Healdsburg Senior Living Community

Type of visit: Case Management - Incident

At approximately 1:00 PM Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management visit and met with newly appointed facility Executive Director (ED), Neysa Hinton. On 6/9/2026 the facility submitted one (1) Incident Report (IR) for Resident 1 (R1) for a medication error. On 6/5/2026, while conducting a standard change of shift Narcotic medication count, staff members S2 and S3 discovered a discrepancy involving Medication-1 (med-1). The Medication Administration Record (MAR) indicated that medication-1 had been signed out by staff member S1. Via the pill count it was determined that the medication had not been administered by S1 to resident R1 per their doctor’s orders. Staff members S2 and S3 immediately reported the discrepancy to Interim Executive Director Shauna Burton. The facility immediately placed resident R1 on alert charting following the missed dose of med-1. R1’s vital signs were monitored for any adverse effects of the missed medication. Resident R1's emergency contact and Primary Care Physician were notified. Resident R1 had no adverse reactions because of the missed dose of medication. This deficiency will be cited. The facility had a 3rd party conduct Medication Management and Resident Care Expectation training for all staff members who administer medications on 6/11/2026. As the facility has already conducted Medication Management Training for all staff who administer medications, the deficiency will be cleared during today's visit. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, 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, 811 Confidential Names, Deficiency clearance letter and Appeal Rights discussed and provided to ED Hinton. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 17, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall...provide for assistance in obtaining such care, by compliance with the following: (4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in that a prescribed medication had not been administered to Resident R1 which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: Licensee or Administrator to conduct Medication Management and Resident Care Expectation training for all staff members who administer medications and provide proof of training to Community Care Licensing by POC due date of 7/17/2026.

Allegation investigated: Staff did not properly transfer residents

At approximately 10:35 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegation and met with Health Services Director (HSD), Tiffany Leos Escobar. During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents. Complaint alleges that facility staff did not properly transfer residents. Witness W1 stated that they witnessed facility staff transferring resident R1 by pulling them up by their arms. On a resident Needs and Services plan dated 3/23/2025 the facility stated that resident R1 needs a “Total Assist” for: Ambulation, Bathing, Dressing, Toileting, Transfer Assistance and Medication Administration. On a Notice of Written Verbal Counsel dated 12/22/2025 staff member S2 was counseled regarding transferring residents inadequately under their armpits alone when the family requested a two (2) person transfer. Continued on 9099-C... Substantiated ...Continued from 9099 The document further states “going forward we must go by the service plan of the residents and use 2-person transfer”. On an LIC 855 Declaration form facility staff member S1 stated that staff member S2 was removed from the memory care unit and that the facility did an on the spot reminder for all Memory Care staff that they must provide care as dictated by the care plan as well as setting up one on one transfer training. Based on LPA’s interviews and record review, 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, are being cited on the attached 9099D. ...Continued from 9099A So, 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. Copy of LIC 9099, LIC 9099D, LIC 9099S and Appeal Rights discussed and provided to HSD Escobar.. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 30, 2026 · control 21-AS-20260122172928

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 28, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated... (a)In addition to the rights listed in... residents in privately operated...the following personal rights:(4)To care,...services that meet their individual needs...by staff...to meet their needs. This requirement is not met as evidenced by: Based on interview & record review, the licensee did not comply with the section cited above in that resident R1’s was provided inadequate care when staff member S2 was transferring them which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: Licensee or Administrator to provide proof that all facility direct care staff have undergone Patient Transfer & Mobility training given after 4/30/2026 to Community Care Licensing by POC due date of 5/28/2026.

Type of visit: Case Management - Other

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management visit related to record keeping at the facility. Today, while initiating a complaint investigation for Compliant Control Number 21-AS-202601221 LPA requested documents from resident R1's file. LPA was informed that the documentation was not available as the new management company, Brightwater, has been removing data from the facility computers and that they no longer had access to certain record keeping systems. California Code of Regulations (CCR) 87506 Resident Records that stated that facilities must maintain original records or photographic reproductions of records for three (3) years following the termination of service to the resident. LPA was previously informed (on 10/23/2025) by the facility Executive Director that paper copies of records will be created and kept at the facility. As records that were requested today were not avaiilbe the facility will be cited for this deficiency. As the facility was previously cited for the same deficiency (on 10/30/2025) within the last year a Civil Penalty of $250.00 will be assessed. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, 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, LIC-421FC, LIC-811 Confidential Names and Appeal Rights discussed and provided to Health Services Director Escobar. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 30, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: Feb 13, 2026

87506 Resident Records (e)Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in that the facility did not retain R1’s original records or photographic reproductions which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: Licensee or Administrator to provide requested documentation and will provide a definitive date on when all required documentation for all current and previous residents will be available at the facility to Community Care Licensing by the POC due date of 2/13/2025.

Type of visit: POC

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced, to conduct a Plan of Correction (POC) visit. On 1/9/2026, LPA issued a citation for a violation of California Code of Regulation section 87211(a)(1)(B) with a plan of correction (POC). The POC called for the License or Administrator to submit an LIC 9098 Proof of Corrections self-certifying that all LIC 624 Unusual Incident/Injury reports will be submitted within the regulated time frame to CCL by POC due date of 1/23/2026. As the licensee failed to submit the documents by the POC due date, the facility will be assessed a civil penalty for $100 per day for the period of 1/24/2026 to 01/30/2026 totaling $700. The civil penalty will continue to accrue $100 per day until the deficiency is corrected. Failure to correct the cited deficiency will result in further civil penalty assessments. Exit interview conducted. Copy of report, LIC 421FC and appeal rights, provided to Health Services Director Tiffany Leos Escobar. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 30, 2026

Allegation investigated: Facility is not maintained in good repair and safe at all times

At approximately 1:55 PM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegation and met with facility back up Executive Director Interim Shauna Burton. Complaint alleges that the facility is not maintained in good repair and that it is not safe at all times. During the investigation, LPA conducted a facility visit, interviewed multiple witnesses and collected records. Reporting party stated, on 9/30/2025 in Memory care unit two (2) [MC2], the ceiling collapsed due to a water leak. The ceiling fell on a resident (resident R1) of the facility while they were sleeping. As a result of the ceiling collapse, resident R1 was transported to the Emergency Room for sustained injuries. Resident R1 was released later in the day and returned to the facility. Continued on 9099-C... Substantiated ...Continued from 9099 LPA requested and was sent un-redacted emergency response documents from the City of Healdsburg Fire Department who responded to the facility’s 911 call. Additionally, the Fire Department sent photographs of the collapsed ceiling. The Fire Department report stated, “The piece of Sheetrock was approximately 3 foot by three foot square and upon further inspection looked as though it was inappropriately attached to the structural members where there was also a bucket up in the rafters which looked as if it were placed there to collect water from a roof leak. Medic 681 assisted the patient onto the gurney, and they were later transported to the hospital for evaluation and treatment of lacerations.” Noted sustained injuries are consistent with the after-visit summary provided by the hospital’s emergency department. Further inter-departmental emails from the Healdsburg Fire Department member HFD1 state, “the work that was done to hole up the section of dry wall looks to be poorly done.” Post accident repair invoices note, “fixed leak on ¾” hot pex line in ceiling,”. During staff interviews when asked when they first heard about the leak in the ceiling in room ten (10), a staff member stated, “for some time now, it would be leaking, then fixed, leaking then fixed.” In another interview when asked what was done to mitigate the potential for injury to the residents, a staff member stated, “we put a container underneath (the leak) to catch water.” Additionally, during an interview a staff member stated, “it was our fault the bucket fell”. Based on LPA’s interviews, photographic evidence, record review and express admission, 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, are being cited on the attached 9099D. As this repeat deficiency occurred within one (1) year of the previous citation, a Civil Penalty of $250.00 will be assessed. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty. Exit interview conducted. Copy of LIC-9099, LIC-9099C, LIC9099D, LIC421FC, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Executive Director Interim Burton. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 9, 2026 · control 21-AS-20251015104959

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jan 12, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interviews photographic evidence, record review and express admission the licensee did not comply with the section cited above in that the facility did not properly repair a leak in a hot pex line in Memory Care 2, room #10 which posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: Licensee to submit plans for how facility maintenance issues are to be reported by staff and how they will be able to assure that all repairs are completed in a timely manner that mitigates the risk to residents in care and staff to Community Care Licensing by POC due date of 1/12/2026.

Type of visit: Case Management - Other

At approximately 1:55 PM Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management visit and met with facility Executive Director Interim, Shauna Burton. On 1/5/2026, Community Care Licensing (CCL) received an LIC 624 Unusual Incident/Injury Report regarding resident R1. The report noted that the incident/injury occurred on 12/10/2025. California Code of Regulations 87211 Reporting Requirements state that any serious injury as determined by the attending physician and occurring while the resident is under facility supervision must be reported to the licensing agency within seven (7) days of the injury occurrence. As the LIC 624 Unusual Incident/Injury Report was sent to CCL after the required seven (7) days, this deficiency will be cited. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, 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, 811 Confidential Names and Appeal Rights discussed and provided to Executive Director Interim Burton. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 9, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Jan 23, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...: (1) A written report shall be submitted to the licensing agency... within seven days... (B) Any serious injury...resident is under facility supervision. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in that an LIC 624 Unusual Incident Injury report for resident R1 was filed with Community Care Licensing (CCL) on 1/5/2026 for an injury that occurred on 12/10/2025 which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: License or Administrator will submit an LIC 9098 Proof of Corrections self-certifying that all LIC 624 Unusual Incident/Injury reports will be submitted within the regulated time frame to CCL by POC due date of 1/23/2026.

Type of visit: Required - 1 Year

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a 1-Year Required inspection and was greeted by acting Administrator/Executive Director (ED), Shauna Burton. The Ridges at Healdsburg serves older adults in Assisted Living (AL) and Memory Care (MC). Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for eighty-two (82) non-ambulatory residents of which six (6) residents can be bedridden. The facility has an approved hospice waiver for six (6) residents. The facility consists of three (3) single-level buildings. The Primary building is for assisted living. Their are two (2) buildings dedicated to memory care. Upon arrival, LPA was informed that there were twenty-one (21) residents in AL and seventeen (17) residents in MC for a total of thirty-eight (38) Residents in care. The facility currently has a probationary license through 12/28/2025. At approximately 9:15 AM LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 9:45 AM, LPA conducted a sample file review of eight (8) staff members. All staff members files were observed with appropriate documentation, proof of training, stipulation training and current 1st Aid and CPR certification on file. LPA also conducted a sample file review for eight (8) residents. Upon review, LPA observed that two (2) of eight (8) residents files (for residents R1 & R2) did not have an annual routine visit with a licensed medical professional. This deficiency will be cited. Six (6) of eight (8) residents' records were observed to have appropriate documentation on file including current Service Plans and Physician's Reports. Continued on 809-C... ...Continued from 809 Brandee Rodriguez’s Administrator Certification 6059911740 is current with an expiration date of 7/12/2026. Shauna Burton's Administrator Certification 6074459740 is current with an expiration date of 1/13/2027. LPA is requesting the following documents submitted to CCLD by 12/20/2025: Updated Admissions Agreement being used by facility's management company Brightwater Senior Living Group, LLC. LIC 610E Emergency Disaster Plan LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, 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, LIC-811 Confidential Names and Appeal Rights discussed and provided to acting Administrator Burton. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Dec 5, 2025

Allegation investigated: Due to lack of staff resident sustained a pressure injury

At approximately 8:50 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegations and met with facility back up Administrator Shauna Burton. During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents. Complaint alleges that due to lack of staff resident sustained a pressure injury. The facility has five (5) levels of care for Assisted Living with level one (1) being the least amount of care and level five (5) being the highest level of care. The facility conducted Resident Assessments of resident R1 on 12/1/2024 and on 5/14/2025. Both assessments of R1 stated that R1 requires level five (5) care. Continued on 9099-C... Substantiated ...Continued from 9099 The Needs and Services Plans (NSP), reflective of the previously noted assessments, states that R1 requires “Total Assist” for Bathing, Grooming, Dressing and Ambulation. The two (2) NSPs also state that for Toileting and Transfers R1 will require a “two (2) person assist”. During review of facility staff schedules LPA observed that only one (1) Caregiver (CG) was assigned to the entire Assisted Living unit. The facility currently has a probationary license. As part of the Stipulation and Waiver, and Order dated 6/30/2022, the License understands that facility staff must be hired in numbers necessary to meet the needs of the residents. To that extent, each Memory Care Unit and Assisted Living unit shall be staffed independently, such that the units do not share direct care staff. The Medication Technician (MT) will not be a direct care staff but may provide support when not distributing medication. LPA reviewed facility charting notes for resident R1 from 4/4/2025 to 7/23/2025. From 4/4/2025 to 4/30/2025 there are four (4) entries. The April entries do not state that R1 is being turned or repositioned. There is one (1) charting note entry for May. The single May entry does not state that R1 is being turned or repositioned. There are twenty-one (21) charting note entries for June for the dates of 6/1/2025 to 6/25/2025. On 6/6/2025 charting notes state, “We noticed the beginning of a peel on the resident bottom. We put barrier cream. RSD has already been notified family and doctor. Please reposition (them) and continue to put barrier cream. Will continue to monitor”. Charting note entries on 6/6/2025 & 6/7/2025 note that barrier cream has been applied. Charting note entry on 6/11/2025 state, “Nurse from Advanced Home health care to assess resident for wound care on their coccyx area. Nurse stated their wound is a Stage 2. Relative/POA will be bringing extra pillows to assist with repositioning them. Care staff are to support repositioning appx every 2 hours or as needed.” Later on 6/11/2025 there are two (2) additional charting note entries that state resident was repositioned every two (2) hours. On 6/12/2025 a charting note entry states that R1 was repositioned every two (2) hours. From 6/13/2025 to 7/23/2025 there were no further charting note entries related to repositioning R1 every two (2) hours. Additionally, there is video showing R1 being moved to a wheelchair positioned at the base of the bed in front of the television at approximately 5:40 AM. Continued on 9099-C2... ...Continued from 9099-C Video shows R1 was moved back into their bed at approximately 1:32 PM. During review of facility staff schedules LPA observed that one (1) Caregiver (CG) was assigned to the entire Assisted Living unit during the thirty (30) days preceding R1’s being diagnosed as a Stage 2 wound. Based on LPA’s interviews and record review, 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, are being cited on the attached 9099D. Exit interview conducted. Copy of LIC-9099, LIC-9099C, LIC-9099C2 LIC-9099D, LIC-811 Confidential Names, Plan of Corrections and Appeal Rights discussed and provided to back up Administrator Burton. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 21-AS-20250808144348

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 19, 2025

87411Personnel Requirements-General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above in that lack of sufficient staffing prevented resident R1 to be repositioned which caused resident R1 to develop a stage 2 pressure wound which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 18, 2025

Plan of correction: Licensee to self certify that the facility will provide sufficient staff to meet the residents needs. Additionally, the Licensee will submit a plan on how the facility's Caregivers will be informed that residents need to be repositioned and how repositioning will be confirmed. Both items will be submitted to Community Care Licensing by POC due date of 11/19/2025.

Allegation investigated: Facility staff did not follow residents care plan Facility staff did not meet residents care needs

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegations and met with facility Administrator Brandee Rodriguez. During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents. Complaint alleges staff did not follow the resident’s care plan and that the staff did not meet the resident’s care needs. The facility has five (5) levels of care for Assisted Living with level one (1) being the least amount of care and level five (5) being the highest level of care. The facility conducted Resident Assessments of resident R1 on 12/1/2024 and on 5/14/2025. Both assessments of R1 stated that R1 requires level five (5) care. The Needs and Services Plans (NSP), reflective of the previously noted assessments, states that R1 requires “Total Assist” for Bathing, Grooming, Dressing and Ambulation. Continued on 9099-C... Substantiated ...Continued from 9099 The two (2) NSPs also state that for Toileting and Transfers R1 will require a “two (2) person assist”. During review of facility staff schedules LPA observed that only one (1) Caregiver (CG) was assigned to the entire Assisted Living unit. The facility currently has a probationary license. As part of the Stipulation and Waiver, and Order dated 6/30/2022, the License understands that facility staff must be hired in numbers necessary to meet the needs of the residents. To that extent, each Memory Care Unit and Assisted Living unit shall be staffed independently, such that the units do not share direct care staff. The Medication Technician (MT) will not be a direct care staff but may provide support when not distributing medication. LPA reviewed the facility call system response logs from 7/1/2025 to 8/7/225 and observed that within this time frame there were five (5) instances where R1 requested assistance, and the response time exceeded fifteen (15) minutes. Additionally, there is video showing R1 being moved to a wheelchair positioned at the base of the bed in front of the television at approximately 5:40 AM. Resident R1 was not moved back into their bed until approximately 1:32 PM when the video shows a single (1) staff member moving R1 into bed although their NSP states that R1 requires a two (2) person assist for transfers. Based on LPA’s observations and record review, 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, are being cited on the attached 9099D. The facility was cited for the same deficiency on 11/19/2024, 5/6/2025 and 7/24/2025. As this repeat deficiency occurred within one (1) year of the previous citations, a Civil Penalty of $1000.00 will be assessed. Exit interview conducted. Copy of LIC-9099, LIC-9099-C, LIC-9099D, Plan of Corrections, LIC-421IM and Appeal Rights discussed and provided to Executive Director Rodriguez. Signature on form confirms receipt of documents. ...Continued from 9099 Additionally, LPA observed that the same four (4) Caregivers were current and have completed the required four (4) hours of additional monthly training as part of the Stipulation and Waiver, and Order dated 6/30/2022. So, 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. Complaint alleges the facility unlawfully evicted resident R1. Witness reported that the facility was requiring resident R1 to move from Assisted Living (AL) to Memory Care (MC) due to a change in R1’s cognitive function. The witness further stated that they asked the facility for proof, in writing, of the cognitive change as diagnosed by a licensed medical professional. Resident R1’s Residence and Care Agreement, section G Change of Level of Care states, “If we determine that you need a different level of care than that which you are currently receiving, we will provide you and your responsible person, if applicable, with written notice of the change.” The facility did not provide proof of any cognitive change for R1. During interviews facility staff members S2 and S3 stated that no written notice was given as they were not requiring that resident R1 move to Memory Care. Staff members S2 and S3 stated that the move would be voluntary. Neither the facility nor the witness was able to provide any documentation stating that the facility was requiring that resident R1 be moved to Memory Care. So, 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. Copy of report discussed and provided to Executive Director Rodriguez. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 30, 2025 · control 21-AS-20250808144348

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(c) · Plan of correction due date: Oct 31, 2025

Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by Based on record review and interviews the licensee did not comply with the section cited above in that staffing in AL is not sufficient per resident care needs including but not limited to requiring a two person assist, which poses a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: Licensee or Administrator will submit a plan to sufficiently staff the facility per resident care needs to CCL by POC due date of 10/31/2025. Facility to submit to CCL updated LIC500 with staff schedules showing adequate staffing by no later than 11/7/2025.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management visit related to record keeping at the facility. On 10/23/2025 while conducting a complaint investigation LPA requested documentation for a former resident (resident R1) of the facility. After asking for the documentation, LPA was informed that the documentation was not available as the new management company, Brightwater, has been removing data from the facility computers and that they no longer had access to certain record keeping systems. LPA informed the facility Executive Director of California Code of Regulations (CCR) 87506 Resident Records that stated that facilities must maintain original records or photographic reproductions of records for three (3) years following the termination of service to the resident. LPA was informed by the facility Executive Director that paper copies of records will be created and kept at the facility. As of today, the requested documentation has not been provided by the facility. The facility is being cited for not maintaining R1’s records on site per regulations. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, 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, 811 Confidential Names and Appeal Rights discussed and provided to Executive Director Rodriguez. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 30, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: Nov 6, 2025

87506 Resident Records (e)Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in that the facility did not retain R1’s original records or photographic reproductions which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: Facility Management company Brightwater to submit an LIC 9088 Proof of Corrections form self certifying that they have read California Code of Regulations (CCL) 87506 Resident Records and to submit the requested documents for R1 to Community Care Licensing by POC due date of 11/06/2025

Type of visit: Case Management - Legal/Non-compliance

At approximately 8:55 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Legal Non-Compliance Case Management inspection and met with Executive Director (ED) Brandee Rodriguez. LPA was informed that there are twenty-one (21) residents in Assisted Living (AL), eight (8) residents in Memory Care Unit 1 (MC1) and thirteen (13) residents in Memory Care Unit 2 (MC2) for a total of forty-two (42) residents. As a requirement of the Stipulation and Waiver; and Order dated, 6/30/2022, the facility submitted a Monthly Quality Assurance (QA) Audit that includes but is not limited to staffing, physical plant, dementia care, medication records and infection control. The following items are some of the requirements required per the current Stipulation and Waiver and Order (dated 6/30/2022) in place for the facility: Facility shall provide a minimum of four (4) hours of training monthly to direct care staff and managers. All staff that provide medication administration must receive one additional hour of training every month. Pacifica shall perform quarterly audits of medication inventory and if errors are found, a plan of correction for each error found shall be included with the applicable audit report Respondent Pacifica understands that facility staff must be hired in numbers necessary to meet the needs of the residents. To that extent, each Memory Care Unit and Assisted Living unit shall be staffed independently, such that the units do not share direct care staff. The Med Tech will not be a direct care staff, but may provide support when not distributing medication. Facility call system and delayed egress shall at all times be fully functional. Continued on 809-C... ...Continued from 809 During inspection LPA reviewed staff schedules from 8/29/2025 through the day shift of 9/25/2025. LPA was informed that the day shift is from 6:00AM to 2:00PM and that the Evening shift is from 2:00PM to 10:00PM. During review of staff schedules LPA observed the following: 8/29/2025: MC2 had only one (1) Caregiver (CG) during the evening shift. 8/30/2025: MC2 had only one (1) CG during the day shift. 9/1/2025: AL, MC1 and MC2 shared only one (1) Medication Technician (MT) per day and evening shifts. 9/2/2025: MC2 had only one (1) CG per the day and evening shifts. 9/3/2025: AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the day shift. MC2 had only one (1) CG for the evening shift. 9/4/2025: MC2 had only one (1) CG during the day shift. AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the evening shift . 9/5/2025: MC2 had only one (1) CG during the day shift. AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the evening shift. 9/6/2025: MC2 had only one (1) CG during the day shift. AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the evening shift. 9/7/2025: MC2 had only one (1) CG during the day shift. AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the evening shift. 9/8/2025: MC2 had only one (1) CG during the day shift. AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the evening shift. 9/10/2025: AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the evening shift. 9/11/2025: AL, MC1 and MC2 shared only one (1) Medication Technician (MT) per day and evening shifts. 9/12/2025: AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the evening shift. 9/13/2025: MC2 had only one (1) CG during the day shift. 9/14/2025: MC2 had only one (1) CG during the day shift. 9/15/2025: AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the evening shift. 9/18/2025: MC2 had only one (1) CG during the day shift. 9/19/2025: MC2 had only one (1) CG during the day shift. 9/25/2025: MC2 had only one (1) CG during the day shift. Continued on 809-C2... ...Continued from 809-C As the facility did not provide adequate staff to meet the needs of residents in care a citation will be issued. The facility was cited for the same deficiency on 10/16/2024,11/19/2024, 5/6/2025 and 7/24/2025. As this repeat deficiency occurred within one (1) year of the previous citations, a Civil Penalty of $1000.00 will be assessed. The facility is constructing an additional building for residents directly behind the primary AL building. The building under construction is next to garden area. While conducting the inspection of the facility grounds LPA observed that the temporary fencing intended to block off the area under construction was knocked down and moved allowing access to the construction area. LPA further observed the door to the new building was propped open. LPA entered the building under construction and observed trip hazards and unsecured toxins. LPA observed that there was no staff or construction personnel in the area. The construction area contained trip hazards and unsecured toxins that could be dangerous to the facility's residents in care. The facility will be issued a citation for not ensuring the construction area was properly secured. LPA has video showing access to the construction area showing the trip hazards and unsecured toxins. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809Ds, LIC-421IM, Plan of Corrections and Appeal Rights discussed and provided to ED Rodriguez. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 25, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Sep 26, 2025

Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by Based on record review and interviews the licensee did not comply with the section cited above in that staffing in MC1,MC2 & AL is not sufficient per resident care needs including but not limited to requiring a two person assist, which poses a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: Licensee or Administrator will submit a plan to sufficiently staff the facility per resident care needs to CCL by POC due date of 9/26/2025. Facility to submit to CCL updated LIC500 with staff schedules showing adequate staffing by no later than 10/15/2025.

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

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that there was open access to the building under construction and various hazards therein, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: Licensee or Administrator will provide a plan of action to keep the building under construction inaccessible to residents in care and will provide pictures of construction area with the temporary fencing in place to Community Care Licensing by POC due Date of 10/2/2025.

Type of visit: Case Management - Legal/Non-compliance

At approximately 8:55 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Legal Non-Compliance Case Management inspection and met with Executive Director (ED) Brandee Rodriguez. LPA was informed that there are twenty-one (21) residents in Assisted Living (AL) and twenty (20) residents in Memory Care (MC) for a total of forty-one (41) residents. As a requirement of the Stipulation and Waiver; and Order dated, 6/30/2022, the facility submitted a Monthly Quality Assurance (QA) Audit that includes but is not limited to staffing, physical plant, dementia care, medication records and infection control. LPA reviewed QA and which noted that the facility reported that AL is not in accord in regards to staffing per the stipulation. As this is being investigated as part of complaint 21-AS-20250808144348 it will not be cited today. The facility has hired additional staff since LPA's last Non-Compliance inspection on 7/24/2025. The following items are some of the requirements required per the current Stipulation and Waiver and Order (dated 6/30/2022) in place for the facility: Facility shall provide a minimum of four (4) hours of training monthly to direct care staff and managers. All staff that provide medication administration must receive one additional hour of training every month. Pacifica shall perform quarterly audits of medication inventory and if errors are found, a plan of correction for each error found shall be included with the applicable audit report Memory Care Unit and Assisted Living unit shall be staffed independently, such that the units do not share direct care staff. The Med Tech will not be a direct care staff, but may provide support when not distributing medication. Facility call system and delayed egress shall at all times be fully functional. Continued on 809-C... ...Continued from 809 LPA reviewed the facility call system logs for from 8/19/2025 through 8/27/2025. LPA observed thirteen (13) instances where the call system response times exceeded fifteen (15) minutes. The longest response time being one (1) hour, one (1) minute and fifty-six (56) seconds. Facility provides monthly training to staff in order to comply with the Stipulation and Waiver, and Order and contracts with a vendor to ensure the staff training requirement are met. LPA reviewed stipulation training documents for four (4) staff members. During audit of stipulation training documents, LPA observed that staff had completed the stipulation training as required. During Today's inspection, LPA toured the AL, MC 1 and MC 2 buildings. LPA also toured the facility grounds. No deficiencies cited during today's visit. Exit interview conducted. Copy of report and discussed and provided to ED Rodriguez. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 28, 2025

Allegation investigated: Inadequate Staffing

Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver findings regarding the above allegation and met with facility Administrator Brandee Rodriguez. Complaint alleges the facility does not have adequate staffing to meet the needs of residents in care. Complainant states that only one direct care provider is scheduled per shift in Memory Care Building 2 and Assisted Living, but the care needs of residents require at least two (2) staff be present, as some residents require a two (2) person assist and some resident’s behaviors require at least two (2) staff members, as one (1) staff member is needed solely for the purpose of redirecting the residents with disruptive and or aggressive behaviors. Continued on 9099-C... Substantiated ...Continued from 9099 The facility is under Stipulation and Order and Waiver (Stip) as of 6/30/22. As a requirement of the Stipulation and Waiver; and Order dated July 18, 2022, page four (4), line items 26-27 and page five (5), line items 1-5, each Memory Care unit and Assisted Living unit will be staffed independently such that the units do not share direct care staff. The medication tech will not be a direct care staff but may provide support/backup when not distributing medication…and staff breaks, and lunch shall be staggered so there is adequate staff coverage. In addition, page five (5) line items 5-7 state that a census of each unit and any two (2) person assist be identified. During the investigation, LPA reviewed staff schedules from 6/18/2025 through 7/2/2025 for Memory Care building 1 (MC1), Memory Care building 2 (MC2) and the Assisted Living building (AL). LPA observed that there was only one (1) Caregiver scheduled for MC2 and AL per shift during this time frame. LPA further observed that on the two (2) person assist census dated 6/13/2025, MC2 residents R2 and R3 were listed as needing a two (2) person assist; however, on the two (2) person assist census dated twelve (12) days later on 6/25/2025 the same two (2) residents were not listed as requiring a two (2) person assist. During records review, LPA observed that there was no change in conditions for these two residents. Additionally, resident R4, who lives in assisted living was listed as requiring a two person assist. During interviews conducted with staff, both S1 and S2 stated that MC2 Resident R1 displays aggressive and disruptive behaviors that require a staff member to address and or redirect resident. During this time, a second (2nd) staff member is required to monitor the other residents. During charting note review, LPA observed fourteen (14) instances of aggressive behavior from R1 towards staff and other residents between the dates of 6/4/2025 to 7/1/2025. Based on LPA record review and interviews, 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, are being cited on the attached 9099D. The facility was cited for the same deficiency on10/16/2024, 11/19/2024 and 5/6/2025. As this repeat deficiency occurred within one (1) year of the previous citations, a Civil Penalty of $1000.00 will be assessed.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 21-AS-20250625095039

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Jul 25, 2025

Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by Based on record review and interviews the licensee did not comply with the section cited above in that staffing in MC2 & AL is not sufficient per resident care needs including but not limited to requiring a two person assist, which poses a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: Licensee or Administrator will submit a plan to sufficiently staff the facility per resident care needs to CCL by POC due date of 7/25/2025. Facility to submit to CCL updated LIC500 with staff schedules showing adequate staffing by no later than 8/15/2025.

Allegation investigated: Licensee does not ensure sufficient staffing is provided resulting in a lack of supervision for residents in care

Licensing Program Analyst (LPA) Robert Frank and arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegation and met with facility Administrator Brandee Rodriguez. Complaint alleges the facility does not have adequate staffing to meet the needs of residents in care. Complainant states that only one direct care provider is scheduled per shift in Memory Care Building 2 and Assisted Living, but the care needs of residents require at least two (2) staff be present, as some residents require a two (2) person assist and some resident’s behaviors require at least two (2) staff members, as one (1) staff member is needed solely for the purpose of redirecting the residents with disruptive and or aggressive behaviors. The same allegation of Inadequate Staffing was filed with Community Care Licensing on 6/25/2025. This same allegation on complaint control #21-AS-20250625095039 was found to be substantiated and a citation was issued. As such, this complaint will be found UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 24, 2025 · control 21-AS-20250714081523

Type of visit: Case Management - Legal/Non-compliance

At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Legal Non-Compliance Case Management inspection and met with Executive Director (ED) Brandee Rodriguez. LPA was informed that there are twenty-two (22) residents in Assisted Living and seventeen (17) residents in Memory Care for a total of thirty-nine (39) residents. As a requirement of the Stipulation and Waiver; and Order dated, 6/30/2022, the facility submitted a Monthly Quality Assurance (QA) Audit that includes but is not limited to staffing, physical plant, dementia care, medication records and infection control. LPA reviewed QA and which noted that the Ice machine, storage shelving for frying pans and top of pan steamer needed to be cleaned. LPA inspected items noted and observed them to have been cleaned. The following items are some of the requirements required per the current Stipulation and Waiver and Order (dated 6/30/2022) in place for the facility: Facility shall provide a minimum of four (4) hours of training monthly to direct care staff and managers. All staff that provide medication administration must receive one additional hour of training every month. Pacifica shall perform quarterly audits of medication inventory and if errors are found, a plan of correction for each error found shall be included with the applicable audit report Memory Care Unit and Assisted Living unit shall be staffed independently, such that the units do not share direct care staff. The Med Tech will not be a direct care staff, but may provide support when not distributing medication. Facility call system and delayed egress shall at all times be fully functional. Continued on 809-C... ...Continued from 809 LPA reviewed the most recent staff schedule to verify that facility has sufficient staff for resident's needs including but not limited to residents needing two person assists. Facility was observed to have inadequate staffing in Memory Care 2 (MC2) and Assisted Living (AL). This deficiency is being cited on complaint number 21-AS-20250625095039. Facility provides monthly training to staff in order to comply with the Stipulation and Waiver, and Order and contracts with a vendor to ensure the staff training requirement are met. During audit of stipulation training documents LPA observed that staff member (S1) did not complete the required medication administration training for May 2025 and for June 2025. This deficiency will be cited. As this deficiency was previously cited within the past year (1/29/2025) a Civil Penalty of $250.00 will be assessed. LPA spot checked Medication for four (4) residents. LPA observed all medications to be centrally stored, secure and with proper documentation. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, 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, LIC-421FC, LIC-811 Confidential Names and Appeal Rights discussed and provided to ED Rodriguez. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 24, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Aug 14, 2025

1569.625 Staff training... (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually... This requirement was not met by licensee as evidenced by: Based on LPA record review, the licensee did not comply with the section cited above in that Staff Member S1 did not complete the one hour (1) monthly training for 5/2025 & 6/2025 as required by the Stipulation and Waiver; and Order dated, 6/30/2022 which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: Licensee or Administrator to submit LIC9098 self-certifying that that required monthly training will be completed. Licensee or administrator will furthur provide Community Care Licensing proof that S1 has completed required trainings for 5/2025 & 6/2025 by POC due date of 8/14/2025.

Type of visit: Case Management - Legal/Non-compliance

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Legal Non-Compliance Case Management inspection and met with Executive Director (ED) Brandee Rodriguez. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA was informed that there are twenty-three (23) residents in Assisted Living and seventeen (17) residents in Memory Care for a total of forty (40) residents. As a requirement of the Stipulation and Waiver; and Order dated July 18, 2022, the facility submitted a Monthly Quality Assurance (QA) Audit that includes but is not limited to staffing, physical plant, dementia care, medication records and infection control. LPA reviewed QA and found that there were dirty vents noted. The vents were cleaned and LPA observed no dirty vents during the inspection noted below. At approximately 9:30 AM, LPA conducted a tour of the facility that included both memory care units, the assisted living care unit and grounds. Facility appeared to be safe, sanitary and in good repair. LPA reviewed the most recent staff schedule to verify that facility has sufficient staff for resident's needs including but not limited to residents needing two person assists. The facility staff two caregivers for each unit on each shift, with a rotating Medication Technician (MT) that will serve as the MT for both Memory Care buildings. Managers will provide additional assistance for breaks and lunches, when needed. Meal breaks were observed to be staggered to allow for ample staff coverage. The facility will be holding a job fair on 6/18/2025 to find potential staff members. Continued on 809-C... ...Continued from 809 Facility provides monthly training to staff in order to comply with the Stipulation and Waiver, and Order and contracts with a vendor to ensure the staff training requirement are met. Per QA, check of staff training was in compliance. LPA reviewed three (3) memory care resident files. Three (3) of (3) resident files were observed to be well organized and thorough with all required documentation including current Appraisals/Needs and Services plan. LPA reviewed five (5) staff files. All staff files were found to be with all required documentation including First Aid and CPR certification and proper annual training and stipulation training documentation. No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to ED Rodriguez. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 17, 2025

Allegation investigated: Facility does not have adequate staffing to meet the needs of residents in care.

Licensing Program Analysts (LPAs) Robert Frank and Christi Coppo arrived unannounced to initiate a Complaint Investigation and deliver findings regarding the above allegation and met with facility Administrator Brandee Rodriguez. Complaint alleges facility does not have adequate staffing to meet the needs of residents in care. Complainant states that only one direct care provider is scheduled per shift, but the care needs of residents require at least two staff be present, as some residents require a two-person assist. During investigation, LPAs reviewed staff schedule for 5/6/25. LPAs observed that staffing for Memory Care buildings 1 and 2 (MC1)(MC2) is such that there are two caregivers scheduled with one Med Tech present. Review of schedule indicates that lunches are not scheduled such that they are staggered to ensure each Memory Care unit has two staff present at all times. Continued on 9099-C Substantiated ...Continued from 9099 Additionally, facility is under Stipulation and Order and Waiver (Stip) as of 6/30/22. As a requirement of the Stipulation and Waiver; and Order dated July 18, 2022, page four (4), line items 26-27 and page five (5), line items 1-5, each Memory Care unit and Assisted Living unit will be staffed independently such that the units do not share direct care staff. The medication tech will not be a direct care staff but may provide support/backup when not distributing medication…and staff breaks and lunch shall be staggered so there is adequate staff coverage. LPAs review of staffing schedule for 5/6/25 shows that there are two (2) direct care staff scheduled for day shift for MC1, with one Med Tech present. However, both the Med Tech and one of the direct care staff are scheduled to take lunch at the same time, 10:00am, leaving only one direct care staff on duty during the lunch break. LPA review of staffing schedule for 5/6/25 shows that there is one (1) direct care staff scheduled for day shift for MC2, with one Med Tech present. However, both the Med Tech and the one (1) direct care staff are scheduled to take lunch at the same time, 10:30am. During investigation, LPAs reviewed resident roster indicating which residents require a two-person assist. Review of roster indicates there are three (3) residents (R1, R2, and R3) in MC1 that require a two-person assist and one (1) resident (R4) in MC2 that requires a two-person assist. So, based on the care needs of residents, facility is found to be out of compliance with the Stip. Based on LPAs’ record review, 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, are being cited on the attached 9099D. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-9099D, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Administrator Rodriguez. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 6, 2025 · control 21-AS-20250501120816

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: May 7, 2025

Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by: Based on LPA and Admin record review, the licensee did not comply with the section cited above in that staffing in MC1 and MC2 is not sufficient per resident care needs requiring a two person assist, which poses a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Licensee or Administrator will submit a plan to sufficiently staff the facility per resident care needs to CCL by POC due date of 5/7/2025. Facility to submit to CCL updated LIC500 showing adequate staffing by no later than 5/28/2025.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analysts (LPAs) Christi Coppo and Robert Frank arrived unannounced to conduct a Legal Non-Compliance Case Management inspection. The following items were indicated as deficient in the most recent audit dated 1/31/2025: Dementia Care. No monthly activity calendar or daily events. The following items were indicated as deficient in the most recent audit dated 2/27/2025: Dining. Food products with no cover or expiration date. Dementia Care. No monthly activity calendar or daily events. The following items were indicated as deficient in the most recent audit dated 5/2/2025: Medication Management. Med cart two (2) has discontinued medications from 4/21/2025. Dementia Care. In Memory Care two (2) curling iron found under sink and small cleaning spray found on night stand. Dementia Care. Scissors stored on the outside of the Med cart in Memory Care Two (2). These Deficiencies will be cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Continued on 809-C... ...Continued from 809 The following items are some of the requirements required per the current Stipulation and Waiver and Order (dated 6/30/2022) in place for the facility: Facility shall provide a minimum of four (4) hours of training monthly to direct care staff and managers. All staff that provide medication administration must receive one additional hour of training every month. Pacifica shall perform quarterly audits of medication inventory and if errors are found, a plan of correction for each error found shall be included with the applicable audit report Memory Care Unit and Assisted Living unit shall be staffed independently, such that the units do not share direct care staff. The Med Tech will not be a direct care staff, but may provide support when not distributing medication. Facility call system and delayed egress shall at all times be fully functional. As it pertains to item #3, LPAs observed one (1) Caregiver (CG) S4, present in Memory Care building Two (MC2). LPAs reviewed facility staff schedule for 5/6/2025 and found that S2 was the only CG scheduled for the Day shift. LPAs further observed that there was only one (1) CG, S5 scheduled for the PM shift. However, there is one resident identified as being a 2-person assist in MC2. Therefore, facility was found to be deficient in requirement required as part of the current Stipulation and Waiver and Order in place for the facility. LPAs reviewed staff schedule for 5/6/25 with Tiffany Leos, Resident Care Coordinator (RCC) and Admin and pointed out the staffing deficiency. This deficiency will be cited in Complaint #21-AS-20250501120816. On 3/26/25 Healdsburg Senior Living (HSL) representatives met with CCL at the Santa Rosa Regional Office. During this meeting items were discussed pertaining to the Stipulation and Waiver and Order dated July 18, 2022. One item identified as needing to be provided to CCL was: Facility will provide a list of all individuals who have acted as the Liaison since the effective date of the Stipulation and Order and how they ensured facility was meeting the mandate as identified in the Stipulation and Order. HSL submitted the list of individuals. However, during today’s visit, Administrator informed LPAs that current designated liaison, Karen Enciso, Regional Director of Operations (RDO) will no longer be with the company as of 5/9/25, at the latest. Continued on 809-C(2) ...Continued from 809-C Therefore, LPAs are requesting that HSL submit a letter to CCL indicating the name of the new liaison and how HSL will ensure facility will meet the mandate as identified in the Stipulation and Order by end of business day 5/9/2025. Per the stipulation, waiver and order page 3, line items 25-27 and page 4, line items 1-11 Facility shall provide a minimum of four (4) hours of training monthly to direct care staff and managers. Staff, S6, S7, S8, S9,S10 and S11 were all identified as having stipulation training completed per respective Monthly Quality Assurance Audit. Per LPA and Administrator review, documentation of required stipulation training does not indicate the number of hours for each session completed. Therefore, LPAs cannot determine the number of hours completed for the monthly training required by the stipulation. Per page four [4] line item 20 and page five [5], line items 5, 6, and 7 of the Stipulation and Order dated July 18, 2022, HSL is to submit a monthly LIC500 along with the census of each unit and two person assists identified. CCL received LIC500s for the months of January, February, Mar, and April. CCL received resident roster identifying resident requiring 2-person assist for the months of March and April, but did not receive a resident roster identifying residents requiring 2-person assist for the months of January and February. Further of audits dated 1/31/2025, 2/27/2025, 3/31/2025 and 5/2/2025 showed some minor instances of non-compliance however the instances were not significant or frequent enough to warrant a health and safety concern. LPAs discussed and reviewed stipulation with the new Administrator Brandee Rodriguez and provided Administrator with a copy of the stipulation. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809Ds, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Administrator Rodriguez. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 6, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: May 27, 2025

Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor...established procedures or which are otherwise to be disposed of shall be destroyed ...This requirement not met by licensee as evidenced by: Based on LPAs review of Monthly Quality Assurance Audit per stipulation dated 5/1/2025, Licensee did not ensure discontinued medications were destroyed, which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Licensee or Administrator will provide proof to CCL that all Medicine Technicians have taken Medication Destruction training in 2025 by the POC due date of 5/27/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87219(f) · Plan of correction due date: May 27, 2025

In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order... This requirement not met by licensee as evidenced by: Based on LPAs review of Monthly Quality Assurance Audit per stipulation dated 1/31/2025 & 2/26/2025, Licensee did not create a monthly activity calendar for Memory Care, which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Licensee or Administrator will provide the monthly activity calendar for May, 2025. Licensee will further provide an LIC 9098 Proof of Corrections self certifying that going forward Activity Calendars will be created and posted for residents by POC due date of 5/27/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: May 7, 2025

Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger... This requirement not met by licensee as evidenced by: Based on LPAs review of Monthly Quality Assurance Audit per stipulation dated 5/2/2025 in Dementia Care, scissors were stored on the outside of the medicine care in Memory Care building two (2) which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Licensee or Administrator will provide an LIC 9098 Proof of Corrections self certifying that CCR Regulation 87309(a) was reviewed with all Memory Care staff by POC due date of 5/7/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(23) · Plan of correction due date: May 27, 2025

All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food...shall be stored in covered containers at appropriate temperatures. This requirement not met by licensee as evidenced by: Based on LPAs review of Monthly Quality Assurance Audit per stipulation dated 2/27/2025, food products were not covered or marked with an expiration date, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Licensee or Administrator will provide an LIC 9098 Proof of Corrections self certifying that proper food service training is completed by all food service personnel by POC due date of 5/27/2025.

Type of visit: Office

On April 4, 2025 at 11am, a meeting was conducted by Assistant Program Administrator (APA) Stacy Barlow to verify Chapter 7 Bankruptcy Report filed by the Pacifica Senior Living as reported by the media. Present during the meeting are: Shelley Grace - Assistant Branch Chief, CCLD Craig Lundgren - Legal Counsel, CCLD Carl Knepler - Chief Executive Officer, Marlene Nelson - Director, Quality Assurance and Risk Management APA Barlow verified with Knepler information received by CCL from the media as follows: • $25M lawsuit against the community located in Bakersfield • Photography lawsuit against one of the properties • lawsuit against a Skilled Nursing Facility (SNF) in the Healdsburg location Knepler states that despite the lawsuits, there is no financial impact to any of the properties, residents or staff of the company. Knepler added there are no vendor issues as well. continuation on LIC 809C Knepler also states that management communicates with the staff and residents to make them aware of the changes. Signages have been changed. Knepler added that the bankruptcy did not affect any of the communities because Pacifica Senior Living Management was no longer the management company for any of the Pacifica Communities, that the communities had given notice to the department and residents back in October or November of last year of the changes in management companies. He said that the judgment in Bakersfield did not involve the operating entity, only the management company. He said there were no other suits pending against any of the Pacifica entities. APA requested the following documents be provided to CCL by today: • Spread sheet of all facilities whose management company was/is Pacifica Senior Living Management Company • management companies for each location • letter provided to the residents notifying them of the changes At the conclusion of the meeting, APA emphasized to Knepler the importance of communicating with CCL any lawsuits that the company may have in the future. Knepler agreed with APA. A copy of this report was provided to Knepler. Original signature is on file with the Pacifica Senior Living Union City facilitythe state’s words, verbatim · CDSS document, Apr 14, 2025

Type of visit: Office

Licensing Program Analyst (LPA) Christi Coppo and LPA Robert Frank, Licensing Program Manager (LPM) Victoria Bertozzi, Regional Office Manager (ROM) Carla Nuti-Martinez met with Healdsburg Senior Living Administrator Jeralyn May and Regional Director of Operations Karen Enciso, Director of Regulatory Compliance Marlene Nelson, Corporate Support Nurse Paulette Rubiales, Jake Call Senior V.P. of Operations joined the call via Teams. During this meeting items were discussed pertaining to the Stipulation and Waiver and Order dated July 18, 2022. CCL staff clarified with facility representatives that questions regarding the Stipulation and Order should be directed to their corporate representatives. Karen was identified as the current Liaison and parties discussed the required monthly documents that must be sent to the department including the Monthly Quality Assurance Audit Report, LIC500 and the resident roster identifying 2-person assists. LPA Coppo clarified as the scheduling of breaks and lunches for direct care staff and Med-Techs such that there are two people on the floor at all times in Memory Care 1 and Memory Care 2 as identified by facility staff. The Administrator agrees and acknowledges that strategic scheduling is required to fulfill the Stipulation. Facility staff clarified their training process including verifying who their vendor is and how they ensure staff on all shifts are trained per the Stipulation and Order, which is in addition to Initial and Annual training required by Title 22 regulation. Continued on LIC809C Continued from LIC9099 Items to be provided to CCL: Facility will provide a list of all individuals who have acted as the Liaison since the effective date of the Stipulation and Order and how they ensured facility was meeting the mandate as identified in the Stipulation and Order. Administrator will submit documentation of their process for conducting training as well as their process for documenting facilities training per Regulations as well as per the Stipulation and Order. No deficiencies cited.the state’s words, verbatim · CDSS document, Mar 26, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Plan of Correction POC visit to clear citations issued to Healdsburg Senior Living on 10/16/24 and 12/12/24. The following citations were outstanding: CCR 87555(b)(8) - issued 12/12/24 CCR 87555(b)(23) - issued 12/12/24 HSC 1569.625(b)(2) - issued 10/16/24 HSC 1569.625(b)(1) - issued 12/12/24 HSC 1569.618(c)(3) - issued 12/12/24 On 12/12/24 LPA conducted the Annual inspection. The following citation was issued for deficiency of CCR 87555(b): Based on LPA observation, the licensee did not comply with the section cited above in that LPA observed box of lettuce and lettuce actively being used to prepare salads to have black wilted leaf tips and/or stalks. Some the leaf tips were both black and had a white fuzzy substance present, which poses a potential health, safety or personal rights risk to persons in care. The following plan of correction was agreed upon with Admin: Facility to submit LIC9098 self-certification of proper food service training completed by all food service personnel by plan of correction due date of 1/2/25. As of today, CCL has not received plan of correction. Today, LPA and Admin toured the kitchen and found a watermelon to have a black fuzzy substance with white fuzzy substance also present. Deficiency is being re-cited today, see 809D. Continued on 809C... Continued from 809... On 12/12/24 LPA conducted the Annual inspection. The following citation was issued for deficiency of CCR 87555(b)(23): Based on LPA observation, the licensee did not comply with the section cited above in that Some food items observed were not covered or not labeled with date of opening: chocolate mousse, cakes, and dishes of fruit, gallon of milk and white food item that looked like mashed potatoes or riced cauliflower, which poses a potential health, safety or personal rights risk to persons in care. The following plan of correction was agreed upon with Admin: Facility to submit LIC9098 self-certification of proper food service training completed by all food service personnel by plan of correction due date of 1/2/25. As of today, CCL has not received plan of correction. Today, LPA and Admin toured the kitchen and observed the following food items not covered or not labeled with date: cart with cakes, bowls of a bread-like food item, and slices of pie. Deficiency is being re-cited today, see 809D. On 10/16/24 LPA delivered to the facility substantiated complaint findings in relation to staff training. The following citation was issued for deficiency of Health and Safety Code (HSC) 1569.625(b)(2): Based on LPA record review, the licensee did not comply with the section cited above in that seven out of seven staff files reviewed, staff did not have the required hours of annual training completed, which poses a potential health, safety or personal rights risk to persons in care. The following plan of correction was agreed upon with Admin: Facility to ensure all staff are current in their annual training. Facility to submit to CCL current annual training records for all care staff and Medication Technicians showing current training completed by plan of correction due date of 11/6/24. As of today, CCL has not received plan of correction. On 10/31/24 LPA received plan from Admin to complete training sometime in December. LPA advised Admin that plan is accepted but deficiency remains outstanding until plan of correction is fulfilled. As of today, CCL has not received the plan of correction. Deficiency is being re-cited today, see 809D. On 12/12/24 LPA conducted the Annual inspection. The following citation was issued for deficiency of HSC1569.625(b)(1): Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S4 and S6 do not have complete required training on file, which poses/posed a potential health, safety or personal rights risk to persons in care. The following plan of Continued on 809C(2)... Continued from 809C... correction was agreed upon with Admin: Facility to submit proof of completed required orientation training for S4 and S6 by plan of correction due date. On 1/7/25 LPA received from Business Operations Manager (BOM) some items that did not fulfill the plan of correction. LPA responded: for the training, for S6 I do not see anything that is current, I need the current completed training as outlined in the regulation. I did the annual on 12/12/24. So, anything after 12/12/23 counts as “current.” For S5, I see a whole bunch of tests and another more detailed Pacifica-specific training log. I need the trainings completed that satisfy the regulation. As of today, CCL has not received plan of correction. Deficiency is being re-cited today, see 809D. LPA discussed with Admin, per the Stipulation and Waiver; and Order page three [3], line items 25-27 and page four [4], line items 1-11, facility shall retain a vendor to provide a minimum of four [4] hours of training monthly to all direct care staff and managers. The training topics shall include the following: job duty expectations, falls/fall response, incontinence care, basic services, prohibited health conditions, personal rights of residents. Reporting requirements, observation of changes in client conditions, requirements for updated medical and functional assessments, dementia related behaviors, maintaining required records for staff and residents, COVID screening processes, and infection control/general sanitation. Further, all staff who provide medication administration must receive one hour of additional training every month. Medication training shall be provided by a Registered Nurse licensed in the State of California. On 12/12/24 LPA conducted the Annual inspection. The following citation was issued for deficiency of HSC 1569.618(c)(3): Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S3, S4, S5 and S6 did not have current 1st Aid/CPR on file, which poses a potential health, safety or personal rights risk to persons in care. The following plan of correction was agreed upon with Admin: Facility to submit picture of current CPR cards for S3, S4, S5 and S6 by plan of correction due date. On 1/2/25 LPA received proof of CPR for S5 and S6, but not S3 and S4. As of today, CCL has not received plan of correction for S3, and S4. Deficiency is being re-cited today, see 809D. Continued on 809C(3)... Continued from 809C(2)... The following deficiencies are being re-cited today for failure to correct: HSC 1569.625(b)(2) HSC 1569.625(b)(1) HSC 1569.618(c)(3) CCR 87555(b)(8) CCR 87555(b)(23) Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. LPA reviewed in detail the Stipulation and Waiver; and Order dated July 18, 2022 with Administrator Jeralyn May. In 2024, LPA only received three [3] LIC 500s: dated 9/11/24, 11/6/24 and one 1/2/25. However, per page four [4] line item 20 and page five [5], line items 5, 6, and 7 of the Stipulation and Order dated July 18, 2022, HSL is to submit a monthly LIC500 along with the census of each unit and two-person assists identified. LPA and Admin discussed the language of the Stipulation and Waiver pages two [2] through six [6] that addresses the need for continuity of compliance. LPA gave Admin a hard copy of Stipulation. As a requirement of the Stipulation and Waiver; and Order dated July 18, 2022, page three [3] line items 17-24, on 1/6/25 the facility submitted a Monthly Quality Assurance (QA) Audit too CCL. The QA includes Continued on 809C(4) Continued from 809C(3) but is not limited to staffing, dining, physical plant, resident rooms, infection control, medication room/cart, and dementia care. LPA reviewed QA and found the following items were indicated as deficient in the most recent audit dated 1/6/25: · Flooring tiles in 300 wing of facility being repaired · Current month’s activity calendar for Memory Care is not up, showing previous month’s calendar Facility provides monthly training to staff in order to comply with the Stipulation and Waiver; and Order and contracts with a vendor to provide the staff training required per the Stipulation and Waiver; and Order. Per QA, facility’s check of staff training was in compliance. LPA reviewed training records, fingerprint clearance, and 1st Aid/CPR of employees identified on the QA report and found documentation to be present. However, training documentation procedure and requirement as outlined in the Stipulation and Waiver; and Order are requires clarification. Admin will attend meeting for clarification at Regional Office in Santa Rosa at a date to be determined. LPA discussed with Admin staffing section of submitted QA. Comments indicate one of the selected staff (S7) is a caregiver and has 1st Aid present only, CPR not required. LPA discussed with Admin the specifications per the QA says: verify First Aid and CPR card is on file and current. LPA discussed with Admin, only one person on duty is required to have CPR. Additionally, LPA met with licensee's auditor (A1) to discuss findings on most recent audit dated 1/6/25. LPA advised that staff (S7) was reported as having 1st Aid training but not required to have CPR. LPA showed A1 the certificate present in S7's file showing they actually do have both 1st Aid and CPR. A1 responded that the certificate is not proof of either First Aid or CPR, only that they completed an online course. LPA then advised if that is correct, and the certificate present actually is not proof, then there is still an inaccuracy. LPA received clarification from Licensing Program Manager (LPM) that certificate is proof of completed 1st Aid. LPA discussed with A1 and Regional Director of Operations (RDO) the regulation requiring that all staff must Continued on 809C(5) Continued from 809C(4) have 1st Aid training, but that only one person on duty is required to have CPR. RDO advised that they ensure all Med Techs have CPR. LPA clarified with A1 and RDO that the staff identified on the QA should have both 1st Aid and CPR as that is what is specified on the QA form. So, A1 should be selecting staff that are required to have it as part of their audit. Therefore, all staff identified on the QA for item #3 under section of Staffing should have both First Aid and CPR. LPA discussed with Admin that on 12/12/24, LPA conducted a Legal Non-Compliance Case Management inspection per the Stipulation and Waiver; and Order dated July 18, 2022. Staff (S6) identified in the audit as having completed training was found not to have completed training on file in the required number of hours. LPA discussed with Admin that on 11/16/24 LPA conducted a Legal Non-Compliance Case Management inspection per the Stipulation and Waiver; and Order dated July 18, 2022. LPA reviewed training records of employees identified on the QA report as having training completed and found documentation present, except for one employee. One employee (S1) identified as having CPR certificate present in their file actually did not have a CPR certification or training certificate present in their file. LPA conducted a tour of the facility that included memory care unit 1, the assisted living care unit and facility grounds. Facility appeared to be safe, sanitary, and in good repair. There is an appeal pertaining to citation issued 12/12/24 for deficiency of regulation 87705(c)(4) submitted by the facility to CCL currently pending. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jan 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(8) · Plan of correction due date: Jan 30, 2025

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPA and Admin toured the kitchen and observed the following food items not covered or not labeled with date: cart with cakes, bowls of a bread-like food item, and slices of pie, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Facility to submit LIC9098 self-certification of proper food service training completed by all food service personnel by plan of correction due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555(b)(23) · Plan of correction due date: Jan 30, 2025

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that the following food items were not covered and/or not labeled with date: cart with cakes, bowls of a bread-like food item, and slices of pie, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Facility to submit LIC9098 self-certification of proper food service training completed by all food service personnel by plan of correction due date.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.618(c)(3) · Plan of correction due date: Jan 30, 2025

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty... This requirement is not met as evidenced by: Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S3 ands S4 did not have current CPR on file, which poses an immedisate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Facility to submit plan to submit picture of current CPR cards for S3 and S4 by plan of correction due date. Picture of current 1st Aid/CPR cards for S3 and S4 no later than 2/12/25.

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.625(b)(1) · Plan of correction due date: Jan 30, 2025

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S4 and S6 do not have complete required training on file, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Facility to submit LIC9098 self-certifying that Admin will attend the Regional Office Meeting to obtain clarification of training required. Once clarification is obtained facility to submit proof of training for S4 and S6 within 3 weeks from the date of the meeting.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Jan 30, 2025

§1569.625 Staff training... (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...This requirement was not met by licensee as evidenced by: Based on LPA and Admin record review, the licensee did not comply with the section cited above in that seven out of seven staff files reviewed, staff did not have the required hours of annual training completed, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Facility to submit LIC9098 self-certifying that Admin will attend the Regional Office Meeting to obtain clarification of training required. Once clarification is obtained facility to submit proof of training for all direct care staff and Med Techs within 3 weeks from the date of the meeting.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Legal Non-Compliance Case Management inspection. The following items were indicated as deficient in the most recent audit dated 12/2/24: Pharmacy transaction binder not organized and/or complete in Memory Care (building not specified) Resident call/signal/pager system was not operating properly in that facility having issues with resetting First Aid Kits missing items Medication requiring refrigeration temperature log was missing signatures Narcotics being signed off and counted for each shift log was missing signatures The following items are some of the requirements required per the current Stipulation and Waiver and Order (dated 6/30/22) in place for the facility: All staff that provide medication administration must receive one additional hour of training every month Pacifica shall perform quarterly audits of medication inventory and if errors are found, a plan of correction for each error found shall be included with the applicable audit report Memory Care Unit and Assisted Living unit shall be staffed independently, such that the units do not share direct care staff. The Med Tech will not be a direct care staff, but may provide support when not distributing medication. Facility call system and delayed egress shall at all times be fully functional As pertains to item #2, LPA observed signature missing on narcotics log check for this morning 12/12/24. Staff (S2) advised LPA that she hadn't signed the log yet. The time was 12:38pm. Audit identified the same issue on 12/2/24. Plan of correction not received when audit was submitted as required by the current Stipulation and Waiver and Order in place for the facility. Continued on 809C... Continued form 809... As pertains to item #3, LPA observed two [2] staff present Memory Care building 1 (MC1) but no med tech present. LPA reviewed facility staff schedule for 12/12/24 and found that S2 was scheduled to rotate between Assisted Living (AL) and MC1. LPA verified schedule is current and accurate with S2. Therefore, facility was found to be deficient in requirement required as part of the current Stipulation and Waiver and Order in place for the facility (deficiency cited, see 809D**civil penaltiy assessed**). As pertains to item #4, LPA observed the pendant call button system to not be properly working. LPA interviewed resident in room 101 (R2). LPA pressed resident's pendant at 11:34am. Staff (S1) arrived at 11:42am to room 101 to take the resident down for lunch. LPA asked caregiver if they were here to answer the pendant call, they said no, and explained that they did not receive a page and were here to take the resident to lunch. Care giver then proceeded to wheel the resident down to the dining area. Admin was approaching down the hall as S1 was leaving. LPA advised Admin of pendant alarm not working. LPA confirmed with Admin that pendant flashed red when LPA pressed it. The pendants flash red when they are activated then turn green once reset/answered by staff. The staff are to receive a page when the pendant is pushed and the call is also logged on the pendant/call button computer. Admin and LPA went to review computer call button log and there was no call showing from room 101. Admin went to resident in dining hall and pressed resident's pendant, S1 was present as well. Once again S1 did not receive the page and the call request was not logged on the call button computer log. Issue reported in audit dated 12/2/24 was "Resident call/signal/pager system was not operating properly in that facility having issues with resetting." However, no plan of correction was submitted with audit as required by the current Stipulation and Waiver and Order in place for the facility (deficiency cited on annual inspection 809D dated 12/12/24). One [1] staff (S6) out of three [3] staff identified in audit as having completed orientation training and CPR card on file were found to actually not be on file and not issued. LPA confirmed with Admin that S6 does not have completed orientation training and current CPR card (deficiency cited on annual inspection 809D dated 12/12/24). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Admin. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Dec 12, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4) · Plan of correction due date: Dec 12, 2024

87705 Care of Persons with Dementia (c) (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and heakth care needs. as identified in their current appraisal/care plan. This requirement was not met by licensee as evidenced by: Based on LPA observation and interview staff schedule for 12/12/24 shows that S2 was scheduled to rotate between Assisted Living (AL) and MC1, which is a defieicncy of the requirements oulined in the current Stipulation and Waiver and Order dated 6/30/2022, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: Facility to submit to CCL facility staff schedule showing Med Tech present in each building without an any rotation between buildings as required per the current Stipulation and Waiver and Order in place for the facility. Facility to also submit LIC500 showing adequate staffing in both Memory Care buildings, in numbers at least as much as outlined in the Stipulation and Waiver and Order dated 6/30/2022 or greater, and in numbers that ensure meeting each resident’s physical, social, emotional, safety and health care needs as identified in their current appraisal/care plan and/or physician's report.**civil penaltiy assessed**

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Jeralyn May. At approximately 10:00am LPA toured the building and grounds. LPA toured kitchen. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Some food items observed were not covered or not labeled with date of opening: chocolate mousse, cakes, and dishes of fruit, gallon of milk and white food item that looked like mashed potatoes or riced cauliflower (deficiency cited, see 809D). LPA observed box of lettuce and lettuce actively being used to prepare salads to have black wilted leaf tips and/or stalks. Some the the leaf tips were both black and had a white fuzzy substance present (deficiency cited, see 809D). LPA observed freezer temperature log to be missing temperature recordings for two AM shifts and one [1] PM shift, and the refrigerator temperature log was missing temperature recordings for three [3] PM shifts and five [5] AM shifts. All bedrooms in Memory Care buildings 1 and 2 were equipped with lighting, night stand, and chest of drawers. All bedrooms viewed in Assisted Living were also equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Residents' main shower/bathroom in Memory Care building 1 had required grab bar but did not have non-skid mat or strips present. Water temperature in sink accessible to residents in care measured at 116.6 degrees F in the outer dining room kitchen sink and 114.2 degrees F in the internal dining room sink, 108.7 degrees F in room 302, 107.2 degrees F in room 101, and 107.4 degrees F in room G, all which are within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 3/12/24. Smoke/Carbon Monoxide detectors located throughout the facility and serviced by a vendor, last serviced on 11/19/24. Facility’s last quarterly disaster drills were conducted on 10/2024. Continued on 809C... Continued from 809... LPA observed the pendant call button system to not be properly working. LPA interviewed resident in room 101 (R2). LPA pressed resident's pendant at 11:34am. Staff (S1) arrived at 11:42am to room 101 to take the resident down for lunch. LPA asked caregiver if they were here to answer the pendant call, they said no, and explained that they did not receive a page and were here to take the resident to lunch. Care giver then proceeded to wheel the resident down to the dining area. Admin was approaching down the hall as S1 was leaving. LPA advised Admin of pendant alarm not working. LPA confirmed with Admin that pendant flashed red when LPA pressed it. The pendants flash red when they are activated then turn green once reset/answered by staff. The staff are to receive a page when the pendant is pushed and the call is also logged on the pendant/call button computer. Admin and LPA went to review computer call button log and there was no call showing from room 101. Admin went to resident in dining hall and pressed resident's pendant, S1 was present as well. Once again S1 did not receive the page and the call request was not logged on the call button computer log (deficiency cited, see 809D). At approximately 1:00pm LPA conducted a spot check of medication and medication records in Memory Care building 2. Medication is centrally stored in a locked cart in a locked room. LPA observed Olanzapine 2.5 mg prescription filled on 12/7/24 for R1 to be missing from the Centrally Stored Medication Log (CSML) (deficiency cited, see 809D). LPA conducted a review of 6 resident records. LPA conducted review of 5 staff records. S3, S4, S5 and S6 did not have current CPR on file (deficiency cited, see 809D). S4 and S6 do not have complete required training on file (deficiency cited, see 809D) Jeralyn May Administrator Certificate 7036260740 expires 11/14/25. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report and Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Admin. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Dec 12, 2024

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: POC

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management to follow up on Incident report submitted 10/23/24 and to conduct a plan of correction visit. LPA met with Resident Services Director Tiffany Roas (RSD). Admin not present but was available by phone. RSD gave Senior Business Office Manager (BOM), Mitchell Moore permission to sign report. LPA reviewed Incident report submitted for resident R1. On 11/7/24 facility reported that R1 fell. R1 was observed on the ground on the backyard patio. Resident was outside sitting with all the other residents in Memory Care #2. Staff suddenly heard a chair hit the floor. A fellow resident stated to staff that she was trying to get up from her chair. R1 was on the floor with their head against the wall, resulting in a wound on the back of their head. Per LPA conversation with Admin, resident stood up and tried to support their weight on the arm of the chair and fell. Staff were present but just could not reach resident fast enough to break their fall. Fall was not a result of lack of staff supervision. R1 placed on 72 hour alert charting and increased monitoring. No deficiency cited. LPA also present at facility to conduct a plan of correction visit. On 10/16/24 citation was issued for deficiency of Health and Safety Code 1569.269(a)(6). The plan of correction required facility to ensure that pendant call button system was in good repair and operational and for staff to be present in sufficient numbers to answer calls in a timely manner, when residents are in need of assistance. Facility was to submit three week pendant call button system log to CCL showing all calls answered within a timely manner by plan of correction due date. Admin agreed that within 15 minutes can be defined as within a timely manner. The plan of correction was due 11/14/24 as an extension was granted by LPA. On 11/13/24 Admin submitted pendant call log. Per LPA review of pendant call log, between 10/30/24 and 11/3/24, pendant response times were greater than 15 minutes a total of 26 times, with the longest being over 1 hour (deficiency cited, see 809D and civil penalty assessed). Continued on 809C... continued from 809... Per Admin, the repairs on the pendant call button system have been completed and issues appear to have been resolved. Per Admin, facility has addressed the response times longer than 15 minutes by completing additional training with those staff that struggled with resetting the pagers. Per Admin, facility had several employees on the PM and NOC shift that were not responding to the pendant calls in a timely fashion; these employees have been disciplined, and will be terminated if they continue with slow response time. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with BOM. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with BOM and a copy of this report was given.the state’s words, verbatim · CDSS document, Nov 19, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Dec 3, 2024

§1569.269 Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by: failure to fulfill deficieny plan of correction issued on 10/16/24 for pendant call button system showing all calls answered with 15 minutes, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 19, 2024

Plan of correction: Facility to submit training logs and termination paperwork for employees that were identified by Admin to have struggled with resetting the pagers or did not repsonse to pendant calls within 15 minutes. Logs and paperwork to be submitted to CCL by plan of correction due date.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Legal Non-Compliance Case Management inspection and met with Resident Services Director Tiffany Roas (RSD). Admin not present but was available by phone. RSD gave Senior Business Office Manager (BOM), Mitchell Moore permission to sign report. As a requirement of the Stipulation and Waiver; and Order dated July 18, 2022, the facility submitted a Monthly Quality Assurance (QA) Audit that includes but is not limited to staffing, physical plant, dementia care, medication records and infection control. LPA reviewed QA and found that there were deficiencies pertaining to medications: two [2] resident rooms were not free of medications and creams/lotions were left out in resident rooms (deficiency cited, see 809D). LPA conducted a tour of the facility that included both memory care units, the assisted living care unit and grounds. Facility appeared to be safe, sanitary and in good repair. Facility provides monthly training to staff in order to comply with the Stipulation and Waiver, and Order and contracts with a vendor to ensure the staff training requirement is met. Per QA, check of staff training was in compliance. LPA reviewed training records of employees identified on the QA report and found documentation present, except for one employee. One employee (S1) identified as having CPR certificate present in their file actually did not have a CPR certification or training certificate present in their file. LPA contacted Director of Regulatory Compliance (DRC), person whom submitted the QA report, to ask about this discrepancy. LPA asked if there were any circumstances under which they would mark that the CPR card was present when it actually was not present, DRC answered that it must have been a mistake but will move forward with increased diligence. Continued on 809C... Continued from 809... LPA reviewed the most recent staff schedule to verify that facility has sufficient staff for resident's needs including but not limited to residents needing two-person assists. Per conversation with Administrator, they staff two caregivers for each unit on each shift, with a rotating Med Tech that will serve as the Med Tech for both Memory Care buildings. Managers will provide additional assistance for breaks and lunches, when needed. Staffing is still an issue, but per LPA review of LIC500 and conversation with Administrator, facility has hired 8 new staff members and a new Resident Care Coordinator. New staff members are currently undergoing their training and will be added to the shift as soon as shadow training is successfully completed. Per Admin, facility is not allowing new hires to be put into the 4/2 rotation (work 4 days, then off 2 days) until they have shadowed a complete 4/2 rotation. Additionally, Admin explained that should the staff be identified not quite ready, facility will have them complete another 4/2 rotation shadowing. Review of audit showed other minor instances of non-compliance however the instances were not significant or frequent enough to warrant a health and safety concern. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with BOM. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with BOM and a copy of this report was given.the state’s words, verbatim · CDSS document, Nov 19, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(f)(2) · Plan of correction due date: Nov 27, 2024

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia (2) Over-the-counter medication, nutritional supplements or vitamins... and toxic substances such as certain plants.... and disinfectants. This requirement was not met by licensee as evidenced by: QA audit report indicated medications found in resident rooms and creams/lotions left out in resident rooms, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 19, 2024

Plan of correction: Facility to conduct in-service training on proper handling and storage of items that must remain inaccessible to residents. Facility to submit training log to CCL by plan of correction due date.

Allegation investigated: Licensee does not provide adequate or proper training Licensee does not ensure adequate staffing Personal Rights Residents needs are not being met

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegations and met with Jeralyn May, Administrator. Complaint alleges licensee does not provide adequate or proper training. Complainant states housekeeping personnel are doing caregiving duties without training. During investigation, seven [7] out of seven [7] staff interviewed state that housekeeping personnel are performing caregiving duties. On 7/12/2024, LPA observed staff identified as housekeeping to be working and providing care to residents in Memory Care building #1 (MC1). During investigation, LPA reviewed training records for seven [7] staff. Seven [7] out of seven [7] staff did not have current training or did not have the required amount of current training hours completed. Based on LPA’s observations, interviews, and record review, 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, are being cited on the attached 9099D. Continued on 9099C... Substantiated continued from 9099... Complaint alleges licensee does not ensure adequate staffing. Complainant states not enough staff to properly transfer residents requiring assistance. Complaint alleges Personal rights. Complainant states residents are not allowed to go to their bedrooms and residents remain in wheelchairs for extended periods of time. During investigation, LPA interviewed seven [7] staff. Five [5] out of seven [7] employees state they need help and don’t have enough staff to meet residents' care needs. Additionally, seven [7] out of seven [7] staff say they do not get breaks because there is not enough staff to cover. Five [5] out of seven [7] staff say at times, there is only one person working in MC1. Only one staff being present could be due to staff lunch or as some staff reported, in the most recent summer months only one person was actually working in MC1 per shift. Additionally, one [1] out of one [1] witness states that there is sometimes only 1 person in MC1 during a shift, but definitely only one during lunches. Three [3] out of seven [7] staff and one [1] out of one [1] witness state that the residents remain in their wheelchairs for extended period of time due to not having enough staff to transfer from wheelchair to the recliners in the living room of MC1. During investigation, LPA reviewed staff schedule. Staff schedule shows that no more than 2 people are assigned to MC1 at any given time, not including coverage during staff lunches. However, LPA review of residents’ physician reports and care plans of the ten [10] residents residing in MC1 shows that: · 9 Need a total assist with Bathing, · 7 Need a total assist with Grooming · 10 Need a total assist with Dressing · 10 Need a total assist with Toileting · 4 Need a total assist with Transfers · 10 Need total assist with Medications · 7 Are identified as a fall risk Continued on 9099C(2)... continued from 9099C... · 1 Need a stand-by assist with Bathing, · 3 Need a stand-by with Grooming · 4 Need a stand-by with Transfers · 4 residents in MC1 require a 2 person assist as indicated by their care plans and as indicated by staff. Based on LPA’s observations, interviews, and record review, 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, are being cited on the attached 9099D. Complaint alleges resident needs are not being met. During investigation, Administrator advised the method by which residents alert staff that they need help or require assistance is through a pendant call button system. Each resident is assigned a pendant. When a resident needs help or assistance with a care need, they push the button on their pendant in order to alert staff to their need. LPA review of pendant log shows that between 6/30/24 and 7/2/24 residents pushed their pendant call button 36 times. Of those 36 times, the wait times until someone arrived to help were: · 8 waited at least 15 minutes, · 11 waited at least 30 minutes, and · 16 either never got a response or there was an error in the pendant log system. LPA review of pendant log shows that between 9/1/2024 and 9/27/2024 residents pushed their pendant call button 621 times. Of those 621 times, the wait times until someone arrived to help were: · 94 waited 15 minutes or more, · 56 waited 30 minutes or more, Continued on 9099C(3)... Continued from 9099C(2)... · 20 waited at least 1 hour, · 7 waited more at least 2 hours, · 3 waited at least 3 hours, · 1 waited at least 5 hours, · 1 waited at least 6 hours, and · 126 either never got a response or there was an error in the pendant log system. Additionally, the pendant call button/pull cord was pushed in Memory Care #1 bathroom or rear door a total of 6 times, where the wait times show as: · 1 for 21 hours, · 1 for 14 hours, · 1 for 7 hours, · 2 for 5 hours, and · 1 time either they never got a response or there was an error in the pendant log system. During investigation, on 7/12/2024 at approximately 10:30am, LPA entered the room of a resident (R6) for the purposes of conducting an interview. Resident informed LPA she has been pressing her pendant for the past 45 minutes and no one has come. LPA then pushed resident's pendant and set the stopwatch timer. LPA observed a caregiver to arrive to answer the pendant 24 minutes after LPA pushed the pendant. During investigation, on 9/27/24 LPA interviewed resident (R4). While interviewing R4, LPA asked to push their pendant in order to confirm caregivers’ response time. LPA waited for 32 minutes. LPA did not observe staff to address the pendant alert while present in the room. Continued on 9099C(4)... continued from 9099C(3) Based on LPA’s observations, interviews, and record review, 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, are being cited on the attached 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Oct 16, 2024 · control 21-AS-20240709101931

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Nov 6, 2024

§1569.625 Staff training... (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually... This requirement was not met by licensee as evidenced by: Based on LPA record review, the licensee did not comply with the section cited above in that seven out of seven staff files reviewed, staff did not have the required hours of annual training completed, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: Facility to ensure all staff are current in their annual training. Facility to submit to CCL currrent annual training records for all care staff and Medication Technicians showing current training completed by plan of correction due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Nov 6, 2024

§1569.269 Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by: Based on LPA record review of facility's pendant call button system log, the licensee did not comply with the section cited above in that between 9/1/2024 and 9/27/2024 residents pushed their pendant call button at least 621 times. Of those 621 times at least 126 either never got a response or there was an error in the pendant log system, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: Facility to ensure that pendant call button system is in good repair and operational, staff is sufficient to answer calls in a timely manner, when residents are in need of assistance. Facility to submit three week pendant call button system log to CCL showing all calls answered within a timely manner by plan of correction due date. Admin agrees that within 15 minutes can be defined as within a timely manner.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4) · Plan of correction due date: Oct 30, 2024

87705 Care of Persons with Dementia (c) (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and heakth care needs. as identified in their current appraisal/care plan. This requirement was not met by licensee as evidenced by: Based on LPA interviews and record review, facility does not have adequate number of direct care staff In Memory Care building #1 to support each resident’s physical, social, emotional, safety, and health care needs as identified in their current appraisal/care plan and/or physician's report, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: Facility to submit to CCL updated LIC500 showing adequate staffing in Memory Care building #1, in numbers at least as much as outlined in the Stipulation and Waiver and Order dated 6/30/2022 or greater, and in numbers that ensure meeting each resident’s physical, social, emotional, safety and health care needs as identified in their current appraisal/care plan and/or physician's report. Additionally, facility will provide written statement indicating how they will secure adequate staffing. Plan to address staffing coverage when staff is at lunch or on break, or when scheduled staff is not present at the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(6) · Plan of correction due date: Oct 30, 2024

87468.2 Additional Personal Rights...(a) In addition to the rights listed in Section 87468.1... residents... shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility. This requirement was not met by licensee as evidenced by: Based on LPA interviews and record review, facility does not have adequate number of direct care staff In Memory Care building #1 to support each resident’s physical, social, emotional, safety, and health care needs as identified in their current appraisal/care plan and/or physician's report, such that they can make choices concerning their daily lives in the facility, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: Facility to submit to CCL updated LIC500 showing adequate staffing in Memory Care building #1, in numbers at least as much as outlined in the Stipulation and Waiver and Order dated 6/30/2022 or greater, and in numbers that ensure meeting each resident’s physical, social, emotional, safety and health care needs as identified in their current appraisal/care plan and/or physician's report. Additionally, facility will provide written statement indicating how they will secure adequate staffing. Plan to address staffing coverage when staff is at lunch or on break, or when scheduled staff is not present at the facility.

Type of visit: Required - 1 Year

Licensing Program Analyst Bertozzi arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Cinthya Gamino. LPA initiated a tour of the facility around 9:50am which included the main Assisted Living building that contains the main kitchen, dining room as well as two separate buildings that contain Memory Care Units 1 and 2 and observed the following: Facility buildings were a comfortable temperature and exits were free from obstruction. LPA went into a sample of resident apartments and found them to be furnished per regulation. Water temperature in apartments tested measured at 89, 111, 115 and 119 degrees F which are not all within the range of 105 to 120 degrees F allowed per regulation. Cleaning supplies and other toxins are locked in various storage rooms and housekeeping carts to ensure resident safety. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications are centrally stored and locked in Medication Rooms and Medication Carts in Assisted Living and both Memory Care Units. Facility has required posters in main areas of the facility. Fire extinguishers were last serviced April 2023. Facility has a vendor who comes in routinely to test the fire system which includes carbon monoxide detectors and the most recent service was conducted November 2023. Facility has a call bell system and each resident room and public restroom has a call bell. Memory care has functional delayed egresses. Six staff files and seven resident files were reviewed. Staff have required First Aid and CPR certificates. Training Records for staff and Medication Records for residents were reviewed. Administrator Certificate for Administrator, Cinthya Gamino, 6062514740, expires 3/3/2024. . Continued on LIC809C Continued from LIC809 Construction areas at the facility have been made inaccessible to ensure resident safety. A building that is under construction in the back of the facility has a fence around it and the former skilled nursing area of the facility that is being remodeled has locking doors to restrict access. Administrator to submit updates of the following documents by 12/28/2023: LIC 308 Designation of Facility Responsibility (if applicable) LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (review and update if changes) Infection Control Plan (if changes) Liability Insurance No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Nov 28, 2023