Haven's House of Assisted Living

Allegation investigated: Facility retianed resident with a prohibited health condition

At approximately 09:45 AM, Licensing Program Manager (LPM) Victoria Bertozzi and Licensing Program Analyst (LPA) Deniz arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with Administrator, April Thomas. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated: “Facility retained resident with a prohibited health condition.” The complaint alleged that the facility retained a resident with a prohibited health condition. The investigation alleged that the resident was frail, bedbound, had bed sores, and required dialysis. However, there was insufficient evidence to establish that the resident's condition met the definition of a prohibited health condition under applicable licensing requirements or that the facility retained the resident in violation of those requirements. Continued on LIC9099-C page... Unsubstantiated Continued from LIC9099 page... Based on the information obtained during the investigation, the allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents. Continued from LIC9099-A page... A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 11, 2026 · control 21-AS-20260618160333

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Sep 21, 2026

87468.2(a)(2) Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities...:(2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This regulation is not met by evidence by; Licensee did not comply with the section cited above in that the licensee received and held R1’s Social Security checks and forwarded the checks to R1’s family member, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: The licensee shall submit a signed declaration stating that the facility and its staff do not receive, hold, or manage Social Security checks or other personal funds on behalf of residents, unless otherwise authorized. The declaration shall include the date and signature of the licensee and must be submitted to CCL by plan of correction due date 09/21/2026.

Type of visit: Case Management - Other

On 08/27/2026, Licensing Program Analyst (LPA) Magdaleno arrived at the facility unannounced to conduct a case management - other visit and met with Licensee/Administrator April Thomas. The purpose of this visit was to discuss a recent fire clearance granting the facility a secured perimeter. Licensee shall submit a written request to Community Care Licensing (CCL) for a waiver to be granted allowing a secured perimeter. Along with this waiver request, Licensee shall submit signed letters from each resident in care and/or their responsible party of their understanding and consent to reside in a facility with a secured perimeter. All paperwork shall be submitted no later then 8/31/2026 by Close of Business Day. Administrator stated paper copy of fire clearance has not arrived and will forward to CCL when available. Administrator also stated they will not be locking the gate until paper copy of fire clearance arrives. LPA provided Administrator with Technical Assistance on the Health and Safety Code regarding Secured Perimeters. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Aug 27, 2026

Type of visit: Case Management - Deficiencies

On 08/20/2026, Licensing Program Analyst (LPA) Ali Deniz arrived at the facility unannounced to conduct a case management–deficiency visit. LPA met with Licensee/Administrator April Thomas. At the time of the visit, the facility had six residents and two staff members present. During the visit, LPA inspected the facility’s exterior exit doors/perimeter fence gates. LPA observed that one exterior exit fence gate was unlocked and a second exterior exit fence gate was locked. Licensee stated that her husband had mistakenly closed and locked the gate a few minutes prior to LPA’s arrival. LPA discussed with the Licensee/Administrator the requirement that the licensee shall ensure the facility’s fire clearance includes approval for locked exterior doors and/or locked perimeter fence gates. LPA advised the Licensee/Administrator to remove the lock from the exterior exit gate to ensure compliance with applicable regulations. LPA further advised the Licensee/Administrator that if the facility wishes to maintain a locked perimeter fence gate, the licensee must obtain the required approval prior to locking the exterior exit gate(s). Licensee/Administrator acknowledged the information and stated an understanding of the requirement. No deficiency cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Aug 20, 2026

Allegation investigated: Physical Abuse. Financial Abuse.

On 07/27/2026, an office meeting was conducted at the Santa Rosa Regional Office. The following individuals were present in the meeting: Regional Manager (RM), Carla Nuti-Martinez, Licensing Program Manager (LPM), Bethany Moellers, Licensing Program Analysts (LPA), Ali Deniz, and Licensee/Administrator April Thomas. During the meeting LPA was able to deliver findings for a Complaint Investigation regarding the above allegations. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Physical Abuse and Financial Abuse.” • Physical Abuse The complaint alleged that the Licensee physically abused residents. The Reporting Party (RP) stated that while assisting Resident 1 (R1) with care, the Licensee bent R1’s arm, causing R1 to state, “Ow April, you are hurting me.” Continued on LIC9099-C page... Substantiated Continued from LIC9099 page... RP further reported that the Licensee waved a closed fist in front of R1’s face and that R1 disclosed the Licensee hits residents. During the investigation, LPA conducted interviews with residents and staff, made observations, and reviewed available documentation. Two staff members reported that the Licensee has been rough with residents and frequently yells at residents and staff. On 07/24/2026, LPA and LPM observed the Licensee speaking loudly to residents and arguing with residents regarding food. During an interview, a resident reported to LPA that the Licensee pushed them. Additionally, during an interview with LPM, the Licensee stated that she grabbed a resident by the wrist and pried the resident’s fingers from a doorway. Based on interviews, observations, and the Licensee’s statements, the allegation is Substantiated. • Financial Abuse The complaint alleged that the Licensee misused residents’ financial resources, including EBT benefits, IHSS funds, and resident checks. The Reporting Party (RP) stated that R1 reported the Licensee was taking R1’s checks and that although R1 had received six checks and never received the funds. During the investigation, LPA conducted interviews with residents and staff. Interviews confirmed that the Licensee maintains control of resident checks until rent payments are received. Interviews also indicated that the Licensee utilizes residents’ EBT benefits and IHSS funds to subsidize facility expenses. Based on interviews and review of available information, the allegation is Substantiated. Based on observations, interviews, and record review, the allegations are substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents. Continued from LIC9099-A page... During the initial visit on 05/06/2026, LPA observed that all resident bedding was in compliance with regulatory requirements. LPA also observed additional bedding supplies stored in the facility closet. During an interview, the Licensee stated that the facility provides and cleans resident bedding as needed. LPA was unable to obtain additional information regarding this allegation. Based on observations and interviews, the allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 27, 2026 · control 21-AS-20260505083955

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jul 28, 2026

87468.1(a)(3) Personal Rights of Residents in All Facilities: (a)(3) To be free from punishment,humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’... This requirement was not met as evidenced by: Based on interviews conducted, records reviewed, and observations made, the facility failed to ensure resident’s rights and protection from abuse. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 27, 2026

Plan of correction: The Licensee agrees to complete a self-certification on physical abuse, financial abuse, and resident rights. The Licensee will submit proof of completion of the self-certification to Community Care Licensing by the Plan of Correction (POC) due date of 07/28/2026.

Type of visit: Office

On 07/27/2026, an office meeting was conducted at the Santa Rosa Regional Office. The following individuals were present in the meeting: Regional Manager (RM), Carla Nuti-Martinez, Licensing Program Manager (LPM), Bethany Moellers, Licensing Program Analysts (LPA), Ali Deniz, and Licensee/Administrator April Thomas. The purpose of today’s meeting was to address recurrent areas of concerns identified by the Department. The following areas were discussed during today's meeting: · Substantiated Complaint Investigation: Complaint 21-AS-20260505083955 and 21-AS-20260618160333 · Administrator Qualifications Facility currently has two complaint investigations that are still being investigated: Complaint 21-AS-20260505083955 and Complaint 21-AS-20260618160333. These investigations involve concerns with personal rights, Facility retained resident with a prohibited health condition, Physical Abuse, Financial Abuse, and Facility is not provided required bedding. Based on interviews, observations, and record review, the Licensee/Administrator failed to demonstrate knowledge of and the ability to conform to applicable laws, rules, and regulations. The investigation determined that the Licensee handling the resident in a rough manner and engaged in financial relation by improperly withholding residents' checks and utilizing residents' benefits for facility operations. These actions constitute violations of resident rights and applicable licensing regulations, demonstrating the Administrator's failure to comply with Title 22 regulations. (See 809-D Page…) LIC809-C page... Continued from LIC809 page... During the meeting CCL requested in the video recording audio need to be turned of in the facility and plan about creating Lock Secured Perimeter by 07/28/2026. Facility is Non-Compliance Plan with an end date of May 2028 and has been referred to TSP. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 27, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(2) · Plan of correction due date: Jul 28, 2026

87405(d)(2) The administrator shall have the qualifications specified in Sections 87405(d) (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on interviews and the Licensee's documented practices, the Licensee failed to perform the duties and responsibilities of the facility administrator as required by Title 22, Which poses immediate risk to the health, safety, and personal rights of persons in care.the state’s words, verbatim · CDSS document, Jul 27, 2026

Plan of correction: The Licensee agrees to complete a self-certification on administrator qualifications and duties. The Licensee will submit proof of completion of the self-certification to Community Care Licensing by the Plan of Correction (POC) due date of 07/28/2026.

Allegation investigated: Facility did not meet resident care needs. Facility did not maintain adequate staff. Facility did not seek timely medical care.

At approximately 09:30 AM, Licensing Program Manager (LPM) Victoria Bertozzi and Licensing Program Analyst (LPA) Deniz arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegations and met with Administrator, April Thomas. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “- Facility did not meet resident care needs, Facility did not maintain adequate staff, and Facility did not seek timely medical care.” The complaint alleged that the facility was operating with insufficient staffing, resulting in residents not receiving adequate care and supervision. The Reporting Party (RP) stated that there was only staff member caring for seven residents, including a resident who required a two-person assist with a Hoyer lift. RP further alleged that a resident R2 sustained injuries from a fall was not provided timely medical care. Continued on LIC9099-C page... Substantiated Continued from LIC9099 page... Facility did not maintain adequate staff – During the initial investigation, LPA observed one staff member on duty while the facility was caring for six residents, including two residents who required two-person assistance with Hoyer lift transfers. The Administrator confirmed that only one staff member was present during portions of the day and that additional assistance was not available until later in the evening. Based on interviews and observations, the facility failed to maintain sufficient staff to meet the care and supervision needs of the residents. Based on interviews, record review, and observations, the allegation is Substantiated. Facility did not seek timely medical care – Per record review of the facility's incident report dated 05/04/2026 indicated that Resident R2 sustained a fall on 04/26/2026. The facility did not seek immediate medical evaluation following the incident. Instead, per the special incident report, the hospice nurse was contacted the following day, and a physician's appointment was scheduled for 05/06/2026. During the investigation, LPA also obtained photographs documenting visible bruising sustained by R2. Based on the available evidence, the facility failed to seek timely medical care for Resident R2 following the fall. Based on interviews, record review, and observations, the allegation is Substantiated. Facility did not meet resident care needs – LPA observed that two residents required two-person assistance with Hoyer lift transfers. Due to insufficient staffing, the facility was unable to consistently provide the level of assistance necessary to safely meet residents' care and supervision needs. Additionally, resident interviews indicated concerns regarding lack of the quality of care provided. Based on observations, interviews, and record review, the allegation is substantiated. Based on observations, interviews, and record review, the allegations are substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents. Continued LIC9099-A page... Facility did not administer resident medication as prescribed – The complaint alleged that the facility resident records were falsified, and prescribed medication was not refilled as requested. During the investigation, the Administrator stated that the resident refused to attend a scheduled physician's appointment. Record review confirmed that Resident R1 had a prescription for the medication in question. Resident R1 stated that the facility failed to schedule the physician's appointment; however, LPA did not obtain sufficient evidence to verify that the facility failed to administer the resident's medication as prescribed. Therefore, the allegation could not be substantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 21-AS-20260429143325

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: Jul 25, 2026

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's ... care needs as identified... This requirement is not met as evidenced by: Based on LPAs observation and record review the facility failed to ensure adequate staffing to meet residents care needs which poses a immdadiate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2026

Plan of correction: Licensee has hired at least two additional staff. Licensee agrees to provide proof of training and an LIC 500 showing sufficient staffing to ensure staffing is adequate to meet residents needs during the in-person meeting at the Santa Rosa Regional Office on Monday, July 27, 2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87654(g) · Plan of correction due date: Jul 25, 2026

87465(g) Incidental Medical and Dental Care Services - 9-1-1 shall be telephoned immediately if an injury or other circumstance has resulted in an imminent threat to a resident’s health, including an apparent life-threatening medical crisis. This requirement is not met as evidenced by: Based on LPA observation, interviews and record review it was determined that staff failed to seek medical attention in a timely manner for R3 which poses a potential risk to the health, safety, and personal rights to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2026

Plan of correction: Licensee agrees to hold an in-service training with all staff regarding policy and procedures for seeking medical attention in a timely manner as incidents and/or observations arise. Proof of training to be provided to CCL during the in-person meeting at the Santa Rosa Regional Office on Monday, July 27, 2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 27, 2026

87411 Personnel Requirements - General:(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident care needs. This requirement is not met as evidenced by: Based on records reviewed, interviews conducted, Licensee did not ensure sufficient staff were present to meet resident needs. This poses an immediate Health and Safety risk to residents.the state’s words, verbatim · CDSS document, Jul 24, 2026

Plan of correction: Licensee agrees to ensure facility has sufficient staff to meet the needs of residents in care. Licensee to submit updated LIC500 to show care giving staffing levels needs the residents. LIC500 to be brought in for the in-person meeting at the Santa Rosa Regional Office on Monday, July 27, 2026.

Type of visit: Case Management - Deficiencies

On 07/24/2026 Licensing Program Manager (LPM), Victoria Bertozzi and Licensing Program Analyst (LPA), Ali Deniz conducted a case management visit. LPM and LPA met with Licensee, April Thomas. Case management visit is being conducted to address concerns revealed during the complaint investigation. During facility visit, LPM Bertozzi overheard the Licensee and Staff having a loud discussion regarding cleaning of the facility. The conversation sounded argumentative in nature to the LPM resulting in the LPM requested that the individuals reduce the volume of their voice. During a discussion regarding a former resident who bruised easily, Licensee indicated that the resident bruised when grabbed by the wrist. Licensee showed LPM by grabbing their left wrist. Licensee then stated that resident would need grab the doorway and staff had to pry their fingers. Licensee went on to explain that resident wanted to walk down the street but it was unsafe so Licensee would have to pull them back. LPM explained that resident's may leave if they choose, accompanied by a staff, which is why the facility must be staff appropriately, explaining that resident's may not be restrained. Licensee then stated that she and the LPM will have to "agree to disagree" to which LPM responded that no, grabbing or restraining a resident is a personal rights violation. Continued on LIC809C At or around 12:00pm, LPM Bertozzi arrived in the kitchen so see what was being offered for lunch. LPM was looking in the refrigerator and observed multiple half sandwiches that said "PB&J" and "P" and were dated 7/24/2026. April explained that those sandwiches should be in the "Community Fridge" located just outside of the kitchen and explained they were a snack. April eventually moved those sandwiches to the community fridge. LPM asked again what was for lunch and Licensee stated that they are going to have teriyaki chicken and then showed LPM frozen dinners in the community fridge. LPM then asked what was for dinner and Licensee said she hadn’t decided yet and it would be spaghetti or hamburgers. She then went to her garage apartment and returned with thawed hamburger meat. LPM asked the Licensee if she ate the food in the facility fridge and she said they all shared food. She then proceeded to go to her apartment and get lunchmeat, April and another staff then began heating up the frozen dinners. I then overheard Licensee ask a resident what they wanted and the resident said salad. Licensee listed the items made in a already made salad. The resident didn’t want that all the ingredients in the pre-made salad so opted for a peanut butter sandwich that the Licensee offered. LPM intervened and ask the resident what they liked on their salad. LPM then offered for resident to look in the fridge. When the resident and LPM went to walk in the kitchen, the Licensee said the resident couldn’t go in kitchen. LPM told the Licensee that the resident could go in the kitchen and opened the fridge. Licensee then told the resident not to touch anything. The resident chose their salad items and Licensee made the a salad. Review of facility Plan of Operation showed that meal times are at 8:00am, 12:00 noon and 5:00pm. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 24, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Jul 25, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement is not met as evidenced by: Based on interview and observation with Licensee, they have conducted physical redirection of at least one resident, This poses an immediate Personal Rights risk to residents.the state’s words, verbatim · CDSS document, Jul 24, 2026

Plan of correction: The licensee agreed to submit a self-certified declaration stating that all resident personal rights regulations have been reviewed with facility staff. Licensee shall submit the declaration as proof of correction to Community Care Licensing (CCL) by the Plan of Correction (POC) due date 07/25/2026.The licensee also agreed to ensure that all residents' personal rights are protected.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.2 · Plan of correction due date: Jul 25, 2026

87468.2 Additional Personal Rights... (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated... To be served food of the quality and quantity necessary to meet their nutritional needs. This requirement is not met as evidenced by: Based on interviews, record review, and observations, LPA determined that the Licensee failed to provide meals at scheduled times and failed to meet the residents' dietary needs. This poses an immediate Personal Rights risk to residents.the state’s words, verbatim · CDSS document, Jul 24, 2026

Plan of correction: Licensee to ensure that meals are served at appropriate times and in a timely manner as per regulations. Licensee to submit a food service menu showing facility schedule of meal times and meals served. Submit POC by due date of 07/25/2026.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ali Deniz conducted a case management regarding incident reports involving resident elopement. LPA met with Licensee, April thomas. Case management visit is being conducted to get more information on incident reports CCL agency recently received (05/06/2026 and 05/24/2026) from the facility. There were two (2) elopement reported to CCL Agency first one submitted on 05/08/2026 which occurred on 05/06/2026 and second incident report submitted on on 06/01 /2026 which occurred on 05/24/2026. In the second incident the neighbor called the police and brought her back. R1 had no injuries, and was is back in the community shortly after. Resident R1 has a diagnosis of dementia and according to medical assessment exhibits wandering behavior. LPA had a discussion about staffing conditions in the facility. Licensee stated they are still working on hiring new staff members. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809-D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 3, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Jun 5, 2026

87705 Care of Persons with Dementia:(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not ensure staff were aware when resident left the building without assistance. This poses an immediate Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2026

Plan of correction: Licensee agrees to ensure elopement plan; and address frequency of awol drills for staff. In addition, to conduct staff training regarding elopment and wandering behaviors. Proof of training with participants signature to be submittet Community Care Licensing by plan of correction due date 06/05/2026

Type of visit: Office

On 05/19/2026, a Non-Compliance meeting was conducted at the Santa Rosa Regional Office. The following individuals were present in the meeting: Regional Manager (RM), Carla Nuti-Martinez, Licensing Program Manager (LPM), Victoria Bertozzi, Licensing Program Analysts (LPA), Ali Deniz, Jill Nakagawa and Licensee/Administrator April Thomas. The purpose of today’s meeting was to address recurrent areas of concerns identified by the Department. On 10/23/2025, Facility received an initial consultation with Department's Technical Support Program (TSP) on the following topics: Record Keeping Medication Management Incident Reporting TSP completed their final consultation meeting with the facility on 02/02/2026. The following areas were discussed during today's meeting: Substantiated Complaint Investigation: Complaint 21-AS-20250815134443 Basic Services Personal Rights Medication Administration Centrally Stored Medications Record Keeping Inadequate Staffing Reporting Requirements Continued on LIC809C Continued from LIC809 Facility currently has two complaint investigations that are still being investigated: Complaint 21-AS-20260505083955 and Complaint 21-AS-20260429143325. These investigations involve concerns with basic services, adequate staffing, not seeking timely medical care, medication administration, and personal rights. Facility's Non Compliance Plan will be in place for 2 years with an end date of May 2028. Facility will be referred to TSP. The Department discussed having TSP work with Licensee on the addressed concerns. No Deficiencies Cited. Exit interview conducted. Copy of report discussed and provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 13, 2026

Type of visit: Required - 1 Year

On 03/12/2026 at approximately 12:25PM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced at this Residential Care Facility for Elderly (RCFE) for the purpose of conducting a Required 1-year inspection. LPA was greeted at the door by Licensee, April Thomas, and was granted access into the facility. Facility has an approved fire clearance and capacity for five (5) non-ambulatory residents and one (1) ambulatory resident. Upon arrival, LPA was informed that there were five (5) residents in care and three (3) staff members on-site. Facility is a 1 story building with 4 Resident bedrooms, 2 bathrooms, one (1) staff room, and common spaces. At approximately 12:45PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 1:10PM, LPA and Licensee toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within the regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. During the kitchen tour LPA observed nineteen (19) expired food cans (Technical Advice given). Toxins are stored in a locked housekeeping closet in the hallway. There was one (1) locked shed in the backyard for storage. Water temperature measured within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire extinguishers were bought on 03/12/2024 and never has been inspected (Technical Violation given). Licensee agrees to get fire extinguishers inspected as soon as possible. Smoke and Carbon Monoxide detectors were present and operational. There was enough lighting in all common areas, resident rooms, and hallways. Facility had emergency lightning supplies. Medication is centrally stored and secure in the closed in hallway. At resident bathroom number four (4) LPA observed unsecured oxygen tanks (Technical Violation Given). Continued on LIC809-C page... Continued from LIC809 page... Drill records weren't available for review, licensee stated that facility conducted last drill on December 2025 (See LIC809-D page). LPA unable to complete the annual visit. LPA will come back another time to complete the inspection. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, and Appeal Rights discussed and provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 12, 2026

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff abandoned resident at hospital.

At approximately 11:30AM, Licensing Program Analyst (LPA) Deniz arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with Administrator, April Thomas. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff abandoned resident at hospital.” The complaint alleged that Resident 1 (R1) was transported to Kaiser Emergency Room on the morning of 08/15/2025, following a fall at the facility. Reporting Party (RP) stated that approximately 15 minutes after R1 arrived at the hospital, facility staff were contacted by hospital staff to coordinate discharge, but Administrator 1 (S1) stated that R1’s room had already been filled and R1 was not welcome back to facility. RP also stated that around 12:15 p.m. the same day, the Administrator 1 (S1) returned to the hospital and dropped off R1’s belongings at the security desk without his personal medications or oxygen tank. Continued on LIC9099-C Substantiated Continued from LIC9099... LPA conducted interviews with S1, who confirmed that R1 had requested to go to the hospital after reporting a fall. S1 stated that they told R1 they would need to pay a transportation fee before to be taken to the hospital for his doctor appointments. R1 declined to make payment without a receipt, the administrator called 911, and R1 was transported by emergency services. S1 confirmed that later the same day, they informed the hospital that R1 would not be returning to the facility and that they dropped off his belongings at the hospital. S1 stated they did not follow up info regarding R1’s condition and could not provide any documentation to support her claim that R1 declined to return to the facility. No written statements, logs, or records were provided to indicate that R1 refused to return. Additionally, R1 had paid rent through 08/22/2025. Based on interview conducted, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents. Continued from LIC9099... S1 denied over charging residents for the cost of medications themselves. LPA requested documentation and reviewed the admission agreement, which reflected a $6 service fee related to medication delivery. No documentation or statements were found indicating that residents were charged for medications beyond the agreed-upon delivery and transportation fee. Based record review, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 21-AS-20250815134443

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: Oct 21, 2025

Additional Personal Rights of Residents... (a) In addition to the rights listed in ...: (20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict... This requirement was not met as evidenced by: Based on interviews and LPA observation of records, it was determined Facility refused to accept the resident (R1) back from the hospital. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: Administrator agrees to read regulation 87468.2 and submit written declaration acknowledging the understanding of regulation and the facility policies and procedures. Items to be submitted by date 10/21/2025.

Type of visit: Case Management - Deficiencies

At approximately 11:30AM, Licensing Program Analysts (LPAs) Ali Deniz arrived unannounced to conduct a Case Management – Deficiencies visit and met with Licensee, April Thomas. During the course of a complaint investigation 21-AS-20250815134443, LPA discovered that the facility failed to report the hospitalization of Resident 1 (R1), who was transported to the emergency room on 08/15/2025 following a reported fall at the facility. Per Title 22, Section 87211(a)(1)(B), the licensee is required to notify the Department within seven days of incident that results in a resident requiring medical treatment. Despite the seriousness of the incident, including injury and hospitalization, the facility did not submit the required incident report to Community Care Licensing (CCL). Furthermore, upon review of the facility file and based on statements from the administrator, it was determined that the facility has never submitted any incident reports to the Department since its initial licensure. This demonstrates a pattern of non-compliance with mandatory reporting requirements. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 7, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Oct 21, 2025

Reporting Requirements (a)Each licensee shall furnish ..., the following: (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... (B)Any serious injury as determined ... . This requirement was not met as evidenced by: Based on observations made, Licensee did not comply with the section cited above, Licensee failed to submit special incident report to the CCL as required which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: Licensee will ensure all resident incidents are reported to CCL as required. Licensee will complete training from an outside vendor on reporting requirements for whole staff and submit a plan for ongoing compliance by 10/21/2025.

Allegation investigated: Facility staff stole resident’s medication.

At approximately 08:50AM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Licensee, April Thomas. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation of “Facility staff stole resident’s medication.” Complainant alleged that Staff Member 1 (S1) observed Staff Member 2 (S2) taking Resident 1’s (R1) medication. LPAs conducted interviews. Interview with Complainant did not provide additional information. Multiple attempts to reach S1 for additional information were unsuccessful. Interview conducted with S2 denied any knowledge of medications being stolen. Multiple attempts to interview R1 were unsuccessful. LPAs conducted a medication audit and were unable to determine if there were missing medication. Continued on LIC9099-C... Unsubstantiated Continued from LIC9099... Based on observations made, interviews conducted, and lack of evidence, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 6, 2025 · control 21-AS-20250516124427

Type of visit: Case Management - Deficiencies

At approximately 08:50AM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to conduct a Case Management – Deficiencies visit and met with Licensee, April Thomas. During the course of the Complaint Investigation received on 05/16/2025, LPAs observed the following deficiencies: During visit conducted on 05/20/2025, LPAs observed the following: •12 pre-poured tablets of Oxycodone located in a plastic cup. • Facility was not documenting their centrally stored medication in its entirety or storing the narcotic medication safely. Per discussion with Licensee, narcotics were being held in their personal room instead the facility's designated area for centrally stored medications. During visit conducted on 07/23/2025, LPAs made the following medication observations: • AM, PM, and Evening medication were pre-poured for residents located in one of the facility’s kitchen cabinets. Per Licensee, the identified medications were poured approximately a week prior to LPAs conducting their visit. LPAs observed that the plastic cups were not labelled to identify the appropriate resident. Per Licensee, they pass the medication daily and therefore know on sight which medication is supposed to be given to each resident. • Multiple weekly medication trays located in the facility’s medication closet with pre-poured medication. • LPAs did not observe a properly documented centrally stored medication log per regulation. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 6, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Aug 18, 2025

87465 Incidental Medical and Dental (h) The following requirements...:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement was not met as evidenced by: Based on observations made, Licensee did not comply with the section cited above. LPAs observed multiple instances of resident medication being pre-poured over 24 hours in advance. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Licensee agreed to conduct all staff training in medication administration to submit CCL with centrally store medication log for all residents in care by plan of correction date (POC) 08/18/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(6) · Plan of correction due date: Aug 18, 2025

87465 (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible a record of centrally stored prescription medications for each resident...: This requirement was not met as evidenced by: Based on observations made, Licensee didnot comply with the section cited above and did not ensure that there was a completed LIC622 or similar document with the all of the regulatory information required. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: Licensee agreed to conduct all staff training in medication administration to submit CCL with centrally store medication log for all residents in care by plan of correction date (POC) 08/18/2025.

Type of visit: Required - 1 Year

At approximately 9:40 AM, Licensing Program Analyst (LPA) Star Stevenson made an unannounced annual required inspection of this licensed senior care facility. LPA met with April Thomas - Administrator. Four (4) staff members were present and four (5) clients in care. Staff member S1 was not associated and cleared to work at the facility (type A deficiency issued) At approximately 10:10 AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. Facility observed to have a large open and shaded outside area, All notices that are required to be posted including personal rights and "see something, say something" and ombudsman have been posted and are in a highly visible area. LPA observed activity supplies for resident use. Facility kitchen, refrigerators and freezers were clean, and a variety of healthy food was stored properly. Toxins and centrally stored meds were observed to be locked in a storage closet. Sharps and knives were locked as required. Water temperature measured within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. At approximately 11:15 AM, LPA reviewed 5 of 5 resident records and found 5 of 5 residents did not have current signed personal rights or consent for medical treatment (technical violations issued) None of the clients in care were indicated as bedridden on the MD LIC602 forms. At approximately 1:30PM, LPA reviewed 4 staff records. 3 of 4 records did not contain health screening as required (technical violation issued). Evidence of current first aid and CPR training were current. Continued on LIC809C Continued for LIC809 Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Proof of control of property (Deed or tax documents showing ownership) LIC500- Personnel Report LIC610E- Disaster Plan (update if need and sign) LIC308 Current designation of facility responsibility) Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Administrator April Thomas, whose signature indicates receipt..the state’s words, verbatim · CDSS document, Mar 10, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator and Licensee arrived to assist LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and licensee discussed magnet release for fire door, process to request a secured perimeter waiver, and securing items in the facility that could pose a hazard to residents. Resident records reviewed. Licensee to include Pre-appraisals, care plans and PRN authorization for all residents. Staff files reviewed. Filles to be better organized and all training documented in files. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Mar 6, 2024

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 11/7/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of conducting a case management and was greeted by Lead Staff, Nathaniel Sherman. The visit is to gather additional documentation for resident (R1) confirming that they have been admitted to the facility as a resident. LPA Tobola received copies of R1's Admissions Agreement and Physician's Report. LPA Tobola confirmed R1 has now been admitted to the facility as a resident. LPA requested for R1's updated Appraisal or Needs & Service Plan to be submitted to CCLD by due date 11/9/2023. In addition, LPA obtained the change of capacity fee from the Administrator to complete the fire clearance inspection process that has been pending. No deficiencies cited during today's visit.the state’s words, verbatim · CDSS document, Nov 7, 2023

Type of visit: Case Management - Other

On 10/19/2023 Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of conducting a case management and was greeted by Licensee, April Thomas. The Department was informed that an individual (I1) was wanting to be associated to the facility as a staff member. Previously I1 had an action against them by the Department and was not to reside, work, live in a CCL facility. The terms of the Accusation, Decision and Order were effective from December 11, 2006 for two years. LPA was informed that (I1) resides at the facility and does provide some services as a staff member. However, I1 does not provide any caregiving duties. I1 resides at the facility due to health concerns and is provided care by Licensee. Licensee has agreed that I1 will be considered a resident and will be in compliance with Title 22 Regulations regarding care and supervision. **Immediate Civil Penalty assessed in the amount of $500 due to caregiver background clearance violation. Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.the state’s words, verbatim · CDSS document, Oct 19, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e) · Plan of correction due date: Oct 20, 2023

All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This was not met as evidence by:** Based on record review and interview with Licensee, the facility did not comply with the section cited above in 1 out of 1 individuals (I1) without proof of background clearance or association to the facility, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Licensee agrees to submitt in writing; a plan to ensure I1 is considered a resident and provide all documents required per regulation (admission agreement, 602, needs/service etc) by POC date 10/20/2023. In addition, Licensee completed an updated LIC200 for increase in capacity and provided to CCLD.