revealed that the resident was encouraged to remain in his room during periods of agitation or after altercations with peers. Resident interview revealed that he felt isolated and believed staff were intentionally keeping him in his room. Outside source interview confirmed that the resident reported being told not to leave his room. Records review showed documentation of one-to-one supervision and safety checks, but no formal room restriction orders. LPA observations revealed that the resident was in his room during the visit and stated he was told not to come out. (continued on LIC9099c) (Continued form LIC9099C) (Page 3 of 3) It was also alleged, the staff are preventing residents from participating in private visitations. More specifically, it was reported that R1 was not allowed to have private visits in his room with R2. Interviews with staff revealed that the Executive Director (ED) advised RP that R2 should not be in R1’s room due to safety concerns, but confirmed that staff did not physically prevent visitation. Staff #1 confirmed that R2 had been in R1’s room and that management had only discussed safety concerns with R1. R1 stated during the interview that he was frustrated about visitation limitations, but did not report being physically prevented from seeing R2. RP did not provide evidence that staff enforced a restriction. No outside sources provided information to support that visitation was restricted. A review of facility records revealed no documentation indicating that staff restricted or denied private visitation. Facility policies do not prohibit private visits in resident rooms. LPA observations confirmed that R1 was seen interacting with other residents and family members and had access to his room and outdoor areas It was also alleged, the staff are not responding to Resident's Representative's requests for communication in a timely manner. More specifically, R1 responsible person's inquiries were not being acknowledged or addressed by facility staff. Interviews with staff revealed that the assigned nurse did not recall specific interactions with R1 and denied receiving complaints. The ED stated that staff made efforts to coordinate care and respond to RP’s concerns. R1 reported during interview that he distrusted the assigned nurse and admitted to refusing insulin and other medications. The pharmacy confirmed that R1 had a prescription for insulin but no refills and that they had contacted the listed physician without response. A review of records showed that insulin and diabetic supplies were available, refusals were documented in the Medication Administration Record (MAR), and staff used community supplies when insurance issues arose. Communication logs reflected multiple contacts with RP. LPA observations confirmed that R1 had access to care services and was not restricted from receiving medications, though he often declined them. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Assistant Executive Director Lynn Torino, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. (Continued from LIC9099) It was alleged staff are not reporting incident(s) involving resident to their responsible party as necessary More specifically, RP reported that she learned from R1—not staff—that R1 had been involved in a physical altercation with another resident and was confined to his room afterward. R1 responsible person stated they was not notified by the facility until two days later and expressed concern that they consistently learn of incidents from R1 rather than staff. Interviews with staff revealed that the ED confirmed R1 was involved in an altercation and was assigned one-on-one supervision afterward. Staff acknowledged that verbal updates were provided to R1 responsible person but no written incident report was issued. During the department interviews R1 confirmed that he informed their responsible person of the incident themselves and stated they were confined to his room, although he had access to the outdoors via a sliding door. R1'S responsible person reiterated that they contacted by the facility after R1 had already told them. No outside sources contradicted R1 responsible persons account. A review of records confirmed that the incident was documented and follow-up actions were taken, but there was no evidence of timely notification to R1 responsible person. LPA observations confirmed that R1 had access to his room and outdoor areas but was not observed in common areas during the investigation period. Based on interviews and record review, the licensee did not notify the responsible person of a significant incident involving Resident #1 (R1), as required by regulation, a preponderance of evidence supports that staff did not consistently report incidents involving the resident to the responsible party as required. Therefore, the allegation is 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 staff. An exit interview was conducted, along with with Assistant Executive Director Lynn Torino, 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 27, 2025 · control 08-AS-20240513141945

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 24, 2025

87211(a)(1)(D)A written report shall be submitted to the… and to the person responsible for the resident within seven days of the occurrence … disposition of the case. (D)Any incident which threatens the welfare, safety or health of any resident…This requirement is not met as evidenced by: Based on interviews and record review, the licensee failed to provide a written report R1’s (RP) of a physical altercation involving R1 and another resident. This failure to provide timely notification occurred in 1 of 1 residents reviewed (R1), This poses a potential health, safety, or personal rights risk to the resident.the state’s words, verbatim · CDSS document, Oct 27, 2025

Plan of correction: Licensee agrees to schedule an in-service training on the topic of reporting requirements to responsible person and send sign-in sheet and training topics to the Department by POC date of 11/24/2025

Allegation investigated: Staff did not ensure resident's blood sugar was checked Staff retaliated against resident in care Staff did not treat resident with dignity and respect

Licensing Program Analyst LPA Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Chris Neale. On May 20, 2024, Community Care Licensing (CCL) received a complaint alleging that staff failed to provide appropriate care to Resident #1(R1), including not checking their blood sugar, retaliating against them after they filed a complaint, and treating them without dignity and respect. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. (Continued on LIC9099) Unsubstantiated (Continued from LIC9099) It was alleged that staff did not ensure the residents’ blood sugar was checked. More specifically, it was alleged that staff failed to check the R1's blood sugar. Staff interviews revealed that BG checks were offered by physician orders and refusals were documented. Resident interview revealed that R1 often refused checks due to discomfort or frustration with staff. Reporting Party (RP) interview confirmed the resident reported missed checks but also acknowledged R1 refusal. Records review showed consistent documentation of refusals by R1 and a temporary supply issue that was addressed. LPA observations confirmed that staff were aware of the care plan and continued to offer services. It was also alleged that staff retaliated against residents in care. More specifically, it was alleged that staff retaliated against the resident after R1 filed a complaint. Staff interviews denied any retaliatory behavior and stated that care was provided consistently. The resident interview revealed that R1 believed staff refused to check R1's sugar in retaliation, but R1 also admitted to avoiding the medication room. The RP interview confirmed R1's belief but acknowledged R1's behavioral challenges. Records review did not show any change in care following the complaint. The department's observations revealed no evidence of retaliation. It was also alleged that staff did not treat residents with dignity and respect. More specifically, staff made inappropriate comments about R1's physical condition. Staff interviews denied making disrespectful comments and described using calm redirection. R1's interview revealed that R1 felt disrespected by a comment from staff, but no witnesses could be identified. The RP interview confirmed the R1's report but could not provide verifiable witnesses. Records review did not reflect any inappropriate staff behavior. The department observations confirmed professional conduct by staff. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Assistant Executive Director Lynn Torino, 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 27, 2025 · control 08-AS-20240520104600

Allegation investigated: Staff did not seek medical attention for a resident in care.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced herself and disclosed the purpose of the visit to Lynn Torino, Assosiate Executive Director. On 10/02/2025, it was alleged that staff failed to seek medical attention for a resident in care. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, the resident’s responsible party, and a review of resident records. (Continued on LIC9099) Unsubstantiated (Continued form LIC9099) Regarding the allegation that staff did not seek medical attention for a resident in care. Mores specifically, that Resident #1(R1), who had a suprapubic catheter, experienced severe pain and made multiple requests for assistance, which were ignored by staff therefore R1 had to call emergency services to get help. Staff interview revealed that the resident was admitted on 09/19/2025, transferred to another building on 09/25/2025, and hospitalized on 09/28/2025. Staff confirmed R1 called emergency services due to suicidal ideation, not pain. Resident representative interview and care notes revealed that the responsible party was contacted by the facility on 10/02/2025. They also confirmed the resident called police due to suicidal thoughts and not due to pain. Records review revealed no documentation of complaints related to catheter pain. The Medication Administration Record (MAR) showed PRN Tylenol was administered on 09/20, 09/21, and 09/22 for general pain and discomfort. The resident was also receiving antibiotics for a UTI and Gabapentin three times daily for nerve pain. Care notes reflected no catheter-related complaints. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Associate Executive Director,Lynn Torino. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Oct 27, 2025 · control 08-AS-20251003015815

Allegation investigated: Facility did not maintain hot water for residents

Licensing Program Analyst LPA Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Chris Neale. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, and records review. On January 11, 2024, it was alleged that the facility did not maintain hot water for residents. More specifically, reporting party (RP) reported that residents often did not receive showers due to a lack of hot water, an issue ongoing since November 2023. Continued on LIC 9099C Substantiated Continued from LIC9099) Staff interviews revealed that hot water sometimes runs out during shower times, requiring staff to stop showers or sometime provide bed baths. Resident interviews confirmed that water temperatures were inconsistent, with some residents reporting cold showers. Water temperature readings were taken in 13 resident rooms across four buildings. Of those, 12 out of 13 rooms had hot water temperatures within the regulatory range of 105°F to 120°F. However, hot water was not consistently maintained within the required range, as confirmed by resident and staff interviews, which included missed bathing opportunities due to a lack of hot water temperature in showers. 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). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Chris Neale, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued on LIC 9099C) Resident interviews revealed that one resident reported concerns regarding Staff #1’s tone and responsiveness. Other residents interviewed described Staff #1 as helpful and did not express concerns about her conduct. Department records review revealed no formal complaints or disciplinary actions against Staff #1. However, the lack of interviews with Residents #1 and #2 limits the department’s ability to fully assess this allegation. This allegation is unsubstantiated due to insufficient evidence. It was also alleged, staff did not meet residents’ dietary needs or serve food of good quality. More specifically, the Reporting Party (RP) stated that Resident #2, who is on a regular diet, was served pureed food, that portion sizes were inadequate, and that a resident was served half a hot dog on molded bread. The RP also stated that residents were not provided snacks between meals. Staff interviews revealed that portion sizes had recently been adjusted and that food is sometimes softened for easier chewing. Staff acknowledged occasional errors in diet type, particularly with new staff. Some staff described the food as mushy or cold, but noted that seconds were available upon request. Resident interviews revealed concerns about small portion sizes and food temperature. Some residents reported being able to request additional servings, though delays were noted. Department records review revealed that the facility uses measured scoops for portion control and a photo of a food sample from January 2024 showed balanced meals. A list of snack items available for purchase from the facility’s store was also reviewed. The concern regarding diet type mismatch could not be verified due to the lack of documentation or interview with Resident #2. This allegation is unsubstantiated due to insufficient evidence. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Chris Neale, 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 17, 2025 · control 08-AS-20240111095638

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(2) · Plan of correction due date: Dec 2, 2025

Based on observation, interviews with staff and residents, and water temperature readings conducted by the Department, the licensee failed to ensure that hot water was maintained between 105°F and 120°F in resident-use areas, as required Based on interview and record review, the licensee did not comply with the section cited above as the facility did not have hot water for multiple idays which posed a potential health and safety risk to (319) of (319) of residents in care at time of complaint.the state’s words, verbatim · CDSS document, Oct 17, 2025

Plan of correction: Licensee agreed to check water tempratures in common showers weekly for 30 days starting on 10/20/25. POC will be provided to LPA by 12/2/2025

Allegation investigated: Questionable Death Facility did not meet resident's hygiene needs

On 10/17/2025 at 9:45AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger meet virtually via Teams to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator Reginald Jones. During the course of investigation, the Department conducted interviews with staff, the residents’ family, and the reporting party. R1's medical records, Physicians report, Diet clarification order, health assessment, services plan, and nurses notes were collected On the allegation: Questionable Death Based on interviews and records review on 1/1/2024 R1 was observed to have missed breakfast and was found in his room on the floor by family around 11:00 am. Continued on LIC9099C... Unsubstantiated ...Continued from LIC 9099 R1’s medical records state three different amounts of time of how long R1 may have been on the ground before being found by family. The first stated R1 was on the ground for an unknown period. The second stated R1 may have been on the ground for more than 24 hours and the third statement stated the R1 was likely on the ground for a couple of days. During the investigation, factual information was obtained that R1 was observed at the facility four times on 12/31/2023, by staff and R2, the last time being around 7:00 PM. During these times R1 did not exhibit any signs of distress or injury. R1 was independent and did not need any assistance with his Activities for Daily Living (ADLs). Although R1 had a call button in his room. There is no corroborating information to show the facility was negligent. On the allegation: Facility did not meet resident's hygiene needs Based on interviews and records review S1 said R1 did not keep a very clean apartment, he wore the same clothes for a few days in a row, and he did not always keep up with his hygiene. R1’s Needs and Service Plan indicated that R1 was Independent and was capable of R1’s own Grooming/Personal Hygiene. S2 said that's how R1 was, he didn't want assistance and didn't allow housekeeping to enter his room to be cleaned. R1 wore repeated outfits, but he was decent looking, he didn't have any stains or rips in his clothing. R1 did not have any hygiene odors, he just wore the same clothing, which made it seem like he wasn't clean. When interviewed R2 stated that R1 was clean and never had odors or poor hygiene 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. Exit interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 08-AS-20240102162224

Allegation investigated: Staff did not prevent resident from harassing another resident in care

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegation(s). LPA introduced themselves and disclosed the purpose of the visit to Lynn Torino, Assitant Executive Director. On 9/10/2025, it was alleged that staff did not prevent a resident from harassing another resident in care. The Department’s investigation consisted of an unannounced facility visit, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations. Staff Interviews revealed that staff are aware of verbal conflicts between residents and have received reports directly from them. Staff said residents feel comfortable bringing up concerns. In one case involving physical contact, staff quickly separated the residents and moved them to different apartments. (Continued on Page 2 9099C) Unsubstantiated Resident Interviews showed that residents usually feel comfortable reporting problems to staff. This corroborated staff interviews. In this case, Resident 1 (R1) did not tell staff about the verbal harassment. R1 said the comments were upsetting and did not feel comfortable revealing the source of the harassment. Resident 2 (R2) confirmed they had witnessed the incidents involving R1. Outside Source Interviews revealed that Outside Source 1 (OS1) acknowledged that verbal harassment among residents occasionally occurs in large facilities, particularly in common areas. OS1 stated that facility staff are generally responsive to verbal complaints and that the Executive Director actively addresses disputes. OS1 further noted that staff are proactive in preventing harassment. Records Review did not reflect any incident reports or staff follow-up regarding the verbal abuse allegations due to lack of reporting by R1. LPA Observations included a review of resident well-being. Residents appeared safe and comfortable in their surroundings, with no signs of distress or unsafe conditions noted during the visit. Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation did not occur and are therefore unsubstantiated. An exit interview was conducted with Lynn Torino, Assistant 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 8, 2025 · control 08-AS-20250911081421

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ramin Hashemi and Amy Rodgers conducted an unannounced Case Management Visit to observe the physical plant. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director, Reggie Jones. The Licensee submitted a written request to the CCLD San Diego Regional Office (RO) applying for approval for delayed egress on all floors of east building and keypad-controlled elevator access on 1st and 4th floor elevators. The request did not involve amending the facility's capacity, ambulatory status, or floor plan. On 09/22/2025, the local fire authority granted a fire clearance to the facility. The fire clearance included approval of the facility's delayed egress doors. During today’s visit, LPAs, accompanied by staff, conducted a tour of the facility, interviewed staff, and reviewed pertinent records. LPsA verified that the facility sketch/floor plan remains consistent with the current layout of the facility. LPA observed no immediate health or safety issues. No deficiencies were cited during today's visit. This portion of the application process is complete. Per CCLD management’s final review and approval, the licensee will be given a new license to reflect the new fire clearance. An exit interview was conducted with Executive Director, Reggie Jones, 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 8, 2025

Allegation investigated: Staff did not ensure medications were given as prescribed

Licensing Program Analyst (LPA), Natasha Persaud, contacted the facility via telephone, to conclude the complaint investigation regarding the above-mentioned allegation. LPA spoke with Executive Director, Reginald Jones. During the investigation, LPA briefly toured the facility, reviewed records, and interviewed staff, residents and outside sources. It was alleged staff did not ensure medications were given as prescribed. Outside Source (OS) reported Resident #1 (R1) has a medication order on file that indicated the medication be administered at 9am. However, staff are administering the medication 1-2 hours later. In the East Building of the facility, the second floor has one (1) medication technician for fifty (50) residents. For most medications, it is acceptable to take a dose up to 1-2 hours later. The facility dispensed the medications within a reasonable time frame. Residents received their prescribed medications. Medication Technician (med tech) explained, if assistance was needed during the dispensing of medications, another med tech would assist. Continued on LIC 9099C. Unsubstantiated The Executive Director (ED) explained they assessed their staffing schedule and determined another med tech was not needed on the schedule. The ED confirmed if assistance is needed, another med tech from a different floor would assist. R1’s interview confirmed they are receiving their medications on time or within a 1–2 hour time frame. R1 also admitted they refuse medications in the morning because they prefer to sleep in. A review of R1’s Medication Administration Records reflected R1’s refusals of medications. The med tech’s interview revealed that when a resident refuses their medications, it’s documented, and the physician and family are notified. Once reported to the physician, only the physician can make the determination if the medication will continue, be modified or discontinued. A review of the internet for WebMD indicated a 2-hour medication window; if it’s been less than 2 hours since the missed/refused dose, to take it; then keep taking later doses as usual. 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 allegation. The allegation was deemed unsubstantiated. An exit interview was conducted via telephone and a copy of this report along with Licensee Rights (LIC 9058 03/22) were emailed to Executive Director, Reginald Jones.the state’s words, verbatim · CDSS document, Oct 3, 2025 · control 08-AS-20250616152810

Allegation investigated: Staff did not respond to resident's call for assistance in a timely manner Licensee charged fees for services that were not listed in the admission agreement Licensee did not provide adequate food service Staff used resident's room as a passageway to another room in the facility

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 Executive Director Reginald Jones. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. On May 21, 2024, it was alleged that staff did not respond to the resident's call for assistance in a timely manner. More specifically, Resident #1 (R1) and other residents experienced long delays in staff response to call buttons. R1 cited an example of a resident waiting on the toilet for an hour. The department observed the facility’s new pendant system and interviewed multiple staff and residents. Staff acknowledged that the previous system had logging issues and that response times varied depending on urgency. (Contuned on LIC 9099C) Unsubstantiated (Continued from LIC 9099) (page 2 of 3) Residents (R2, R3) confirmed that staff responded quickly, though R3 noted occasional delays of 15–20 minutes. Staff interviews (S1, S2) acknowledged that wait times could be longer during peak hours, but staff communicated with residents when delays occurred. While some delays were acknowledged, there is insufficient evidence to support that staff failed to respond in a timely manner in violation of regulations. The facility has since upgraded its call system, and multiple residents confirmed timely assistance. It was also alleged licensee charged fees for services not listed in the Admission Agreement. More specifically, R1 alleged that the facility charged a $5 tray service fee and a $2.49 rent payment processing fee, neither of which was disclosed in the Admission Agreement. Review of R1’s Tenant Ledger showed no charges for tray service or rent processing fee. The Admission Agreement (Exhibit 4) clearly lists a $5 tray service fee, and staff (S6, S7) confirmed that Assisted Living Waiver residents like R1 were not charged. The $2.49 fee is a third-party processing fee disclosed during onboarding and is optional; residents may pay by check without a fee. The $5 tray fee is disclosed in the Admission Agreement, and there is no evidence R1 was charged. The $2.49 fee is not imposed by the facility and is avoidable. There is insufficient evidence to support that a tray service fee was charged, as well as the optional fee processing charge. It was also alleged Licensee did not provide adequate food service. More specifically, residents were served cold food, had long wait times, and were denied food. LPA reviewed menus, observed meal service, and interviewed staff and residents. Menus showed multiple entrée options and a dietitian's approval. Residents (R2, R3, R4) reported satisfaction with food and timely service. Staff (S3–S5) explained that delays occurred when residents arrived early or requested tray service. LPA observed 9 trays being delivered to residents who were either bedbound or paying for the service. The facility provided adequate food service with multiple options and reasonable delivery times. No evidence supports that residents were denied meals or consistently served cold food. (Continued on LIC 9099C page 3) (Continued from LIC 9099C) (Page 2 of 3) It was also alleged that staff used the resident's room as a passageway to another room in the facility. More specifically, R1, the staff entered R1’s room through the patio door on two occasions, startling R1 and their roommate. R1 no longer resides at the facility and could not be interviewed. Staff (S6) confirmed the concern was reported and internally investigated. The department observed R1’s former room and found that the sliding door had two interior locks and no exterior access. The Executive Director confirmed that staff do not have keys to patio doors. No witnesses or documentation corroborated the alleged entry. There is no evidence to support that staff used R1’s room as a passageway. The physical layout and locking mechanisms make unauthorized entry unlikely without resident cooperation. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Reginald Jones, 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-20240521090426

Allegation investigated: Staff did not ensure that the resident's hygiene care needs were met at the facility Staff did not serve dinner to resident in care

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to initiate a complaint investigate and deliver findings. LPA was met by and granted entry into the facility by Administrator Lynn Torino, with whom the purpose of the visit was discussed. On August 21, 2025, the Community Care Licensing Division (CCLD) received a complaint alleging Resident #1(R1) does not receive assistance with shaving, and staff do not provide a meal upon return to the community. The investigation included staff and resident interviews, records review, and relevant documentation review. (Continued LIC9099) Unsubstantiated (Continued from LIC9099) Regarding the allegation that R1 did not receive assistance with shaving and grooming. During the facility visit on August 27, 2025, the department observed that R1, who has a documented diagnosis of dementia, did not exhibit signs of facial hair overgrowth, missed grooming, or skin irritation. The department also interviewed R1, who confirmed they have designated shower days and a relative who takes them to get a haircut and a shave once in a while. The department interviewed staff. They confirmed that R1 requires assistance with shaving, showers, and dressing and confirmed that R1 is provided these services. The department review of the shower schedule confirmed that R1 was assigned designated shower days consistent with facility policy. The department observations also revealed R1's closet with several flannel jackets in the same color palette. Interviews with other residents on R1’s floor revealed no concerns regarding hygiene care. An interview with Resident #2(R2) reveals they have direct observation of R1 and share meals often with R1, and have not observed R1 to be unclean or disheveled. Regarding the allegation, the Staff did not serve dinner to residents in care. More specifically, R1 was not served dinner after being out in the community and returning after dinner service. During the facility visit on August 27, 2025, the department observed nutrition drinks in the refrigerator of R1's room. Interviews with other residents on R1’s floor revealed no concerns regarding missed meals and indicated that if they ask the staff, they will receive a meal. An interview with Resident #2(R2) reveals they have direct observation of R1 and share meals often with R1, and have not observed R1 missing meals. However, they did state they have their own snacks in the room and have never asked for food outside of the designated meal service. Based on interviews, and records review and department observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator Lynn Torino whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 08-AS-20250821142904

Allegation investigated: Staff handles resident in a rough manner.

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to further investigate and deliver findings for a complaint investigation. LPA was met by and granted entry into the facility by Adminstrator Lynn Torino, with whom the purpose of the visit was discussed. On July 15, 2025, Community Care Licensing (CCL) received an allegation that a staff member handled residents in a rough manner. More specifically, it was alleged that Staff #1 (S1) handled Resident #1 (R1) roughly while changing bedding with the resident still in bed. The investigation included department observations, interviews with staff and residents. (Continued on LIC9099C) Unsubstantiated (continued from LIC9099) During the department’s interview, R1 stated that S1 is “just always too much in a rush,” but did not report any injury, pain, or prior incidents. R1 had not previously reported the concern to facility staff. A review of R1's records and staff interviews indicate R1 has limited mobility, prefers to remain in her bed all day, and does not socialize in the community. Staff reported R1 has a history of stating staff handle them roughly even when staff is not touching R1. The Department interviewed residents on the same floor as R1 and they consistently deny any staff member has handled them roughly or observed staff handling residents roughly. The Executive Director reports that no complaints had been received regarding S1 or staff handling R1 roughly, and confirmed S1 was reassigned to a different floor following an observation related to an unrelated matter. 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 allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator Lynn Torino whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 08-AS-20250715134301

Allegation investigated: Staff did not assist resident with incontinence care Staff did not assist resident with showers

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to initiate a complaint investigate and deliver findings. LPA was met by and granted entry into the facility by Administrator Lynn Torino, with whom the purpose of the visit was discussed. On January 30, 2025, the Community Care Licensing Division (CCLD) received a complaint alleging that staff failed to assist Resident #1 (R1) with incontinence care and showers. The investigation included staff and resident interviews, records review, and relevant documentation review. (Continued on LIC 9099C) Unsubstantiated (Continued from LIC9099) The Department interviewed R1 and they stated they do not require assistance with toileting or showers, reporting no concerns with staff and asserting they manage their own hygiene. However, their statements conflicted with staff interviews and documentation, which indicated that R1 does require assistance and has a history of refusing hygiene care. Staff confirmed that R1 was placed back on the facility’s shower schedule following her discharge from hospice. They reported that R1 frequently refuses showers and incontinence care, often stating she has already bathed or can manage independently. No staff reported observing wounds, skin breakdown, or other signs of neglect. An outside source (OS1) confirmed that R1 had been receiving hospice services, during which hospice staff provided showers. OS1 reported no hygiene concerns during their most recent visit. Interviews with other residents on R1’s floor revealed no concerns regarding hygiene or incontinence care. Residents reported receiving appropriate assistance, and no one observed others in soiled briefs or with poor hygiene. The department also observed adequate hygiene supplies in the shower rooms. A review of the shower schedule confirmed that R1 was assigned designated shower days consistent with facility policy following her hospice discharge. Based on interviews, and records review and department observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator Lynn Torino whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 08-AS-20250130141917

Allegation investigated: Facility staff failed to safeguard clients personal belongings

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced complaint visit to initiate a complaint investigation on the above-mentioned allegations. LPA met Executive Director (ED), Reggie Jones and discussed the purpose of the visit. According to the allegation on July 25, 2025, the facility did not return Resident #1's (R1's) belongings upon move out. Interviews with ED Jones and a review of documents state that on June 7, 2025, R1 removed all items from the facility, including personal belongings from the unit and community storage. The move-out acknowledgment form was signed by R1. R1’s family member confirmed that all belongings were removed during the move-out process and placed in an off-site storage unit. Based on interviews, and records review there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with ED Joner, to whom a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 18, 2025 · control 08-AS-20250715162940

Allegation investigated: Staff not following resident’s dietary needs.

Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced inspection visit to initiate a complaint investigation. LPA was met by, granted entry into the facility and discussed the visit with Executive Director, Reginald Jones. On August 11, 2025 Community Care Licensing (CCL) received a allegation that the staff were not following the resident’s dietary needs. More specifically, resident #1(R1) has elevated blood sugar levels due to the facility not providing a specific diet. The investigation included a review of resident records, including physician reports and care plans, interviews with facility staff, and observations of meal service. The facility is required to provide meals that meet the nutritional needs of residents and accommodate prescribed dietary modifications. The facility is also required to provide necessary care and supervision to meet residents’ needs, including dietary needs. (continued on LIC9099C) Unsubstantiated (continued from LIC9099) Resident records reviewed during the investigation indicated that residents with diabetes had physician-prescribed dietary modifications documented in their care plans. Interviews with Food Service Directory and caregivers confirmed that meals were prepared with consideration for diabetic residents, including portion control and reduced sugar options. Observations during meal service showed that residents were offered appropriate food choices consistent with their dietary needs. R1's interviewed did not express concerns about the meals provided and expressed they have personal rights to make food choices. The Department has investigated the above-mentioned allegation and based on interviews and records review no evidence was found to support the allegation staff were not following the R1's dietary needs, the preponderance of the evidence has not been met, therefore, this allegation is deemed UNSUBSTANTIATED. A copy of this report along with licensee rights was given to Executive Director, Reginald Jones whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 08-AS-20250811101732

Allegation investigated: Staff over-medicated resident

Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced inspection visit to initiate a complaint investigation. LPA was met by, granted entry into the facility and discussed the visit with by Health Services Director Lynn Torino and Health Services Director Stacy Tinoko. On July 25, 2025, it was reported to the Department that staff was over-medciated a resident. During today's visit, LPA A. Rodgers, reviewed records and interviewed staff which revealed the resident in question does not reside in the Grossmont Gardens Senior Living. Based on information obtained during the investigation the allegation is false, could not have happened and/or is without reasonable basis. An exit interview was conducted with Health Services Director Lynn Torino, to whom a copy of this report, along with Licensee/Appeal Rights, was provided to them at the conclusion of the visit. Their signature on this form acknowledges the receipt of these rights. Unfoundedthe state’s words, verbatim · CDSS document, Jul 31, 2025 · control 08-AS-20250725114159

Allegation investigated: Staff do not administer resident's medication as prescribed.

Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced inspection visit to initiate a complaint investigation. LPA was met by, granted entry into the facility and discussed the visit with by Health Services Director Lynn Torino and Health Services Director Stacy Tinoko. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, and residents. It was alleged staff do not administer resident #1(R1) medication as prescribed. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report.] (Continued on LIC9099C) Unsubstantiated (continued form LIC9099) During the investigation, the facility was briefly toured, records were reviewed, and interviews were conducted with staff and residents. It was alleged that staff do not administer resident #1(R1) medication as prescribed. R1 has a diagnosis of Type 2 Diabetes as well as hypertension. Staff interviews and records revealed that the facility is consistently performing blood glucose checks and administering insulin based on the results, in accordance with the physician's orders. Review of R1's medical records and staff interviews confirmed that glucose monitoring and medication administration are occurring routinely. R1 revealed during the interview that staff either conduct glucose checks at the nurses' station or come directly to them if needed. However, multiple staff interviews indicate that R1 has demonstrated inconsistent compliance with dietary recommendations, which may contribute to the elevated glucose levels. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed UNSUBSTANTIATED. A copy of this report along with licensee rights was given to Health Services Director Lynn Torino whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jul 31, 2025 · control 08-AS-20250722083402

Allegation investigated: Staff did not keep the facility free from odors Staff did not keep the facility clean and sanitary

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegations. LPA met with Health Services Director, Stacy Tinoco. During the investigation, the facility was briefly tourede, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged that staff did not keep the facility free from odors. It was reported there were devices on the walls that continually emit very strong, toxic chemical sprays throughout the lobby of the main administration building. On 05/07/25, LPA observed a small device affixed to the wall but there was no fragrance being emitted. The Executive Director’s (ED) interview confirmed the facility was contracted with a professional company that monitored the device. The devices were small diffusers that emit an oil-based fragrance, nothing toxic. The ED stated they discontinued the use of the diffuser on 04/30/25 due to one resident having an issue with it. The facility no longer has an active contract with the professional fragrance company. ED confirmed no other residents were affected by the scent. Continued on an LIC 9099C. Unsubstantiated Staff interviews confirmed the fragrance was no longer in use and there have been no complaints of the odor/fragrance. Resident interviews also confirmed there were no concerns over the fragrance. Family members of residents were also interviewed and did not have any concerns over the fragrance from the small diffusers. It was also alleged that staff did not keep the facility clean and sanitary. It was reported there was feces in the washing machine located in the West Building, and dirt on the carpet. Staff reported the laundry room located in the West building is used by independent residents. The West Building laundry room also has an area that items can be rinsed prior to washing if needed. Housekeeping staff confirmed they clean the laundry rooms daily and have not observed feces in the machine. One resident reported there was feces in the machine but unable to report date. Additional resident interviews confirmed feces have not been observed in the washing machines. Staff confirmed the facility is cleaned daily and there was no dirt on the carpets. The housekeeping staff confirmed the vacuum cleaners are working. On 05/07/25, LPA observed common areas and some resident rooms, there was no observation of dirt or debris on the carpets. 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 03/22) were provided to Health Services Director, Stacy Tinoco whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jul 7, 2025 · control 08-AS-20250430130239

Allegation investigated: Staff did not treat resident with dignity Staff did not assist resident with hygiene needs Staff did not assist with laundry service

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegations. LPA met with Executive Director, Reginald Jones. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff did not treat resident with dignity, staff did not assist resident with hygiene needs, and staff did not assist with laundry service. All allegations are in reference to Resident #1 (R1). Outside Source #1 (OS1) reported that on 03/06/25, a facility staff member threw a blanket at R1 and was rude to R1. On 03/13/25, LPA reviewed video footage of the encounter with facility staff and R1 that occurred on 03/05/25. The video revealed a staff wheeling R1 in their wheelchair to a common area and left R1 with OS1, who was going to transport R1 to an appointment. The staff member returned briefly and gently wrapped R1 in a blanket and bent down and kissed R1 on the cheek. There was no footage of the blanket being thrown at R1 or R1 not being treated with dignity. Continued on an LIC 9099C. Unsubstantiated OS1 also reported that on 03/06/25, R1 had crusty eyes, body odor, poor dental, clothes soiled, smelled of urine, and dried feces on their clothing. Staff interviews confirmed R1 was not presented that way to OS1 and was clean. Staff stated the police arrived at the facility and observed R1’s clothing, there were no feces observed on R1’s clothing. Additional staff interviews confirmed R1 was non-compliant with care by resisting care from facility staff. Staff explained R1 was a two person assist due to R1 being combative and injuring staff while providing care. An interview with outside source #2 (OS2), confirmed R1 was non-compliant with care. R1’s interview was unsuccessful due to their diagnosis of a Major Neurocognitive Disorder. A review of the facility’s Observations/Daily Logs dated January, February and March of 2025, all indicated R1 was injuring staff while they provide care and R1’s non-compliance to care. Staff explained that when R1 is combative they give R1 time to calm down and will return and provide care. Staff confirmed R1’s needs are met. OS2’s interview stated R1’s laundry is laundered by R1’s family. The family takes R1’s clothing to their house, launders it and brings it back to the facility, either the same the week or the following week. The facility launders R1’s whites, linens and towels. Resident interviews confirmed they are treated with dignity, their hygiene needs are met, and they receive laundry services from staff. 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 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names list to identify Resident #1]the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 08-AS-20250307104318

Allegation investigated: Staff are not allowing resident to choose their own physician

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the investigation regarding the above mentioned allegations. LPA met with Executive Director, Reginald Jones. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff are not allowing Resident #1 (R1) to choose their own physician. Outside source #1 (OS1) reported R1’s Primary Care Physician was no longer allowed to treat R1. R1 was placed on hospice services and the PCP was no longer treating R1, due to hospice agency using their own physician. R1 has a diagnosis of a Major Neurocognitive Disorder but was involved with decision making. R1’s Power of Attorney (POA) agreed to hospice services as they were told it would be extra help for R1. The POA’s interview confirmed not having knowledge that when a resident was placed on hospice, they no longer retain their PCP. Once POA was made aware residents could retain their PCP along with hospice services, they agreed to have R1 return to PCP. Continued on an LIC 9099C. Unsubstantiated POA also explained that PCP was unresponsive and not assisting R1. Therefore, there were no issues with releasing PCP from R1’s care. Executive Director explained R1 and POA made the decision to chose hospice agency and not retain PCP. ED stated they were aware residents are allowed to retain their own PCP during hospice services. There was conflicting information provided by the hospice agency. All parties involved have been made aware of how hospice agency and PCPs are allowed to treat the resident simultaneously. 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 allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 08-AS-20250530094445

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA conducted the visit with Executive Director, Reginald Jones. The facility has an approved fire clearance for delayed egress in the East Building on the first and third floor only. LPA, accompanied by Executive Director, toured the interior and exterior of the facility, and inspected multiple rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows 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 resident activities. Hot water temperature at taps accessible to residents were all compliant and measured between 109 and 117 degrees F.. The refrigerator temperature was 40 F and freezer temperature was 0 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, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. There was a swimming pool with a locked gate surrounding the pool. Per the Executive Director, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed multiple staff and residents. The interviews did not raise any significant licensing concerns. LPA reviewed multiple staff and resident records. 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 Executive Director, Reginald Jones 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 28, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced Case Management - Other visit. LPA met with Administrator, Lynn Torino and discussed the purpose of the visit. The facility submitted a request for delayed egress exits in the facility's East Building on the first, and third floors, only. On 02/20/25, the fire department inspected, verified, and granted the delayed egress exits, for the requested areas. Today, LPA toured the first, second, and third floors and observed delayed egress on each floor. One of the delayed egress exits located on the third floor was not working. The Environmental Services Director stated it was inoperable and they needed to order parts. They were not aware it was inoperable, until LPA made them aware. LPA reviewed the facility's sketch requesting delayed egress. The second floor was not included on the sketch to identify delay egress will be in use. LPA spoke with the Executive Director (ED), Reginald Jones via telephone, while at the facility. The ED stated they walked each floor of the East Building with the Fire Marshal and it was confirmed the facility could use delayed egress on the first, second, and third floor. Therefore, they have been using delayed egress on all three floors. LPA confirmed with the Fire Marshal that the facility sketch was followed to grant the fire clearance for delayed egress on two of the four floors. The Fire Marshall confirmed the facility never had approval for delayed egress on the second floor. As of today, the ED requested staff cease the use of delayed egress on the second floor and understood it must be approved by the fire department before operating. LPA also observed the first floor was made a secured floor by the use of key pad located by the elevator. The key pad requires a code in order to exit the first floor by elevator. Only staff have the key code. If residents want to leave the floor they require staff to escort them and enter the code to exit. Staff explained the first floor of the East building is being made into a another memory care unit. However, the licensee did not apply for secured/locked perimeter on the first floor. Continued on an LIC 809C. The ED was made aware and under the assumption delayed egress was the same as secured perimeter. The ED requested today that the staff disable the key pad on the first floor, until approved. Today, the ED had staff appointed to oversee the elevator, while the key pad is deactivated to ensure residents with a Major Neurocognitive Disorder are safe from elopement and harm. The ED was made aware the delayed egress and secured perimeter require the fire department's approval. The ED was also made aware civil penalties are being assessed and will continue until corrected, by submission of applications. deficiencies were issued along with civil penalties. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Lynn Torino whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, May 7, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: May 8, 2025

Care of Persons with Dementia. Licensees that lock exterior doors...and continuing requirements: The licensee shall ensure...fire clearance includes approval of locked exterior doors...equipment needed to unlock exterior doors or perimeter fence gates. This requirement is not met as evidenced by: Based on observations, interviews and record review, the licensee did not obtain an approved fire clearance to lock the first floor by use of a key pad code to exit via elevator for 144 out of 372 residents [R1-R144] , which poses an immediate health and safety risk to residents.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Executive Director, had staff disable the key pad requiring a code to exit the first floor, removing immediate threat and it will not be use until approved by the fire department. In addition, the ED stated they will submit an application to apply for secured perimeter. A civil penalty was assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87203 · Plan of correction due date: May 8, 2025

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. Based on observations, interviews and record review, the licensee did not follow the approved fire clearance for delayed egress for 144 out of 372 residents [R1-R144] , which poses an immediate health and safety risk to residents.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Executive Director, had staff disable the delayed egress on the second floor of the east building, removing immediate threat and it will not be use until approved by the fire department. In addition, the ED stated they will submit an application to apply for delayed egress on the second floor of the East building. A civil penalty was assessed.

Allegation investigated: Staff unlawfully evicted a resident

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit regarding the allegation mentioned above. LPA met with Health Services Director, Stacy Tinoco. During the investigation, records were reviewed and interviews conducted with staff and outside sources. It was alleged staff unlawfully evicted Resident #1 (R1). It was reported R1 went to the hospital and was ready for discharge, but the facility staff did not allow R1 to return. R1’s Physician’s Report dated 09/16/24 indicated R1 had a diagnosis of a Major Neurocognitive Disorder and required assistance with bathing, dressing/grooming, toileting, and medication management. R1’s Service Plan dated 02/20/25 reflected R1 frequently resists care. R1 went to the hospital on 04/02/25 via ambulance from the facility due to increased agitation and several cases of R1 hurting caregivers. A review of facility records indicated the Executive Director (ED) communicated with R1’s responsible party regarding R1 requiring a higher level of care. Grossmont Gardens Assisted Living Observations documentation dated 04/03/25 indicated the ED spoke with R1’s responsible party regarding R1’s aggressive behaviors. Continued on an LIC 9099C. Unsubstantiated It also showed the responsible party agreed R1 should not return and needed a higher level of care to get medications managed. Per ED’s documentation, R1’s responsible party would be informing the hospital and medical provider not to discharge R1 back to the facility. Grossmont Gardens Assisted Living Observations documentation dated 04/04/25 indicated the ED spoke with R1’s responsible party and the responsible party stated they would be at the facility over the weekend to move R1’s items out. It also stated R1 will not be returning and will be going to a higher level of care. The documentation dated 04/05/25 stated the hospital called and was attempting to set up transportation back to the facility. The facility nurse advised the hospital that R1 was not returning per R1’s responsible party and the responsible party wanted R1 to go to a higher level of care facility. The facility’s documentation stated the hospital staff will contact the responsible party. The facility nurse’s interview revealed they did not deny R1’s return to the facility but was following the instructions of R1’s responsible party. The hospital staff’s interview confirmed the facility nurse did not deny the return of R1. However, conflicting information was provided and needed to be confirmed. The facility’s documentation dated 04/06/25 indicated R1’s responsible party was provided all of R1’s medications, as they were no longer going to reside at the facility. There was some miscommunication between the facility, R1’s responsible party, and the hospital. It was agreed upon by the ED and R1’s responsible party that R1 required a higher level of care but a date was not determined for relocation. However, the documentation identified 04/03/25, which was prior to the discharge date, that R1 would not be returning to the facility, per R1’s responsible party. Per facility staff, R1 was not evicted or issued a notice of eviction, the facility acted upon the discussion had with R1’s responsible party and supplied that information to the hospital staff. 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 allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Health Services Director, Stacy Tinoco whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Apr 15, 2025 · control 08-AS-20250407152901

Allegation investigated: Facility did not follow infection control guidelines

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to conclude a complaint investigation. LPA identified herself and discussed the allegations mentioned above with Health Service Director, Stephanie Scudder and Executive Director, Reginald Jones. During the investigation, LPA briefly toured the facility, requested records, interviewed staff, residents, and outside sources. It was alleged facility did not follow infection control guidelines. On 02/11/25, the facility had a Norovirus outbreak with fourteen (14) cases. The facility continued to have an outbreak with positive cases thru 02/16/25. During the duration of the outbreak the facility did not follow infection control guidelines. Facility activities and dining continued amongst residents. A review of facility correspondences indicated the facility notified San Diego Epidemiology on 02/14/25, which was three (3) days after the outbreak. Continued on an LIC 9099C. Substantiated San Diego Epidemiology provided guidance to include the following: request symptomatic residents remain in their rooms until symptom-free for at least 48 hours; if possible, provide in-room meal service and restrict ill residents from participating in group activities; temporarily discontinue or limit group activities; and disinfect common areas and high-touch surfaces with an EPA-registered cleaning product effective against Norovirus. The facility had Sani-Cloth Germicidal Disposable Wipes, which can be used to disinfect Norovirus, but only used for hard surfaces. Resident interviews confirmed not having knowledge of the outbreak. Some residents that were infected stated they continued to eat meals in the dining room and stayed away from their friends by choice, not to infect others. Infected residents revealed they were not provided guidance by staff to self-isolate. Therefore, they continued to interact with other residents. Resident interviews also confirmed staff entered the resident’s room during the infected time period without PPE. In addition, residents stated signs were not posted on their doors to reflect contagious outbreak. A resident not infected revealed they were not made aware by staff the facility had an outbreak. Per the Executive Director, emails were sent to the resident and responsible parties. However, some residents do not have access to emails. A review of the facility records indicated the email was sent to the residents/responsible parties on 02/17/25, which was after the infected period. The email stated “We will continue to provide you with updates as they become available. Please know that we are strictly adhering to all directions from the local and state health department.” The facility did not follow the recommendation of the health department to limit activities and dining. Outside source interviews revealed there were no follow up emails sent to families. Outside source interviews confirmed they were not notified about the outbreak until days later after the outbreak. Outside interviews also stated there were no signs posted in the facility warning people of the outbreak. One resident went to the hospital and upon return the following the day, their room was not disinfected. The room was observed with liquid feces on the floor, carpet, and bedding. Staff explained they have disinfectant wipes that could have cleaned the feces off the floor. However, available products to staff did not include a bleach-based solution to disinfect the room, at the time of the resident’s return. Staff explained they were not aware the resident was returning to the facility from the hospital. LPA explained all rooms should be disinfected on a regular basis when there is an infectious outbreak. Staff stated an order must be placed to clean the carpets, as that is not handled by caregivers or housekeeping. The facility shall be prepared to ensure infection control guidelines are followed, regardless of the time of day or resident’s absence from the community. Continued on an LIC 9099C. The resident’s room was disinfected by the resident’s family member using a bleach-based solution. The facility should have mitigated the infection by ensuring the infected resident rooms were disinfected and activities and dining should have been limited. The infected residents were walking around the facility and interacting with the other residents. The Executive Director (ED) explained isolation of residents can be difficult on residents when they are not able to interact/socialize with one another. LPA explained it was more important to stop the spread of the virus, which is harmful to residents. The facility has a Lead Infection Preventionist assigned to the facility. However, they were not aware of the details of the outbreak and/or involved with the mitigation. According to the ED there are two (2) assigned Leads to the facility, which was not documented. In addition, the Lead documented on their Infection Control Plan should have been involved to assist with mitigation. Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Health Service Director, Stephanie Scudder whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Mar 13, 2025 · control 08-AS-20250218121152

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(a) · Plan of correction due date: Apr 10, 2025

Infection Control Requirements A licensee shall ensure that infection control practices are maintained as follows: This requirement is not met as evidenced by: Based on interviews, the licensee did not ensure infection control guidelines were followed for 26 out of 374 (R1-R26) residents, which posed a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 13, 2025

Plan of correction: Eexecutive Director agreed to have staff trained on infection control and update their infection control plan to reflect the Lead Preventionist.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Incident. LPA met with Health Service Director, Stephanie Scudder and Executive Director, Reginald Jones. Community Care Licensing received a self reported incident involving Resident #1 (R1). The incident report indicated R1 reported on 03/04/25 that back in October of 2024, R1 wrote a $400.00 check to a Grossmont Gardens caregiver. R1 stated the money given was a loan and the caregiver agreed to pay R1 back once they received their paycheck. R1 reached out to the caregiver but unable to connect. The caregiver no longer works at the facility as was terminated on 10/28/2024. The Executive Director explained not having knowledge the caregiver accepted money from the resident. The ED will have staff trained regarding accepting monetary gifts. No deficiencies were issued today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Health Service Director, Stephanie Scudder whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Mar 13, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident. LPA met with Executive Director, Reginald Jones. The facility self reported an incident involving Resident #1 (R1). The report indicated on 12/14/24 staff observed R1 walking around with bruising to their eye. The facility's nurse assessed R1 and determined R1 required medical attention. R1 was transported to the hospital for evaluation. It was determined R1 wanted to self harm themselves. R1 was independent of activities of daily living and drives their own vehicle. Executive Director has a plan in place for R1's return to the facility. No deficiencies were issued today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Dec 31, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA met with Executive Director, Reginald Jones and discussed the purpose of the visit. During today's visit, LPA briefly toured the facility and collected resident records. No deficiencies were issued. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Dec 12, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management- Incident visit. LPA met with Executive Director, Reginald Jones and discussed the purpose of the visit. The facility self reported an incident involving Resident #1 (R1). The report indicated R1 was agitated and attempting to elope from the community out of another resident's room. R1 was unsuccessful and redirected back to the hallway. R1 wore a wander guard, which alerted staff of the attempted elopement. However, staff were unable to reset it after it alerted due to R1's agitation, aggression, and refusal. The caregiver assisting R1, left R1 to assist another resident. Upon staff's return at approximately 5:30pm, R1 was not in their room or the designated floor where they reside. R1 resides in the facility's secured memory care unit with a coded elevator. R1 was able to leave the facility by sneaking pass the elevator while it was actively closing and putting their hand through to stop it. Staff searched for R1, contacted local law enforcement, and notified R1's responsible party. Local law enforcement found R1 and returned R1 to the facility at approximately 8:00pm, no injuries were sustained. ED also stated R1's responsible party wanted R1 to remain at the facility. However, another facility would be suitable. R1's responsible party agreed to transfer R1 to a higher level of care facility. R1 has a one on one companion when they are not at their program until transferred to the new secured facility. The Executive Director (ED) explained R1 moved into the facility on 10/29/24, had medication changes and and eloped on 10/30/24. The ED stated R1's responsible party indicated the change in medication could have been the cause for R1's aggression and anxiety. According to the ED R1 moved out of the facility on 11/01/24. Due to the facility's knowledge of R1 wanting to elope and not ensuring R1's safety, a deficiency was issued. Based on interviews and record review, a deficiency is being issued on the attached LIC 809D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]the state’s words, verbatim · CDSS document, Nov 6, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 4, 2024

Basic Services. Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure observation of the resident, once the resident attempted the first elopement 1 out of 379 [R1] residents, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: Executive Director stated staff will attend elopement training and submit proof of training by POC due date. In addition, ED stated there is already signage present regarding not letting residents out without notifying staff. ED stated he will add more signage to ensure resident's safety.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Incident visit. LPA met with Executive Director, Reginald Jones to discuss the purpose of the visit.. Today's visit was in response to a timely self reported incident that occurred on 08/24/24 involving Resident #1 (R1) and Staff #1 (S1). The incident report stated S1 hit R1 four (4) days prior on 08/21/24 for refusing medication. The facility assessed R1 and there were no injuries. The Executive Director met with R1, R1's responsible party to discuss the incident and unpaid rent. After the incident was reported, the facility implemented a two (2) persons assist required for all care and medication pass to ensure witnesses present for all care for R1. S1 denied the allegation and stated R1 refuses medication regularly but there has never been an issue of abuse. R1's Medication Administration Record confirmed R1 regularly refuses medications. It was also reported the incident occurred 08/21/24 and/or 08/23/24, conflicting statements were made about the date of the incident. Resident interview indicated not being aware of the incident and never witnessing S1 hit R1. The facility observed R1 having increased confusion and scheduled an appointment for R1 with R1's physician and a psychologist. R1 moved out of the facility on 09/14/24 with an outstanding balance. No deficiencies were observed or cited during today's visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1 and Staff #1]the state’s words, verbatim · CDSS document, Oct 4, 2024

Allegation investigated: Staffing is not sufficient to meet resident's care needs

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Executive Director Reggie Jones and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA observation, records review and interviews with facility staff, residents and outside sources. It was alleged that staffing was not sufficient to meet resident's care needs. It was reported that their were not enough staff on the fourth floor to meet all of the residents’ care needs. It was also reported that during the afternoon and night shifts, their are only two staff members to care for approximately 40 residents. LPA reviewed facility staffing records and resident logs for the month of April 2024 through July 2024. The records indicated that staffing levels consistently met the requirements set forth by regulatory standards and internal policies. Unsubstantiated Records review further revealed that the resident census on the fourth floor was an average of 30-33 residents. The AM staffing ratio on the fourth floor was regularly at; two caregivers, one med-tech and one LVN. The PM staffing ratio was regularly at two caregivers and one med-tech This staffing ratio was consistent on all facility floors. The staffing schedule also revealed a "floater" staff was available to assist where ever needed, on all shifts. Analysis of staffing schedules showed that the facility maintained adequate staffing ratios to address the needs of residents. LPA interviewed a fourth floor resident who stated that they have lived at the facility for four years. Resident stated that in general the facility staff are "nice and well trained.' Resident further stated that they immediately receive assistance from staff, whenever it is needed. Interviews with direct care staff (DSC) and human resources staff (HRS) confirmed that staffing levels were sufficient and that there were no shortages impacting the quality of care. Direct Care Staff 1 (DSC1) stated that even though they provide the care that the residents need, at times the family members of the residents become upset because they want "one on one" care for their loved one. DSC1 further stated that they had support from management in regards to resident care. Direct Care Staff 2 (DSC2) stated that the work environment can be challenging when residents exhibit behaviors and become aggressive, as a result DSC2 believes more staff is needed. LPA interviewed outside agency (OA) who stated that he has visited the facility and specifically the fourth floor many times. OA stated that from his assessment facility staff "do try really hard." OA stated that although he 'doesn't like the current regulation" he agreed that the allegation should be unsubstantiated. LPA interviewed Executive Director who stated that he and his staff review the care needs of the residents on a monthly basis. ED stated that they specifically review the resident to staff ratio. ED believes they have sufficient staffing to meet the care needs of the residents. Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid. An exit interview was conducted with Reggie Jones. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Reggie Jones whose signature below verifies receipt of these rightthe state’s words, verbatim · CDSS document, Aug 28, 2024 · control 08-AS-20240724163501

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director, Reginald Jones. Today's visit was in response to a timely self reported incident that occurred on 07/22/24 involving Resident #1 (R1). Per the report, Staff #1 (S1) provided improper care to R1 by forcing R1 to shower, against their will. Executive Director stated S1 was suspended and later terminated on 07/29/24. S1 was terminated as it's against facility for violating a resident's personal rights. LPA performed a facility tour/welfare check on remaining residents and collected pertinent records. No deficiencies were observed or cited during today's visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1 and Staff #1]the state’s words, verbatim · CDSS document, Aug 21, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Reggie Jones. Today's visit was in response to licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 07/11/2024. [See LIC 811 Confidential Names List for a description of R1]. Per the report, R1 passed away on 07/08/2024. LPA performed a facility tour/welfare check on remaining residents and collected pertinent records. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Reggie, to whom a copy of this report, 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, Jul 16, 2024

Type of visit: Collateral

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced collateral visit to the facility. The purpose of the visit was to conduct an interview with Resident One (R1) regarding a complaint that is not related/associated with this facility. LPA was greeted and was granted entry by Executive Director Reginald Jones, where LPA explained the purpose of the visit. No heath and safety concerns were observed at the time of LPAs visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Executive Director Jones.the state’s words, verbatim · CDSS document, May 22, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA was greeted and allowed entry into the facility and conducted the visit with Executive Director (ED), Reginald Jones. LPA, accompanied by ED, 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. Resident 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 resident activities. Hot water temperature at taps accessible to residents were all compliant and measured between 106 F and 116 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, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. There is a locked pool on the premises. Per the ED, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed multiple staff and residents. LPA reviewed multiple staff and resident records/files. 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 Executive Director, Reginald Jones 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 7, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA met with Executive Director, Reginald Jones and discussed the purpose of the visit. The facility self-reported an incident that occurred on 04/28/24 involving Resident #1 (R1). R1's Physician's Report dated 05/05/23, indicated R1 is not allowed to leave the facility unassisted. The report stated at 9:20pm staff were unable to locate R1 during routine rounds. A room to room search was initiated but unsuccessful. R1 was last observed by staff at 9pm walking around by the activities room. R1's responsible party was notified, and the La Mesa Police department responded and assisted with the search. At 11:45pm the community received a phone call from someone stating they encountered R1 and R1 stated they lived at the facility. Police and paramedics responded to address given for R1's location. R1 reported they fell and had an abrasion to their forehead. Paramedics transported R1 to the hospital for evaluation. The facility reported at the hospital, there were no significant findings / injury. R1 sustained an abrasion visible to the left side of forehead and left wrist. Resident returned to the facility on 04/29/24. R1 reported they went out front to get some fresh air and then got "turned around". Staff increasing safety checks and monitoring R1. The facility has also provided R1 with a wander guard as a safety precaution. The facility followed their Absentee Notification Protocol. No deficiencies were issued today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, May 7, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA met with Executive Director, Reginald Jones and discussed the purpose of the visit. The facility self reported an incident involving Resident #1 (R1). The report indicated on 03/06/24, R1 fell and sustained a laceration to their head. The facility acted appropriately with medical care. At the hospital, R1 received sutures to their head along with a diagnosis of Salmonella. According to the Executive Director (ED) their Infection Prevention Specialist has been working with the Department of Public Health regarding contact tracing. The Infection Prevention Specialist stated there were a total of four (4) resident cases. However, some were isolated incidents based off uncleanliness. All residents are doing well and were prescribed antibiotics. Today, LPA observed the walk-in fridge and freezer at the facility, it was clean and maintained. The facility has one main kitchen that serves food to all the buildings. Therefore, it does not appear to be an issue with food contamination. On 03/22/24 the Infection Prevention Specialist conducted an In-Service Training on Infection Control on 03/22/24, proof of training was collected. The Infection Prevention Specialist stated she will continue to communicate with Department of Public Health until the case is closed by Public Health. The facility also self reported an incident involving Resident #2 (R2). R2 eloped from the facility on 03/15/24. The ED explained R2 was fairly new the community as of 02/15/24. R2's Physician's Report dated 01/17/24, indicated R2 cannot leave the facility unassisted. R2 was found by a citizen that called 911 for R2. R2 was transported to the hospital for evaluation, with no injuries. The ED stated they searched for the resident, notified R2's responsible party, and notified local law enforcement. The facility followed their Absentee Notification Plan. R2 returned to the facility and was provided with a wander guard bracelet and relocated from the Assisted Living portion of the facility to their secured Memory Care Unit. No deficiencies were observed today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1 and Resident #2]the state’s words, verbatim · CDSS document, Mar 26, 2024

Type of visit: POC

Licensing Program Analyst (LPA), Natasha Persaud conducted a Plan of Correction visit. LPA met with Executive Director, Reginald Jones. On 01/05/24, the facility was issued a deficiency for an unlawful eviction. The Executive Director attended training on Eviction Procedures and provided proof of training. The deficiency has been corrected. No deficiencies were observed today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jan 17, 2024

Allegation investigated: Unlawful eviction

Licensing Program Analyst (LPA), Natasha Persaud conducted a complaint investigation visit regarding the above mentioned allegation. LPA met with Executive Director, Reginald Jones. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, and outside sources. It was alleged the facility unlawfully evicted Resident #1 (R1). On 12/27/23, R1 fell and was transported to the hospital. The hospital discharged R1 on 12/27/23 and sent R1 back to the facility via transport. When R1 arrived back at the facility the same day, the facility denied their return. The facility told transport they would not be accepting R1 back and told transport to take R1 back to the hospital, which they did. Outside source interviews confirmed the Executive Director declined the return again on 12/28/23, and R1 remained at the hospital. Continued on an LIC 9099C. Substantiated On 12/29/23, the Executive Director was contacted again to accept R1 back to the facility, the Executive Director declined again. Further interviews revealed on 12/31/23, the Executive Director declined R1’s return again. On 01/03/24, LPA intervened and spoke with the Executive Director advising him they must take the resident back as that is their home. The Executive Director explained had already spoken with the hospital and was accepting R1 back into the facility. The Executive Director agreed to allow R1 to return. R1 returned to the facility on 01/04/24. The Executive Director, explained the reason R1 was not allowed to return was because they were awaiting a care plan from the hospital and wanted to appropriately assess R1. The Executive Director also stated part of the reason for not allowing R1 to return was due to a behavioral disturbance caused by R1. Based on interviews, 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 being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Jan 5, 2024 · control 08-AS-20231229124840

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Feb 2, 2024

Eviction Procedures. The licensee may evict a resident for one or more of the reasons...Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement is not met as evidenced by: Based on interviews, the licensee did not issue a written notice of eviction for 1 out of 314 [R1] residents, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 5, 2024

Plan of correction: The Executive Director allowed R1 to return to the facility. Executive Director agreed to attend training on Eviction Procedures and send proof of training by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Collateral Visit. LPA was greeted by, identified himself to, and discussed the purpose of the visit with Associate Executive Director Lane Hermosillo. During today’s visit, LPA conducted staff interviews to aid in an investigation involving a different licensed care facility. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Hermosillo, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Dec 27, 2023

Allegation investigated: Medications not given as prescibed

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and discussed the allegation mentioned above with Assistant Administrator, Lane Hermosillo and Executive Director, Reginald Jones. During today’s visit, the facility was briefly toured, records reviewed, and interviews with staff, resident, and outside sources. It was alleged medications were not given as prescribed. It was reported Resident # 1 (R1) was over medicated by being provided additional medications not prescribed. R1 was admitted to the facility on 11/18/23 and taken to the hospital on 11/25/23 for an altered mental state from being overmedicated. R1’s Physician Report dated 11/14/23 indicated R1 required assistance with medication management, which was being provided by the facility. A review of R1’s records indicated the medications provided to R1 were prescribed by the physician. Outside source interviews revealed that R1’s primary care physician was on leave and there was an on-call physician filling in. Continued on an LIC 9099C. Unsubstantiated The on-call physician provided the outdated medication list, which was signed and dated by the physician. A review of facility records reflected the medication list from the primary care physician’s office showed the medication list was current as of 11/14/23 and was signed by a physician on 11/17/23, indicating it was accurate. The facility’s internal records reflected R1’s responsible party was notified that an eye drop brought into the facility with the other medications was not present on the medication list. The facility made the responsible party aware they cannot dispense the eye drop without an order. The facility was aware of medication protocols and provided medications that were present and prescribed. R1’s interview revealed they were provided with more medications than they usually take. Also, R1 confirmed their regular primary care physician was out on leave and the assistant provided them with an outdated list. R1’s physician’s office provided a current medication list dated 11/28/23, which reflected less medications. The facility followed R1’s physician’s orders on file and administered the medications as prescribed by the physician. The facility did not overmedicate R1, the medication orders were followed. 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 allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Dec 5, 2023 · control 08-AS-20231130145142